Untreated postpartum depression is common affects the health of the woman, infant, and family. Pregnant women should receive information about the signs and symptoms of postpartum depression and its effects. Treatment depends on the severity of symptoms and the level of functional impairment and can include social support, psychological therapy, and pharmacotherapy (generally an SSRI as first-line treatment). A new Clinical Practice article explains further.
• What are some of the risk factors for postpartum depression?
The strongest risk factor for postpartum depression is a history of mood and anxiety problems and, in particular, untreated depression and anxiety during pregnancy. The rapid decline in the level of reproductive hormones after childbirth probably contributes to the development of depression in susceptible women, although the specific pathogenesis of postpartum depression is unknown; in addition to hormonal changes, proposed contributors include genetic factors and social factors including low social support, marital difficulties, violence involving the intimate partner, previous abuse, and negative life events.
• What is the natural course of postpartum depression?
The natural course of postpartum depression is variable. Although it may resolve spontaneously within weeks after its onset, approximately 20% of women with postpartum depression still have depression beyond the first year after delivery, and 13% after 2 years; approximately 40% of women will have a relapse either during subsequent pregnancies or on other occasions unrelated to pregnancy.
Morning Report Questions
Q: How would you evaluate a woman for possible postpartum depression?
A: The best method for detecting postpartum depression remains controversial. Administration of the 10-item Edinburgh Postnatal Depression Scale (EPDS) is recommended by both the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics as a method of identifying possible postpartum depression. The U.S. Agency for Healthcare Research and Quality suggests that serial testing, beginning with the use of a sensitive, two-question screening tool relating to feelings of depression or hopelessness and of a lack of interest or pleasure in activities, followed by the use of a second, more specific instrument for women who give a positive answer to either screening question, may be a reasonable strategy to reduce both false positive and false negative results. The evaluation of women with possible postpartum depression requires careful history taking to ascertain the diagnosis, identify coexisting psychiatric disorders, and manage contributing medical and psychosocial issues. During the process of history taking, special attention should be given to a personal or family history of depression, postpartum psychosis, or bipolar disorder, especially if depression or bipolar disorder had been associated with pregnancy. Coexisting anxiety and obsessive–compulsive symptoms are common among women with postpartum depression and should be investigated further. Women should be asked about social support as well as substance abuse and violence involving an intimate partner. An examination to assess mental status should be conducted, as well as a physical examination if symptoms suggest a medical cause. Laboratory investigations should be performed as indicated; measurement of hemoglobin and thyroid-stimulating hormone levels are generally recommended.
Q: What are some of the antidepressants that are used in women with postpartum depression who are breast-feeding?
A: Although data on long-term child development are limited, in most cases breast-feeding need not be discouraged among women who are taking an antidepressant medication. Selective serotonin reuptake inhibitors (SSRIs) pass into breast milk at a dose that is less than 10% of the maternal dose, and drugs in this class are generally considered to be compatible with breast-feeding of healthy, full-term infants. Despite some variability among SSRIs in terms of their passage into breast milk, switching the antidepressant medication because of lactation is not usually recommended for women who had previously been receiving effective treatment with a given agent, owing to the risk of a relapse of depression. Serotonin norepinephrine reuptake inhibitors (SNRIs) or mirtazapine are commonly used either when SSRIs are ineffective or when a woman has previously had a positive response to these agents since available data also suggest minimal passage into breast milk. Data on safety for these agents remain limited, however, since fewer than 50 cases have been reported in which women who were breast-feeding were taking either SNRIs or mirtazapine.