Postpartum depression is one of the most common nonobstetric complications associated with childbearing, and poses potential serious threat to the mother's and the infant's well-being and development.1,2 Studies suggest that a history of untreated depression before pregnancy increases the risk of depression after delivery or during subsequent pregnancies, and this risk increases with maternal age.3,4 In comparison, younger women, ages 15 to 24 years, had a lower risk of postpartum depression compared with mothers ages 25 to 29 years.3 Women over age 30 years have a statistically significant increased risk of postpartum depression.3 Women over age 35 years are considered to be of advanced maternal age.3
Many of the factors for postpartum depression in older mothers involve anxiety, sleep disturbances, feeling overwhelmed, and preoccupation or perception of adverse outcome.5,6 Compared with younger women, older women generally have higher educational levels and professional positions with increased responsibilities and can suffer from elevated stress, and additional burdens of contributing to the family finances.7,8 They also may be less able to handle the rigors of pregnancy.7,8
Although advanced maternal age is known as an important risk factor for postpartum depression, research has predominantly focused on the psychosocial consequences of younger mothers.9 This article focuses on the risk factors, pathophysiology, clinical manifestations, diagnosis, and treatment of postpartum depression in women age 35 years and older.
Of the many risk factors associated with postpartum depression (Table 1), the strongest risk factor appears to be a previous history of depression or anxiety.10
Postpartum depression can affect women of all racial and ethnic backgrounds; the highest reported incidence is in American Indian/Alaska Natives at 14%, followed by non-Hispanic blacks (12.8%), mixed race (11.5%), non-Hispanic whites (11%), Hispanics (10.9%), and Asian and Pacific Islanders (7.9%).11
Among women who have recently delivered, the incidence of postpartum depression increased with age compared with the incidence of depression in women who had not recently delivered.12 In another study, psychologic, biologic (the stress biomarkers cortisol and alpha-amylase), and social variables were evaluated and compared by age.13 In this study, surprisingly, postpartum depression and parenting stress increased in both younger and older women.13 In this study, older women had improved social function, defined as family function, maternal attitude, and social support, which may help compensate for the increased postpartum depression and higher cortisol levels seen in advanced age.13 As maternal age at first childbirth increases in most high-income countries, so has concern with infertility, miscarriage, stillbirth, low birth weight, chromosomal abnormalities, and perinatal morbidity and mortality, all of which have been identified as potential postpartum depression triggers.14
Women as young as age 30 years may experience postpartum depression due to an impairment of the hypothalamus pituitary adrenal axis (HPA) associated with stress and age.13,15 Stress stimulates the release of glucocorticoids from the adrenal cortex and usually stimulates a negative regulation of the HPA. Cortisol is the main marker of the HPA axis. Prolonged periods of stress can cause higher levels of cortisol through receptor blockage of the negative feedback of the HPA axis. Age has also been reported to be positively associated with cortisol secretion during depression. A high level of cortisol causes the brain to be more susceptible to depression. Impairment of regulation of the HPA disrupts the body's ability to reduce cortisol levels. Lower cortisol levels are needed for cognitive and emotional processing.13,15
CLINICAL MANIFESTATIONS AND DIAGNOSIS
Postpartum depression can manifest with a wide range of symptoms (from anxiety and irritability to suicidal ideation) and multiple levels of severity.10,16 Diagnosis is made using the criteria in Table 2; postpartum depression is defined as the onset of depression symptoms during pregnancy or within 4 weeks postpartum.10,16 Depression may be diagnosed after this timeframe; however, the symptoms would not meet the criteria for postpartum depression.10
“Baby blues” are common in the days after delivery and need to be distinguished from postpartum depression. “Baby blues” can occur in up to 70% of new mothers exhibiting brief, mild depression symptoms that present 2 to 5 days after delivery; symptoms do not last longer than 2 weeks.10 The duration of symptoms is important in making a diagnosis of postpartum depression as the criteria for major depressive disorder define symptoms being present most of the day for at least 2 consecutive weeks.16
If postpartum depression is suspected, use a two-question screening tool.10,17 Ask the patient to respond yes or no to these questions:
- During the past month, have you often been bothered by feeling down, depressed, or hopeless?
- During the past month, have you often been bothered by having little interest or pleasure in doing things?10,17
If the patient responds affirmatively to either question in the screening tool, follow up with either the Edinburgh Postnatal Depression Scale (EPDS) or Patient Health Questionnaire-9 (PHQ-9). Using these questionnaires after completing the screening tool can help establish a diagnosis with more chances to decrease false-positive testing.10 Screening before pregnancy, during, immediately after, and at the first several well-child evaluations would be a beneficial practice approach. Having more education and awareness for mothers about postpartum depression may help women realize they are not abnormal for having these symptoms and may encourage women to seek treatment when needed. Simply screening women for postpartum depression has been shown to reduce the prevalence of depression and increase remission or treatment responses.18
When taking a patient history, rule out any manic symptoms in order to distinguish postpartum depression from bipolar disorder or psychosis. Ask the patient if she has had more than 4 consecutive days of an elevated mood different from her normal day-to-day functioning; this can separate out a possible bipolar diagnosis.10
Ruling out other causes of depression symptoms is needed when making a diagnosis of postpartum depression. Blood work can be obtained to rule out thyroid disorders or anemia.10 A thorough family history, ruling out substance abuse, and assessing social support available to the family may also be helpful to assess risk.10
Treatment for postpartum depression is the same for all women regardless of age. Cognitive behavioral therapy (CBT) strategies have been shown to be the most effective nonpharmacologic treatment, with no risk to mother or infant.10,18,19 Other interventions such as peer support, talking therapies provided by RNs, or in-home visits by RNs also have shown success without risk. Optimal duration of therapy is between 12 and 16 weeks.10 Greater length of therapy correlates with a greater reduction of symptoms for the longest duration of time.18 A limitation of CBT is that it often is unavailable for low-income mothers.
Therapies such as acupuncture and bright light therapy show no change in symptoms.18 Electroconvulsive therapy for women with severe unipolar and bipolar depression worsened by pregnancy can be useful with no risk to the fetus.20
Research recommends pharmacologic management of postpartum depression by primary care providers, who should initiate therapy when the patient does not respond to psychotherapeutic intervention or does not have access to these interventions.10 Remember that maternal metabolism is slow in the first few weeks postpartum, and start with a lower dose.21
Less than 10% of maternal doses of selective serotonin reuptake inhibitors (SSRIs) pass into breast milk.21 Sertraline has the lowest maternal milk/plasma ratio and has shown a quicker symptom reduction time compared with CBT.10,21 Citalopram, fluoxetine, and venlafaxine have a high maternal milk/plasma ratios and should only be considered when the mother has had a previous positive response to these drugs.21 When SSRIs are not effective, consider selective norepinephrine reuptake inhibitors or mirtazapine.21 Avoid bupropion, which can pass into breast milk and cause seizures in infants.10 Also avoid tricyclic antidepressants and monoamine oxidase inhibitors, which can easily pass into breast milk.10
Nonpsychotropic chemicals such as selenium, omega-3 fatty acids, and docosahexaenoic acid have been studied but have not been shown effective for treating postpartum depression.21 Hormone therapy can be effective; however, it is infrequently used, little research exists, and thus psychiatry and primary care have been reluctant to prescribe these drugs for treating postpartum depression.21
Older women are more apt to be on other medications and clinicians must consider drug-drug interactions, especially in regards to those who metabolize with the cytochrome P450.
When women do not respond to initial pharmacologic treatment, have thoughts of self-harm or harming others, or have psychosis, consider prompt referral to psychiatry.10
Postpartum depression can be worsened by difficulties with breastfeeding. When this is the case, women should be supported in their decision to continue or discontinue breastfeeding.10
Interestingly, research shows that women who have had previous treatment for depression, fear, or panic in the week before being asked about symptoms of postpartum depression often are the least likely to be willing to receive treatment for postpartum depression.22 Therefore, the provider should take extra care to fully explore symptoms of postpartum depression in this population of women.
Screen mothers over age 30 years for postpartum depression at all visits during pregnancy and postpartum, especially focusing on women with a history of depression and anxiety. Start with the two-question screening tool, followed by an EPDS or a PHQ-9. Although further research is needed in older mothers, with proper screening, clinicians can guide patients to various beneficial treatments.
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