Postpartum Major Depression

1. See Also
   1. Major Depression
2. Epidemiology
   1. Postpartum Blues: 50-80% of post-partum women
   2. Postpartum Depression: 7-15% of post-partum women (within first 3 months of delivery)
   3. Postpartum Major Depression: 5-7% of post-partum women (within first 3 months of delivery)
   4. Postpartum Psychosis: 1-2 per thousand postpartum women
3. Risks
   1. Postpartum Depression with a prior pregnancy (recurrence in 25-50% of women)
   2. Antepartum Depression
   3. Prior history of Major Depression
   4. Prior history of psychiatric disorder
   5. Lack of Social Support
   6. Emotional stress
   7. Gesational Diabetes
   8. Milgrom (2008) J Affect Disord 108(1-2):147-57
4. Symptoms
   1. Depression lasts >2 weeks (contrast with Postpartum Blues)
   2. Comorbid anxiety and agitation
   3. Most common symptoms
      1. Sadness is less commonly reported than in non-Postpartum Major Depression
      2. Guilt
      3. Worthlessness
      4. Anhedonia
      5. Decreased energy
      6. Difficulty sleeping when the baby is sleeping
   4. High risk symptoms
      1. Intrusive thoughts of hurting the newborn (may present as avoidance of the infant)
      2. Suicidal thoughts
         1. Active Suicidal Ideation with a plan requires emergent psychiatric evaluation
         2. Passive Suicidal Ideation (e.g. no plan, but a wish go to sleep and not wake up) is more common
            1. Risk for progression to active Suicidal Ideation
5. Differential Diagnosis
   1. Baby Blues
      1. Lasts <10 days (contrast with more than 2 weeks for depression)
      2. Onset within a few days of delivery
      3. Mild to no dysfunction (compared with moderate to severe dysfunction in depression)
   2. Bipolar Disorder
   3. Postpartum autoimmune Thyroiditis
6. Evaluation
   1. See Depression Screening Tools
   2. Edinburgh Postnatal Depression Scale
      1. http://www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf
   3. Patient Health Questionaire 9 (PHQ-9)
7. Labs
   1. Thyroid Stimulating Hormone (TSH)
8. Management: Non-medication
   1. Psychotherapy
   2. Consider low dose Estrogen Replacement
      1. Transdermal Estrogen postpartum
   3. Adjust social situation
      1. Longer maternity leave
      2. Return part-time
9. Management: Medications
   1. Women not Breast Feeding
      1. Selective Serotonin Reuptake Inhibitors (SSRI)
   2. Women who are Breast Feeding
      1. Safest agents (undetectable in Breast Milk)
         1. Sertraline (Zoloft)
         2. Paroxetine (Paxil)
         3. Nortriptyline
      2. Agents with acceptably low levels in Breast Milk
         1. Fluoxetine (Prozac)
         2. Citalopram (Celexa)
10. Resources
    1. Patient Education materials form Minnesota Department of Health
       1. http://www.health.state.mn.us/divs/fh/mch/fhv/strategies/ppd/index.html
11. References
    1. Ahokas (2000) J Clin Psychiatry 61:166-9
    2. Hirst (2010) Am Fam Physician 82(8): 926-33
    3. Wisner (2002) N Engl J Med 347(3): 194-99