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Depression, Postpartum

Basics

  • Major depressive disorder onset or recurrence in the postpartum period (first 12 weeks postpartum, but can occur up to 1 year).
  • Differs from postpartum “blues” which resolve within 10 days postpartum.
  • Symptoms similar to major depression: sleep disturbances, anhedonia, psychomotor changes.

Epidemiology

  • Incidence: 9–14% of postpartum women affected.

  • 50% enter pregnancy depressed or develop symptoms during pregnancy.

Etiology and Pathophysiology

  • Multifactorial: hormonal fluctuations (estrogen, progesterone), neuroactive steroids, cytokines, HPA axis changes, oxytocin, vasopressin.
  • Genetic and epigenetic factors.
  • Psychosocial stressors and biologic predisposition.

Risk Factors

  • Prior PPD, history of MDD or anxiety during pregnancy.
  • Premenstrual dysphoria, family history of depression.
  • Poor pregnancy outcomes (preterm, stillbirth, neonatal death).
  • Substance use, unplanned pregnancy, psychosocial stressors, lack of social support, intimate partner violence.
  • Young maternal age, multiple births.
  • Higher rates in African American and Hispanic women.
  • Postpartum pain, fatigue, sleep disturbances.
  • Recent immigration, adverse childhood experiences.
  • Decrease or cessation of antidepressants during pregnancy.

Prevention

  • Universal depression screening during pregnancy and postpartum using validated tools.
  • Psychotherapy (CBT, IPT) effective in prevention in at-risk women.
  • SSRIs (sertraline) may reduce PPD incidence in high-risk women.

Commonly Associated Conditions

  • Bipolar disorder, dysthymia, cyclothymic disorder, postpartum blues.

Diagnosis

History

  • Depressed mood, anhedonia, guilt, low self-esteem.
  • Sleep changes, energy decrease, poor concentration.
  • Psychomotor agitation or retardation.
  • Suicidal ideation.

Differential Diagnosis

  • Postpartum blues (resolves within days).
  • Postpartum psychosis (psychiatric emergency).
  • Postpartum anxiety, OCD.
  • Hypothyroidism/postpartum thyroiditis.
  • Bipolar disorder.

Diagnostic Tests

  • Labs usually not required; consider CBC, TSH, B12 based on history.
  • Urine analysis, drug screen if indicated.
  • Edinburgh Postnatal Depression Scale (>11 positive).
  • PHQ-9 screening.
  • Partner version of Edinburgh scale for additional insight.

Treatment

General Measures

  • Assess suicidality, homicidal ideation, psychosis.
  • Hospitalize if safety risks present.
  • Psychotherapy first line in mild depression.
  • Pharmacotherapy for moderate to severe symptoms.
  • Outpatient combined psychotherapy and medication may be beneficial.

Medications

  • Nonbreastfeeding: SSRIs (sertraline, fluoxetine, escitalopram, citalopram), SNRIs (venlafaxine, duloxetine), atypical antidepressants (bupropion, mirtazapine), TCAs (nortriptyline).
  • Avoid paroxetine during pregnancy due to fetal risk.
  • Breastfeeding: sertraline and paroxetine preferred (lowest milk transfer).
  • Avoid fluoxetine, citalopram, venlafaxine during breastfeeding.
  • Start low doses and titrate slowly; minimize polypharmacy.
  • Continue efficacious medication rather than switching if stable.
  • Discuss risks/benefits with patient and partner.

Second Line

  • Switch antidepressants or augment in treatment-resistant PPD.
  • Electroconvulsive therapy for severe or refractory cases.

Additional Therapies

  • CBT and interpersonal therapy effective.
  • Psychoeducation, listening visits, psychodynamic therapy helpful.
  • Brexanolone (FDA-approved IV infusion for severe PPD; costly, limited availability; monitor sedation and consciousness).

Complementary & Alternative Medicine

  • Breastfeeding benefits maternal mood.
  • Infant massage, sleep interventions, exercise, light therapy may help.

Inpatient Care

  • Indicated for suicidality, psychosis, infanticide risk, inability to care for self/infant, severe weight loss.

Ongoing Care

  • Collaborative care model with primary care and infant’s physician.
  • Monitor maternal and infant well-being.

Diet

  • Emphasize good nutrition and hydration during breastfeeding.
  • Multivitamin and omega-3 fatty acid supplementation have mixed evidence.

Patient Education

  • Resources: Postpartum Support International, La Leche League, Center for Women’s Mental Health.
  • Book: This Isn’t What I Expected by Kleiman and Raskin.

Prognosis

  • Treatment remission improves child mental health outcomes.
  • Untreated or undertreated depression may become chronic.
  • Untreated PPD linked to poor mother-infant bonding and developmental delays.
  • Postpartum psychosis linked to suicide and infanticide.

Complications

  • Suicide, self-harm.
  • Infant neglect or harm.
  • Preterm birth and low birth weight.

ICD10 Codes:
- F53 Puerperal psychosis
- O90.6 Postpartum mood disturbance

Clinical Pearls:
- Universal screening in pregnancy and postpartum recommended.
- Early diagnosis and treatment reduce long-term morbidity.
- Psychotherapy effective for mild/moderate PPD; medication strongly indicated for severe cases.
- Antidepressants generally safe during pregnancy and lactation, individualized per patient.