Postpartum Depression

The Diagnostic and Statistical Manual of Mental Disorders (i.e., DSM-IV) does not list postpartum psychiatric disorders separately but instead uses a specifier, for example, “with postpartum onset” to describe any depressive, manic, or mixed episode (in major depressive disorder, bipolar disorder, or brief psychotic disorder) when the episode occurs within the first 4 weeks after delivery. Although risk of postpartum psychiatric illness is the highest in the first 4 weeks after childbirth, several different studies indicate that women remain at very high risk for affective illness during the first 3 months after delivery. In fact, women remain at heightened risk up to 1 year after childbirth. Thus many experts define postpartum psychiatric illness as any episode occurring within the first year after childbirth.

POSTPARTUM BLUES

During the first week after the birth of a child, many women experience a brief period of affective instability, commonly referred to as postpartum blues or the “baby blues.” Given the high prevalence of this type of mood disturbance, it may be more accurate to consider the blues as a normal experience associated with childbirth rather than a psychiatric disorder. Women with postpartum blues report a variety of symptoms, including a rapidly fluctuating mood, tearfulness, irritability, and anxiety. These symptoms typically peak on the fourth or fifth day after delivery and may last for a few days, remitting spontaneously within 2 weeks of delivery.

POSTPARTUM DEPRESSION

Ten to 15 percent of women will present with more significant depressive symptoms or postpartum depression after childbirth. Unlike the blues, PPD is more pervasive and may significantly interfere with a mother’s ability to function and to care for her child. Clinically, an episode of PPD is indistinguishable from other types of major depressive episodes, with symptoms of depressed mood, irritability, loss of interest in their usual activities, sleep disturbance, and fatigue. Women often express ambivalent or negative feelings toward their infant and may express doubts about their ability to care for their child. Anxiety symptoms may be prominent in this population, and women may present with comorbid generalized anxiety, panic disorder, or obsessive-compulsive disorder (OCD).

POSTPARTUM PSYCHOSIS

This is the most severe form of postpartum psychiatric illness. It is a rare event that occurs in approximately 1 to 2 of 1000 women after childbirth. Its presentation is often dramatic, with onset of symptoms early, typically within the first 2 postpartum weeks. Longitudinal studies indicate that most women with postpartum psychosis suffer from bipolar disorder, and the symptoms of postpartum psychosis most closely resemble those of a rapidly evolving manic or mixed episode. The earliest signs are restlessness, irritability, and insomnia, followed by a rapidly shifting depressed or elated mood, disorientation or confusion, and disorganized behavior. Delusional beliefs are common and often center on the infant.

TREATMENT

Because the blues are typically mild and resolve on their own, no specific treatment is required. The treatment of postpartum depression depends on its severity. Milder cases may respond to psychotherapy, whereas more severe depressive symptoms are best treated with a combination of psychotherapy and medication. In this setting, selective serotonin reuptake inhibitor (SSRI) antidepressants are used most commonly because they are effective for both depression and anxiety and are compatible with breastfeeding. Postpartum psychosis is a psychiatric emergency and typically requires hospitalization. Symptoms are treated with a combination of antipsychotic medications, benzodiazepines, and mood stabilizers. Electroconvulsive therapy (ECT) may be helpful for treating psychosis or severe postpartum depression.

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