Postpartum Major Depression

See Also

Major Depression

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

Risk Factors

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
Prior history of psychiatric disorder
Emotional stress or maternal anxiety
Lack of Social Support
Single parent
Lower socioeconomic status
Gesational Diabetes
Fear of child birth
Tobacco use
Age over 40 years old
Milgrom (2008) J Affect Disord 108(1-2):147-57 [PubMed]

Symptoms

Depression lasts >2 weeks (contrast with Postpartum Blues)
Comorbid anxiety and Agitation
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
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

Diagnosis

See Major Depression Diagnosis
Major Depression diagnosed during pregnancy or within 4 weeks postpartum
1. Some experts recommend extending cut-off to one year after delivery

Differential Diagnosis

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)
Bipolar Disorder
Postpartum autoimmune Thyroiditis

Evaluation
Depression Screening Tools

See Depression Screening Tools
AAP recommends screening at perinatal visits and Well Child Visits (2, 4 and 6 months)
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
Patient Health Questionaire 9 (PHQ-9)
1. Free tool, completed in <5 minutes, with good efficacy (>75% sensitive, 90% specific)
2. Test Sensitivity
Postpartum Depression Screening Scale (PDSS)
1. Commercial product with 35 items, available for a fee
2. Good efficacy (>91% sensitive, >72% specific)

Labs

Thyroid Stimulating Hormone (TSH)

Management
Non-medication

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

Management
Medications

Approach
1. Typically taper off Antidepressants after 6-12 months of depression remission (esp. if first depression episode)
Women not Breast Feeding
1. Selective Serotonin Reuptake Inhibitors (SSRI)
Women who are Breast Feeding
1. Safest agents (undetectable in Breast Milk)
  1. Sertraline (Zoloft) - preferred agent
  2. Paroxetine (Paxil)
    1. However, Teratogenic if patient becomes pregnant again (therefore generally avoided)
2. Agents with acceptably low levels in Breast Milk
  1. Escitalopram (Lexapro) - preferred agent
  2. Citalopram (Celexa)
  3. Venlafaxine (Effexor)
3. Agents that are safe, but excessive sedation or other side effects
4. Agents to avoid 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
Refractory Postpartum Depression
1. Intravenous Brexanolone
  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 agebts
  4. Risk of sedation and loss of consciousness (REMS program)
    1. Monitor for eccessive sedation and apnea (e.g. Pulse Oximetry)
  5. Astronomically expensive ($34,000)
  6. Unknown safety in Lactation
  7. (2019) Presc Lett 26(5)
Avoid ineffective agents or those with insufficient evidence to support
1. Avoid low dose Estrogen Replacement (also increases VTE Risk)

Complications

Infant
1. Failure to Thrive
2. Attachment disorder
3. Developmental Delay (at one year old)
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

Resources

Patient Education materials form Minnesota Department of Health
1. http://www.health.state.mn.us/divs/fh/mch/fhv/strategies/ppd/index.html

Prevention

See Evaluation above for screening tools
1. Perform at perinatal visits and Well Child Visits
Consider home health visits, peer support for high risk mothers
1. First-time mothers
2. Teen mothers
3. Traumatic delivery

References