Prevalence

50%-85%

10% of women who give birth

25% of postpartum women with history of major depression—risk further increased with intrapartum onset

50% of postpartum women with history of postpartum depression

0.1%-0.2% of all childbirths

Increased risk with history of bipolar disorder, postpartum psychosis, and/or family history of mood disorders

Risk factors

History of premenstrual dysphoric disorder

History of major depression

Family history of depression

History of major depression

Intrapartum depression

Previous postpartum depression

History of oral contraceptiveassociated dysphoria

Stressful life events

Lack of support from a partner or spouse or others

Unplanned pregnancy

Single

Primiparous

Delivery via cesarean section

About 50% of deliveries associated with no perinatal complications

Course

Beginning first 2-4 d after giving birth, peaking between postpartum days 5-7 and dissipating by the end of the second postpartum week

Resolves spontaneously

Onset within the first 4 weeks

Can begin within days of delivery with mean time to onset 2-3 weeks and a second peak 1-3 months after delivery

Usually episodic, with subsequent episode of symptoms within a year or two after birth

Subsequent pregnancies increase risk of further episodes

Clinical features

Tearfulness, mood lability, some sleep disturbance, irritability, and anxiety

Tearfulness, interpersonal hypersensitivity, sometimes mood lability, excessive anxiety, insomnia (even when the infant is sleeping and not needing attention), anhedonia, sometimes suicidal thoughts and thoughts of harming the baby, feelings of guilt and inadequacy

In rare cases, severe depression may present with psychotic symptoms

Early presentation mimics postpartum blues/depression

Evolves into a delirium-like, disorganized, labile, and psychotic state

Psychotic features include paranoia, delusions (e.g., defective or dead baby), and command auditory hallucinations (e.g., infanticide)

Obsessive concerns about the baby’s health and welfare, including feelings of wanting to harm the baby and/or themselves

Evaluation

Assessment can be aided by using the Edinburgh Postnatal Depression scale (EPDS) Thyroid function should be evaluated as the postpartum period is a time of increased risk for thyroid dysfunction.

Rule out general medical conditions, including thyroid disorders (e.g., postpartum thyroiditis, hypothyroidism), autoimmune disorders, substance use, and endocrine disorders such as Cushing and Sheehan syndrome

Treatment

No aggressive treatment required

Reassurance, support, education

Monitor to ensure symptoms do not persist or evolve into postpartum depression

Psychoeducation, reassurance, support

Individual (cognitive, supportive, interpersonal), group psychotherapy

Psychosocial assistance to decrease stressors

Psychopharmacology

After remission, consider continuing antidepressant medication for 6-12 months, but long term in patients with history of 3 or more episodes

If there is history of postpartum depression, consider prophylactic antidepressant therapy either in the last trimester or immediately after delivery.

Hospitalization

Electroconvulsive therapy

Considered a psychiatric emergency

Acute treatment:

Acute pharmacological treatment with mood stabilizers, antipsychotics, and/or benzodiazepine prn agitation

Be aware of evidence available regarding safety of use during pregnancy and breastfeeding

Electroconvulsive therapy should be considered for refractory postpartum psychosis

Coordinate social support

Pediatrician must monitor infant and get baseline behavior, sleep, and feeding patterns

Indications for hospitalization include mother’s fears of harming her children, obsessive concerns about the child’s safety and well-being, and expressed fears of harming herself and her baby

Chronic management:

Monitor patient carefully when tapering medications to avoid decompensation

Monitor patient for recurrence of symptoms during subsequent pregnancies and consider prophylaxis if indicated

General considerations

More likely to engage in negative parenting behaviors

Older children of depressed mothers may demonstrate behavioral problems, delayed cognitive and linguistic development, and a higher risk for the development of psychiatric problems

Screening postpartum women is critical due to the estimated risk of 5% of women committing suicide and 4% committing infanticide