eMedicine Specialties > Obstetrics and Gynecology > Obstetrical Complications

Postpartum Depression

Author: Ruta M Nonacs, MD, PhD, Associate Director of the Perinatal Psychiatry Clinical Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School
Contributor Information and Disclosures

Updated: Dec 4, 2007

Background

During the postpartum period, up to 85% of women experience some type of mood disturbance. For most women, symptoms are transient and relatively mild (ie, postpartum blues); however, 10-15% of women experience a more disabling and persistent form of mood disturbance (eg, postpartum depression, postpartum psychosis).

Postpartum psychiatric illness was initially conceptualized as a group of disorders specifically linked to pregnancy and childbirth and thus was considered diagnostically distinct from other types of psychiatric illness. More recent evidence suggests that postpartum psychiatric illness is virtually indistinguishable from psychiatric disorders that occur at other times during a woman's life.

Although effective nonpharmacologic and pharmacologic treatments are available, both patients and their caregivers frequently overlook postpartum depression. Untreated postpartum affective illness places both the mother and infant at risk and is associated with significant long-term effects on child development and behavior; therefore, prompt recognition and treatment of postpartum depression are essential for both maternal and infant well-being.

Postpartum Blues

• Up to 85% of women experience postpartum affective instability.
• Rapidly fluctuating mood, tearfulness, irritability, and anxiety are common symptoms.
• Symptoms peak on the fourth or fifth day after delivery and last for several days, but they are generally time-limited and spontaneously remit within the first 2 postpartum weeks.
• Symptoms do not interfere with a mother's ability to function and to care for her child.
• Women with more severe symptoms or symptoms persisting longer than 2 weeks should be screened for postpartum depression.

Postpartum Psychosis

• Postpartum psychosis is the most severe form of postpartum psychiatric illness.
• The condition is rare and occurs in approximately 1-2 per 1000 women after childbirth.
• At highest risk are women with a personal history of bipolar disorder or a previous episode of postpartum psychosis.
• Postpartum psychosis has a dramatic onset, emerging as early as the first 48-72 hours after delivery. In most women, symptoms develop within the first 2 postpartum weeks.
• The condition resembles a rapidly evolving manic or mixed episode with symptoms such as restlessness and insomnia, irritability, rapidly shifting depressed or elated mood, and disorganized behavior.
• The mother may have delusional beliefs that relate to the infant (eg, baby is defective or dying, infant is Satan or God), or she may have auditory hallucinations that instruct her to harm herself or her infant.
• Risks for infanticide and suicide are high among women with untreated postpartum psychosis.

Screening for Postpartum Mood Disorders

• Despite multiple contacts with medical professionals during the postpartum period, patients and their caregivers often overlook postpartum affective illness. Too often, postpartum depression is dismissed as a normal or natural consequence of childbirth.
• Women commonly report the persistence of depressive symptoms for many months before the initiation of treatment. Although symptoms of depression may remit spontaneously, many women are still depressed one year after childbirth.
• Predicting who is at risk for postpartum psychiatric illness is difficult. Individuals at greatest risk often have a prior history of postpartum depression or psychosis, personal or family history of mood disorder, or depression during the current pregnancy. Other risk factors include inadequate social supports, marital dissatisfaction or discord, and recent negative life events such as a death in the family, financial difficulties, or loss of employment.
• Screening of all mothers during the postpartum period is indicated.
• Screening women for depressive symptoms during pregnancy may also help to identify those women at higher risk for postpartum depression.
• The Edinburgh Postnatal Depression Scales¹ is a 10-item self-rated questionnaire used extensively for detection of postpartum depression. A score of 12 or more on EPDS or an affirmative answer on question 10 (presence of suicidal thoughts) requires more thorough evaluation. The EPDS may be included in routine well-baby and pediatric visits.

Treatment

Postpartum blues

• Postpartum blues is typically mild in severity and resolves spontaneously.
• No specific treatment is required, other than support and reassurance.
• Further evaluation is necessary if symptoms persist more than 2 weeks.

Postpartum depression

• Postpartum depression manifests along a continuum; some patients may experience relatively mild or moderate symptoms, or they may present with a more severe form of depression, characterized by prominent neurovegetative symptoms and marked impairment of functioning.
• Exclude medical causes for mood disturbance (eg, thyroid dysfunction, anemia). Initial evaluation includes a thorough medical history, physical examination, and routine laboratory tests.
• The severity of illness should guide treatment.
• Nonpharmacologic treatment strategies are useful for women with mild-to-moderate depressive symptoms. Individual or group psychotherapy (cognitive-behavioral and interpersonal therapy) are effective. Psychoeducational or support groups may also be helpful. These modalities may be especially attractive to mothers who are nursing and who wish to avoid taking medications.
• Pharmacologic strategies are indicated for moderate-to-severe depressive symptoms or when a woman does not respond to nonpharmacologic treatment. Medication may also be used in conjunction with nonpharmacologic therapies.
  • Selective serotonin reuptake inhibitors (SSRIs) are first-line agents and are effective in women with postpartum depression. Use standard antidepressant dosages, eg, fluoxetine (Prozac) 10-60 mg/d, sertraline (Zoloft) 50-200 mg/d, paroxetine (Paxil) 20-60 mg/d, citalopram (Celexa) 20-60 mg/d, or escitalopram (Lexapro) 10-20 mg/d. Adverse effects of this drug category include insomnia, jitteriness, nausea, appetite suppression, headache, and sexual dysfunction.
  • Serotonin-norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine (Effexor) 75-300 mg/d or duloxetine (Cymbalta) 40-60 mg/d, are also highly effective for depression and anxiety.
  • Tricyclic antidepressants (eg, nortriptyline 50-150 mg/d) may be useful for women with sleep disturbance, although some studies suggest that women respond better to the SSRI drug category. Adverse effects of the tricyclic antidepressants include sedation, weight gain, dry mouth, constipation, and sexual dysfunction.
  • Typically, symptoms start to diminish in 2-4 weeks. A full remission may take several months. In partial responders, increasing the dosage may be helpful.
  • Anxiolytic agents such as lorazepam and clonazepam may be useful as adjunctive treatment in patients with anxiety and sleep disturbance.
  • Preliminary data suggest that estrogen, alone or in combination with an antidepressant, may be beneficial; however, antidepressants remain the first line of treatment.
• If this is the first episode of depression, 6-12 months of treatment is recommended. For women with recurrent major depression, long-term maintenance treatment with an antidepressant is indicated.
• Inadequate treatment increases the risk of morbidity in both mother and infant.
• Earlier initiation of treatment is associated with better prognosis.
• Inpatient hospitalization may be necessary for severe postpartum depression.
• Electroconvulsive therapy (ECT) is rapid, safe, and effective for women with severe postpartum depression, especially those with active suicidal ideation.

Puerperal psychosis

• Puerperal psychosis is a psychiatric emergency that typically requires inpatient treatment.
• Most patients with postpartum psychosis have bipolar disorder. Acute treatment includes a mood stabilizer (eg, lithium, valproic acid, carbamazepine) in combination with antipsychotic medications and benzodiazepines.
• ECT (often bilateral) is well tolerated and rapidly effective.
• Risk of suicide is significant in this population.
• Rates of infanticide associated with untreated puerperal psychosis are as high as 4%.

Special Concerns

Breastfeeding and psychotropic medications

• Women who plan to breastfeed must be informed that all psychotropic medications, including antidepressants, are secreted into breast milk. Concentrations in breast milk vary widely.
• Data on the use of tricyclic antidepressants, fluoxetine, sertraline, and paroxetine during breastfeeding are encouraging, and serum antidepressant levels in the breastfed infant are either low or undetectable. Reports of toxicity in breastfed infants are rare, although the long-term effects of exposure to trace amounts of medication are not known.
• Infant serum blood levels of antidepressants are not typically obtained unless the question of toxicity in the infant arises.
• Women treated with valproic acid and carbamazepine should avoid breastfeeding because these agents have been associated with hepatotoxicity in the infant.
• Breastfeeding in women treated with lithium should be pursued with caution because lithium is secreted at high levels in breast milk and may cause significant toxicity in the nursing infant. If the breastfed infant is exposed to lithium in the breast milk, periodic monitoring of lithium levels and thyroid function is indicated.
• Avoid breastfeeding in premature infants or in those with hepatic insufficiency who may have difficulty metabolizing medications present in breast milk.

Prevention of postpartum psychiatric illness

• Women at high risk for postpartum illness should be identified prior to delivery.  This includes women with a prior episode of postpartum illness and women with histories of either unipolar or bipolar depression.  Women who experience depression during pregnancy should also be considered at high risk for postpartum illness. 
• In addition to monitoring, women with a history of recurrent depression or a history of postpartum depression may benefit from prophylactic treatment with an antidepressant medication. If antidepressants are not used during pregnancy, they may be initiated shortly before or immediately after delivery to reduce the risk of recurrent illness.
• Women with bipolar disorder or a history of postpartum psychosis may benefit from prophylactic treatment with lithium, initiated either prior to or within 24 hours of delivery.
• The prophylactic efficacy of nonpharmacologic interventions in this setting has not been fully assessed, although one study reported lower rates of postpartum depression in a group of women receiving interpersonal therapy for depression during pregnancy.

Impact of postpartum depression on child development

• A large body of literature suggests that a mother's attitude and behavior toward her infant significantly affect mother-infant bonding and infant well-being and development. Postpartum depression may negatively affect these mother-infant interactions.
• Mothers with postpartum depression are more likely to express negative attitudes about their infant and to view their infant as more demanding or difficult. Depressed mothers exhibit difficulties engaging the infant, either being more withdrawn or inappropriately intrusive, and more commonly exhibit negative facial interactions. These early disruptions in mother-infant bonding may have a profound impact on child development.
• Children of mothers with postpartum depression are more likely than children of nondepressed mothers to exhibit behavioral problems (eg, sleep and eating difficulties, temper tantrums, hyperactivity), delays in cognitive development, emotional and social dysregulation, and early onset of depressive illness.

Pathophysiology

• Hormonal factors
  • Levels of estrogen, progesterone, and cortisol fall dramatically within 48 hours after delivery.
  • Women with postpartum depression do not differ significantly from nondepressed women with regard to levels of estrogen, progesterone, prolactin, and cortisol or in the degree to which these hormone levels change; however, affected individuals may be abnormally sensitive to changes in the hormonal milieu and may develop depressive symptoms when treated with exogenous estrogen or progesterone.
• Psychosocial factors
  • Women who report inadequate social supports, marital discord or dissatisfaction, or recent negative life events are more likely to experience postpartum depression.
  • No consistent association between obstetric factors and risk for postpartum depression is apparent.
• Biologic vulnerability
  • Women with prior history of depression or family history of a mood disorder are at increased risk for postpartum depression.
  • Women with a prior history of postpartum depression or psychosis have up to 90% risk of recurrence.

Conclusion

Postpartum psychiatric illness consists of a highly prevalent group of disorders that affect women during the childbearing years. While postpartum blues is typically benign and self-limited, postpartum depression and postpartum psychosis cause significant distress and dysfunction. Despite multiple contacts with medical professionals during the postpartum period, puerperal mood disorders are frequently missed, and many women go without treatment.

Untreated mood disorders place the mother at risk for recurrent disease. Furthermore, maternal depression is associated with long-term cognitive, emotional, and behavioral problems in the child. One of the most important objectives is to increase awareness across the spectrum of health care professionals who care for women during pregnancy and the puerperium so that postpartum mood disorders may be identified early and treated appropriately. Effective pharmacologic and nonpharmacologic therapies are available.

For excellent patient education resources, visit eMedicine's Depression Center. Also, see eMedicine's patient education articles Depression and Postpartum Depression.

Keywords

puerperal depression, postpartum blues, baby blues, postnatal depression, puerperal psychosis, infanticide, suicide, postpartum affective illness, postpartum psychosis, postpartum affective instability, Edinburgh Postnatal Depression Scale, EPDS, electroconvulsive therapy, ECT, puerperal mood disorders

• Search for CME/CE on This Topic »

• Normal and Abnormal Puerperium (Obstetrics and Gynecology)
• Psychosocial and Environmental Pregnancy Risks (Obstetrics and Gynecology)

• Depression Center
• Postpartum Depression Causes
• Postpartum Depression Treatment
• Depression Overview
• Postpartum Depression Overview
• Postpartum Depression Symptoms

• Pediatric NPs May Help Identify Postpartum Depression: An Expert Interview With June Andrews Horowitz, PhD, RN, CNS-BC, FAAN
• Quick Screening Tools May Help Identify Postpartum Depression
• Relief of Postpartum Depression Also Improves Sexual Dysfunction

• Three-Item Questionnaire Effectively Identifies Postpartum Depression?
• Postpartum Depression: Racial Differences and Ethnic Disparities in a Tri-Racial and Bi-Ethnic Population
• Functional Status Outcomes in Mothers With and Without Postpartum Depression

• Depression Resource Center