Postpartum Major Depression

Aka: Postpartum Major Depression, Postpartum Depression, Postpartum Blues, Postnatal Depression, Peripartum Depression, Puerperal Depression, Antidepressants in Lactation, Antidepressants in Breast Feeding

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II. Definitions

  1. Peripartum Depression
    1. Depression during pregnancy or in the 12 months following delivery that lasts longer than 2 weeks
  2. Postpartum Blues
    1. Onset of depressed mood within a few days of delivery
    2. Depressed mood lasts <10 days (contrast with more than 2 weeks for depression)

III. 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

IV. Risk Factors

  1. History of Major Depression is greatest risk factor (OR 29)
    1. Postpartum Depression with a prior pregnancy (recurrence in 25-50% of women)
    2. Antepartum Depression
    3. Prior history of Major Depression
  2. Prior history of other psychiatric disorder (e.g. Anxiety Disorder)
  3. Emotional stress or maternal anxiety
  4. Fear of child birth
  5. History of physical or sexual abuse
  6. Unplanned or Unwanted Pregnancy
  7. Pregnancy complications
    1. Pregnancy loss
    2. Preterm delivery
    3. Traumatic birth
  8. Breast Feeding difficulties
  9. Lack of Social Support
  10. Single parent
  11. Lower socioeconomic status
  12. Gesational Diabetes (or pre-Gestational Diabetes)
  13. Tobacco use
  14. Age extremes
    1. Teen Mothers
    2. Age over 40 years old
  15. References
    1. Milgrom (2008) J Affect Disord 108(1-2):147-57 [PubMed]

V. Symptoms

  1. Depression symptoms last >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
    7. Poor concentration
  4. High risk symptoms (emergent mental health evaluation indications)
    1. Homicidal Thoughts
      1. Intrusive thoughts of hurting the newborn (may present as avoidance of the infant)
    2. Psychosis
      1. Hallucinations
      2. Delusions
      3. Rambling or pressured speech
    3. 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

VI. Labs

  1. Not routinely indicated
  2. Thyroid Stimulating Hormone (TSH)
    1. Consider if indicated by additional findings
  3. Hemoglobin
    1. Consider if not recently obtained postpartum

VII. Diagnosis

  1. See Major Depression Diagnosis
  2. Peripartum Depression
    1. Depression diagnosed during pregnancy or within 12 months postpartum
    2. Persistent symptoms >2 weeks

VIII. 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
    1. Exclude mania
  3. Postpartum autoimmune Thyroiditis

IX. Evaluation: Depression Screening Tools

  1. See Depression Screening Tools
  2. Screening Intervals
    1. AAP: Screen at perinatal visits and Well Child Visits (2, 4 and 6 months)
    2. USPTF: Screen starting in second trimester for those with Peripartum Depression risk factors
    3. Also screen for Suicidality and homicidality
  3. Edinburgh Postnatal Depression Scale
    1. http://www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf
    2. 10 item, free tool, completed in <5 minutes, with good efficacy (>75% sensitive, >76% specific)
    3. Preferred first-line screening for Postpartum Depression over PHQ-9
  4. Patient Health Questionaire 9 (PHQ-9)
    1. Free tool, completed in <5 minutes, with good efficacy (>75% sensitive, 90% specific)
  5. Postpartum Depression Screening Scale (PDSS)
    1. Commercial product with 35 items, available for a fee
    2. Good efficacy (>91% sensitive, >72% specific)

X. Management: Non-Medication

  1. Psychotherapy (esp. Cognitive Behavioral Therapy)
  2. Adjust social situation
    1. Longer maternity leave
    2. Return part-time

XI. Management: Standard Medications

  1. Approach
    1. Typically taper off Antidepressants after 6-12 months of depression remission (esp. if first depression episode)
  2. Women not Breast Feeding
    1. Selective Serotonin Reuptake Inhibitors (SSRI)
  3. Women who are Breast Feeding
    1. Safest agents in Lactation (undetectable in Breast Milk, L2 Risk)
      1. Sertraline (Zoloft) - preferred agent
      2. Paroxetine (Paxil)
        1. Safe in Lactation, but NOT in pregnancy
        2. Teratogenic if patient becomes pregnant again (therefore generally avoided)
    2. Agents with acceptably low levels in Breast Milk (L3 Risk)
      1. Escitalopram (Lexapro) - preferred agent
      2. Citalopram (Celexa)
      3. Venlafaxine (Effexor)
    3. Agents that are safe in Lactation, but excessive sedation or other side effects
      1. Nortriptyline
      2. Mirtazapine (Remeron)
      3. Fluvoxamine (Luvox)
    4. Agents to avoid in Lactation due to infant risks
      1. Fluoxetine (Prozac)
        1. Low levels in milk, but still more adverse effects in infants
        2. Teratogenic if patient becomes pregnant again (therefore generally avoided)
      2. Bupropion
        1. Risk of Seizures in newborns
  4. Avoid ineffective agents or those with insufficient evidence to support
    1. Avoid low dose Estrogen Replacement (also increases VTE Risk)
    2. Insufficient evidence for any supplement (e.g. St John's Wort, Folate, Vitamin D)

XII. Management: Medications for Refractory Postpartum Depression

  1. Zuranolone (Zurzuvae)
    1. Indicated in Postpartum Depression starting in third trimester or first month postpartum
    2. Like IV Brexanolone, mimics Allopregnanolone (GABA Receptor agent), known to decrease peripartum
    3. Schedule IV Controlled Substance
    4. Taken orally with a fatty meal in the evening for 14 days
      1. Started within 12 months of delivery, at a cost of $14,000/course
    5. Adverse effects include drowsiness and confusion
      1. Avoid driving for 12 hours after each dose
      2. Avoid with other CNS Depressants (e.g. Opioids, Alcohol)
    6. Drug Interactions include CYP3A4 Inducers (e.g. Phenytoin)
    7. Unknown safety in Lactation (may cause sedation in the nursing infant)
    8. Avoid in pregnancy (use Contraception)
    9. (2024) Presc Lett 31(2): 10-11
  2. Intravenous Brexanolone (Zulresso)
    1. Mimics Allopregnanolone (GABA Receptor agent) which normally decreases in peripartum period
    2. Intravenous infusion over 60 hours with onset of action by 24-48 hours
    3. Used in addition to standard SSRI agents
    4. Risk of sedation and loss of consciousness (REMS program)
      1. Monitor for excessive sedation and apnea (e.g. Pulse Oximetry)
    5. Schedule IV Controlled Substance
    6. Astronomically expensive ($34,000)
    7. Unknown safety in Lactation
    8. (2019) Presc Lett 26(5)

XIII. Complications

  1. Infant
    1. Failure to Thrive or Growth Faltering
    2. Attachment disorder
    3. Developmental Delay (at one year old)
  2. Mother
    1. Typical Major Depression symptoms (low energy, Insomnia, decreased concentration)
    2. Maternal Suicide
      1. Postpartum Suicide accounts for 20% of postpartum deaths
      2. Second only to Pulmonary Embolism as most common cause of postpartum death

XIV. 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
  2. Mothers and Babies Program (CBT Approach to counseling)
    1. http://www.mothersandbabiesprogram.org/
  3. Reach Out, Stand Strong, Essentials (ROSE) for New Mothers (interpersonal therapy approach to counseling)
    1. Taught as a part of some prenatal classes
    2. {https://www.publichealth.msu.edu/flint-research/the-rose-sustainment-study]

XV. Prevention

  1. See Evaluation above for screening tools
    1. Perform at perinatal visits and Well Child Visits (esp. with risk factors present)
  2. Consider home health visits, peer support for high risk mothers
    1. First-time mothers
    2. Teen Mothers
    3. Traumatic delivery
  3. Counseling is effective and recommended by USPTF in the prevention of perinatal depression for those at risk
    1. See Risk Factors above
    2. Consider starting to screen for risk factors and Peripartum Depression in the second trimester of pregnancy
    3. See Evaluation Tools above for the diagnosis of perinatal depression
    4. Refer for Cognitive Behavioral Therapy (or interpersonal therapy) for those at risk
      1. Also see Resources above (e.g. Mothers and babies, ROSE Program)
  4. Other measures
    1. Single postpartum dose of Esketamine in those at risk for Postpartum Depression reduced risk
      1. Wang (2024) BMJ 385:e078218 [PubMed]

XVI. References

  1. (2017) Presc Lett 24(4): 20
  2. (2019) Am Fam Physician 100(6): 364A-C [PubMed]
  3. Ahokas (2000) J Clin Psychiatry 61:166-9 [PubMed]
  4. Hirst (2010) Am Fam Physician 82(8): 926-33 [PubMed]
  5. Justesen (2023) Am Fam Physician 108(3): 267-72 [PubMed]
  6. Langan (2016) Am Fam Physician 93(10):852-8 [PubMed]
  7. Wisner (2002) N Engl J Med 347(3): 194-99 [PubMed]

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