II. Definitions
- Peripartum Depression
- Depression during pregnancy or in the 12 months following delivery that lasts longer than 2 weeks
- Postpartum Blues
- Onset of depressed mood within a few days of delivery
- Depressed mood lasts <10 days (contrast with more than 2 weeks for depression)
III. Epidemiology
- Postpartum Blues: 50-80% of post-partum women
- Postpartum Depression: 7-15% of post-partum women (within first 3 months of delivery)
- Postpartum Major Depression: 5-7% of post-partum women (within first 3 months of delivery)
- Postpartum Psychosis: 1-2 per thousand postpartum women
IV. Risk Factors
- History of Major Depression is greatest risk factor (OR 29)
- Postpartum Depression with a prior pregnancy (recurrence in 25-50% of women)
- Antepartum Depression
- Prior history of Major Depression
- Prior history of other psychiatric disorder (e.g. Anxiety Disorder)
- Emotional stress or maternal anxiety
- Fear of child birth
- History of physical or sexual abuse
- Unplanned or Unwanted Pregnancy
- Pregnancy complications
- Pregnancy loss
- Preterm delivery
- Traumatic birth
- Breast Feeding difficulties
- Lack of Social Support
- Single parent
- Lower socioeconomic status
- Gesational Diabetes (or pre-Gestational Diabetes)
- Tobacco use
- Age extremes
- Teen Mothers
- Age over 40 years old
- References
V. Symptoms
- Depression symptoms last >2 weeks (contrast with Postpartum Blues)
- Comorbid anxiety and Agitation
- Most common symptoms
- Sadness is less commonly reported than in non-Postpartum Major Depression
- Guilt
- Worthlessness
- Anhedonia
- Decreased energy
- Difficulty sleeping when the baby is sleeping
- Poor concentration
- High risk symptoms (emergent mental health evaluation indications)
- Homicidal Thoughts
- Intrusive thoughts of hurting the newborn (may present as avoidance of the infant)
- Psychosis
- Hallucinations
- Delusions
- Rambling or pressured speech
- Suicidal thoughts
- Active Suicidal Ideation with a plan requires emergent psychiatric evaluation
- Passive Suicidal Ideation (e.g. no plan, but a wish go to sleep and not wake up) is more common
- Risk for progression to active Suicidal Ideation
- Homicidal Thoughts
VI. Labs
- Not routinely indicated
-
Thyroid Stimulating Hormone (TSH)
- Consider if indicated by additional findings
-
Hemoglobin
- Consider if not recently obtained postpartum
VII. Diagnosis
- See Major Depression Diagnosis
- Peripartum Depression
- Depression diagnosed during pregnancy or within 12 months postpartum
- Persistent symptoms >2 weeks
VIII. Differential Diagnosis
- Baby Blues
- Lasts <10 days (contrast with more than 2 weeks for depression)
- Onset within a few days of delivery
- Mild to no dysfunction (compared with moderate to severe dysfunction in depression)
-
Bipolar Disorder
- Exclude mania
- Postpartum autoimmune Thyroiditis
IX. Evaluation: Depression Screening Tools
- See Depression Screening Tools
- Screening Intervals
- AAP: Screen at perinatal visits and Well Child Visits (2, 4 and 6 months)
- USPTF: Screen starting in second trimester for those with Peripartum Depression risk factors
- Also screen for Suicidality and homicidality
-
Edinburgh Postnatal Depression Scale
- http://www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf
- 10 item, free tool, completed in <5 minutes, with good efficacy (>75% sensitive, >76% specific)
- Preferred first-line screening for Postpartum Depression over PHQ-9
-
Patient Health Questionaire 9 (PHQ-9)
- Free tool, completed in <5 minutes, with good efficacy (>75% sensitive, 90% specific)
- Postpartum Depression Screening Scale (PDSS)
- Commercial product with 35 items, available for a fee
- Good efficacy (>91% sensitive, >72% specific)
X. Management: Non-Medication
- Psychotherapy (esp. Cognitive Behavioral Therapy)
- Adjust social situation
- Longer maternity leave
- Return part-time
XI. Management: Standard Medications
- Approach
- Typically taper off Antidepressants after 6-12 months of depression remission (esp. if first depression episode)
- Women not Breast Feeding
- Women who are Breast Feeding
- Safest agents in Lactation (undetectable in Breast Milk, L2 Risk)
- Sertraline (Zoloft) - preferred agent
- Paroxetine (Paxil)
- Agents with acceptably low levels in Breast Milk (L3 Risk)
- Escitalopram (Lexapro) - preferred agent
- Citalopram (Celexa)
- Venlafaxine (Effexor)
- Agents that are safe in Lactation, but excessive sedation or other side effects
- Agents to avoid in Lactation due to infant risks
- Fluoxetine (Prozac)
- Low levels in milk, but still more adverse effects in infants
- Teratogenic if patient becomes pregnant again (therefore generally avoided)
- Bupropion
- Risk of Seizures in newborns
- Fluoxetine (Prozac)
- Safest agents in Lactation (undetectable in Breast Milk, L2 Risk)
- Avoid ineffective agents or those with insufficient evidence to support
- Avoid low dose Estrogen Replacement (also increases VTE Risk)
- Insufficient evidence for any supplement (e.g. St John's Wort, Folate, Vitamin D)
XII. Management: Medications for Refractory Postpartum Depression
-
Zuranolone (Zurzuvae)
- Indicated in Postpartum Depression starting in third trimester or first month postpartum
- Like IV Brexanolone, mimics Allopregnanolone (GABA Receptor agent), known to decrease peripartum
- Schedule IV Controlled Substance
- Taken orally with a fatty meal in the evening for 14 days
- Started within 12 months of delivery, at a cost of $14,000/course
- Adverse effects include drowsiness and confusion
- Avoid driving for 12 hours after each dose
- Avoid with other CNS Depressants (e.g. Opioids, Alcohol)
- Drug Interactions include CYP3A4 Inducers (e.g. Phenytoin)
- Unknown safety in Lactation (may cause sedation in the nursing infant)
- Avoid in pregnancy (use Contraception)
- (2024) Presc Lett 31(2): 10-11
- Intravenous Brexanolone (Zulresso)
- Mimics Allopregnanolone (GABA Receptor agent) which normally decreases in peripartum period
- Intravenous infusion over 60 hours with onset of action by 24-48 hours
- Used in addition to standard SSRI agents
- Risk of sedation and loss of consciousness (REMS program)
- Monitor for excessive sedation and apnea (e.g. Pulse Oximetry)
- Schedule IV Controlled Substance
- Astronomically expensive ($34,000)
- Unknown safety in Lactation
- (2019) Presc Lett 26(5)
XIII. Complications
- Infant
- Failure to Thrive or Growth Faltering
- Attachment disorder
- Developmental Delay (at one year old)
- Mother
- Typical Major Depression symptoms (low energy, Insomnia, decreased concentration)
- Maternal Suicide
- Postpartum Suicide accounts for 20% of postpartum deaths
- Second only to Pulmonary Embolism as most common cause of postpartum death
XIV. Resources
- Patient Education materials form Minnesota Department of Health
- Mothers and Babies Program (CBT Approach to counseling)
- Reach Out, Stand Strong, Essentials (ROSE) for New Mothers (interpersonal therapy approach to counseling)
- Taught as a part of some prenatal classes
- {https://www.publichealth.msu.edu/flint-research/the-rose-sustainment-study]
XV. Prevention
- See Evaluation above for screening tools
- Perform at perinatal visits and Well Child Visits (esp. with risk factors present)
- Consider home health visits, peer support for high risk mothers
- First-time mothers
- Teen Mothers
- Traumatic delivery
- Counseling is effective and recommended by USPTF in the prevention of perinatal depression for those at risk
- See Risk Factors above
- Consider starting to screen for risk factors and Peripartum Depression in the second trimester of pregnancy
- See Evaluation Tools above for the diagnosis of perinatal depression
- Refer for Cognitive Behavioral Therapy (or interpersonal therapy) for those at risk
- Also see Resources above (e.g. Mothers and babies, ROSE Program)
- Other measures
- Single postpartum dose of Esketamine in those at risk for Postpartum Depression reduced risk
XVI. References
- (2017) Presc Lett 24(4): 20
- (2019) Am Fam Physician 100(6): 364A-C [PubMed]
- Ahokas (2000) J Clin Psychiatry 61:166-9 [PubMed]
- Hirst (2010) Am Fam Physician 82(8): 926-33 [PubMed]
- Justesen (2023) Am Fam Physician 108(3): 267-72 [PubMed]
- Langan (2016) Am Fam Physician 93(10):852-8 [PubMed]
- Wisner (2002) N Engl J Med 347(3): 194-99 [PubMed]