POSTPARTUM DEPRESSION

POSTPARTUM DEPRESSION - NancyByatt, DO, MBA; RebeccaLundquist, MD
BASICS
DESCRIPTION
Postpartum depression, postpartum blues, and postpartum psychosis are the 3 main behavioral conditions that may occur after the delivery. Any recurring psychiatric condition may also reoccur or have it's onset in the postpartum. (1)[C]
• System(s) Affected: Nervous
• Synonym(s): Postnatal depression; Postgestational depression
GENERAL PREVENTION
• Routinely assess women in the 3rd trimester to diagnose depression and risk factors for depression and begin treatment before or immediately after delivery. (2)[A]
• Edinburgh Postnatal Depression Scale should be used as a screening tool (2-4)[A]
EPIDEMIOLOGY
• Predominant age: Women of reproductive age. It has been also described in mothers adopting a baby. (1)[C]
• Predominant sex: Female only
Prevalence
Of new mothers, 10-19% develop postpartum depression. 1-2 woman per 1,000 normal births develop postpartum psychosis, which is a psychiatric emergency. (5)[B]
RISK FACTORS
• Previous episodes of postpartum depression
• Previous episodes of depression
• History of depression during pregnancy
• Family history of depression
• Early childhood losses
• Growing up with alcoholic dysfunctional parents
• Unwanted pregnancy
• Socioenconomic stress
• Lack of social and family support system (6,7)[C]
ETIOLOGY
Unknown. Perhaps multifactorial, including biologic-genetic predisposition in terms of brain chemistry, sudden drop in estrogen and progesterone levels at delivery, and psychosocial stressors.
ASSOCIATED CONDITIONS
• Bipolar mood disorder
• Depressive disorder not otherwise specified
• Dysthymic disorder
• Cyclothymic disorder
• Recurrent major depressive disorder (6,8)[C]


DIAGNOSIS
SIGNS AND SYMPTOMS
• Sleep increase/decrease
• Interest in formerly compelling or pleasurable activities diminished
• Guilt, low self-esteem
• Energy poor
• Concentration poor
• Appetite increase/decrease
• Psychomotor agitation or retardation
• Suicidal ideation
TESTS
Lab
Thyroid-stimulating hormone test (8)[A]
Imaging
Head CT/MRI rarely needed
Diagnostic Procedures/Surgery
• Edinburgh Postnatal Depression Scale is primary screening tool
• Beck, Hamilton, and Zung depression inventories may provide information about the severity of the depression and suicidal risks. (2-4)[A]
DIFFERENTIAL DIAGNOSIS
• Baby blues: Mood lability, not a psychiatric disorder, resolves within a couple of weeks
• Postpartum psychosis: A psychiatric emergency
• Postpartum anxiety/panic disorder
• Postpartum obsessive-compulsive disorder
• Hypothyroidism
• Sleep apnea
• Postpartum thyroiditis can occur in up to 7.5 % of patients and can present as depression (9)[A]
TREATMENT
STABILIZATION
• Most patients respond to outpatient-basis individual psychotherapy in combination with pharmacotherapy.
• Support/therapy groups may be helpful.
• Assess patients for homicidal and suicidal ideation and any thoughts of harming baby (9)[A]
• Visiting nurse services can provide direct observations of the mother about safety issues and mother-child bonding (7)[A]
• Obtain psychiatric consultation for patients with psychotic symptoms: If psychotic delusions or hallucinations are present, immediate hospitalization is mandatory. The psychotic mother should not be left alone with the baby. (1,8,10)[A]
GENERAL MEASURES
• Proper sleep and rest for the new mother are important for stable mood (7)[C]
• Patient education and providing reading material for the patient and her family may be helpful and valuable. (7)[C]
• Psychotherapy treatment: Interpersonal psychotherapy and cognitive behavior therapy shown to be effective (11,12)[C]
• Bright light therapy may be helpful. (13)
Diet
• Good nutrition and hydration
• The addition of a multivitamin with minerals may be helpful.
Activity
Based on patient's physical condition
SPECIAL THERAPY
Physical Therapy
Occupational therapy consultation may be useful.
MEDICATION (DRUGS)
First Line
• Selective serotonin reuptake inhibitors (SSRIs) are generally effective and safe. (14)[A]
- Fluoxetine (Prozac): 20-80 mg/d PO (most activating of all SSRIs); less expensive (14)[A]
- Sertraline (Zoloft): 50-200 mg/d PO (sedating) (14)[A]
- Paroxetine (Paxil): 20-60 mg/d PO (sedating) (15)[A]
- Citalopram (Celexa): 20-60 mg/d PO (10)[C]
• Tricyclic antidepressants are effective and less expensive. They are lethal in overdose and have unfavorable side effects. (16)[A]
• Bupropion (Wellbutrin): 150-450 mg/d PO in patients with depression plus psychomotor retardation, hypersomnia, and with weight gain. Bupropion is less likely to cause weight gain or sexual dysfunction. It is highly activating. (17)[A]
• Mirtazapine (Remeron): 15-45 mg/d PO qhs. This antidepressant (not an SSRI) helps with sleep restoration and weight gain; no sexual dysfunction (18)[A]
• Venlafaxine (Effexor XR): A dual-action antidepressant that blocks the reuptake of serotonin in doses of up to 150 mg/d and then blocks the reuptake of norepinephrine in doses of 150-450 mg/d PO (18)[A]
• Contraindications to treatment with antidepressants
- Known drug allergy
- Some antidepressants are excreted in breastmilk. Consult with the infants' pediatrician. (1)[D], (13,19)[A]
• Precautions
- Bipolarity requires treatment with mood stabilizer
- Antidepressants generally compatible with lactation. Must consult with pediatrician. For further info see book, Medications and Mothers Milk by Thomas Hale, PhD.
- Avoid tricyclic antidepressants in mothers with a known history of suicide attempts. (19)[A]
• Significant possible drug interactions
- Do not use any previously mentioned antidepressants with any agent in the monoamine oxidase inhibitor class. (9,19)[A]
Second Line
Electroconvulsive therapy (ECT): Some patients who cannot tolerate the antidepressant medication or who are actively engaged in suicidal self-destructive behaviors or who have a previous history of responding favorably to ECT, should be seriously considered for such treatment. (10)[C]
FOLLOW-UP
DISPOSITION
Admission Criteria
Presence of suicidal or homicidal ideation and/or psychotic symptoms and/or thoughts of harming baby (1,8,10)[C]
Discharge Criteria
Absence of suicidal or homicidal ideation and/or psychotic symptoms and/or thoughts of harming baby (8,10)[C]
Issues for Referral
Patient and family should be referred for psychotherapy. Referral for psychiatric follow-up if psychiatric medications are indicated. (20)[C]
PROGNOSIS
Generally good. Improvement is expected within a few months to a year. Some patients, particularly those with undertreated or undiagnosed depression, may develop chronic depression requiring long-term treatment. (12)[C]
COMPLICATIONS
• Suicide
• Self-injurious behavior
• Psychosis
• Neglect of baby
• Harm to the baby (1,8,10)[A]
PATIENT MONITORING
Observe quality and safety of mother's interaction with baby. Home observation and monitoring are helpful. (7)[A]
REFERENCES
1. Seyfried LS, Marcus SM. Postpartum mood disorders. Int Rev Psychiatry. 2003;15:231-242.
2. Georgiopoulos AM, et al. Routine screening for postpartum depression. J Fam Pract. February 2001;50:117-122.
3. Austin MP, Lumley J. Antenatal screening for postnatal depression: A systematic review. Acta Psychiatr Scand. 2003;107:10-17.
4. Holden JM. Postnatal depression: Its nature, effects and identification using the Edinburgh Postnatal Depression Scale. Birth. 1991;18:211-221.
5. Gavin NI, et al. Perinatal depression: A systematic review of prevalence and incidence. Obstet Gynecol. 2005;106:1071-1083.
6. Henshaw C. Mood disturbance in the early puerperium: A review. Arch Women Ment Health. 2003;6(suppl 2):S33-S42.
7. Ogrodniczuk JS, Piper WE. Preventing postnatal depression: A review of research findings. Harvard Rev Psychiatry. 2003;11:291-307.
8. Wisner KL, Parry BL, Piontek CM. Postpartum depression. N Engl J Med. 2002;347:194-199.
9. Stagnaro-Green A. Postpartum thyroiditis. Best Pract Res Clin Endocrinol Metab. 2004 Jun;18(2):303-316.
10. Marcus SM, et al. Treatment guidelines for depression in pregnancy. Int J Gynaecol Obstet. January 2001;72:61-70.
11. O'Hara MW, et al. Efficacy of interpersonal therapy for postpartum depression.Gen Psychiatry. 2000;57:1039-1045.
12. Steinberg SI, Bellavance F. Characteristics and treatment of women with postpartum depression. Int J Psychiatry Med. 1999;20:209-233.
13. Corral MK, Dernetra AK. Bright light therapy's effect on postpartum depression. Am J Psychiatry. 2000;157:303-304.
14. Kulin NA, et al. Pregnancy outcome following maternal use of the new selective serotonin reuptake inhibitors: A prospective controlled multicenter study. J Am Med Assoc. 1996;279:609-61.
15. Patuszak A, et al. Pregnancy outcome following first-trimester. J Am Med Assoc. 1993;269:2246-2248.
16. Stowe ZN, et al. Sertraline and desmethylsertraline in human breast milk and nursing infants. Am J Psychiatry. 1997;269:1255-1260.
17. Kendell RE, Chalmers JC, Platz C. Epidemiology of puerpereal psychoses. Br J Psychiatry. 1987;150:662-673.
18. Glaxo Wellcome. Bupropion pregnancy registry interim report. Research Triangle Park, NC: Glaxo Wellcome; 1999.
19. American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder (revision). Am J Psychiatry. 2000;157:1-45
20. Tammentie T, et al. Family dynamics and postnatal depression. J Psychiatr Ment Health Nursing. 2004;11:141-149.
MISCELLANEOUS
See also: Depression