Postpartum Depression: So Common, Yet So Commonly Missed

Background

Quick facts: 

Risk factors for PPD: 

  • Personal history of depression or anxiety
  • Young maternal age
  • Lack of support
  • Lower socioeconomic class
  • Unintended pregnancy
  • Family history of perinatal mood and anxiety disorder
  • Alcohol or substance use
  • NICU stay, birthing complications, difficulties with breastfeeding

Clinical significance of PPD: 

  • Impairs the relationship bond between mother and child
    • Missed feeding cues, fussier babies, withdrawn mother, difficulty with feeding/sleeping schedule
  • Decreased rate of breastfeeding
  • Decreased interest in caring for the baby
  • Missed well child and preventative visits, increased frequency of ED/sick visits
  • Decreased ability to use the anticipatory guidance recommended by PCPs
  • Increased risk of behavioral and mood disorders in the child
  • Increased risk of domestic abuse and child neglect

Diagnosis: DSM-5

The diagnostic criteria for PPD are the same criteria that are used to diagnose major depression. In clinical practice, the term PPD is used to describe depression that begins within 12 months of childbirth. However, PPD is not a separate diagnosis in the DSM-5; instead, patients are diagnosed with major depression along with the specifier “with peripartum onset” for episodes that arise within 4 weeks postpartum. For episodes of postpartum depression that present more than four weeks after delivery, no modifier is available in DSM-5.

The DSM-5 also notes the following:

  • 50% of “postpartum” major depressive episodes actually begin prior to delivery. Thus, these episodes are referred to collectively as peripartum episodes. Women with peripartum major depressive episodes often have severe anxiety and even panic attacks.

Postpartum Blues & Psychosis

Postpartum blues (maternity blues or baby blues) refer to a transient condition characterized by several mild depressive symptoms such as sadness, crying, irritability, anxiety, insomnia, exhaustion, and decreased concentration, as well as mood lability that may include elation. Symptoms typically develop within two to three days of delivery, peak over the next few days, and resolve within two weeks of onset.

The clinical picture of postpartum psychosis includes rapid onset of psychotic symptoms including hallucinations and delusions, bizarre behavior, confusion, and disorganization that may appear to be delirium. Postpartum psychosis constitutes a medical emergency and generally requires rapid intervention and hospitalization, as well as a comprehensive medical evaluation and psychiatric management.

The DSM-5 also notes the following: 

  • Prospective studies have demonstrated that mood and anxiety symptoms during pregnancy, as well as the “baby blues,” increase the risk for a postpartum major depressive episode.
  • Peripartum-onset mood episodes can present either with or without psychotic features. Infanticide is most often associated with postpartum psychotic episodes that are characterized by command hallucinations to kill the infant or delusions that the infant is possessed, but psychotic symptoms can also occur in severe postpartum mood episodes without such specific delusions or hallucinations.
  • Postpartum mood (major depressive or manic) episodes with psychotic features appear to occur in from 1 in 500 to 1 in 1000 deliveries and may be more common in primiparous women.
  • The risk of postpartum episodes with psychotic features is particularly increased for women with prior postpartum mood episodes but is also elevated for those with a prior history of depressive or bipolar disorder (especially bipolar 1 disorder) and those with a family history of bipolar disorders.
  • Once a woman has had a postpartum episode with psychotic features, the risk of recurrence with each subsequent delivery is between 30 and 50%. Postpartum episodes must be differentiated from delirium occurring in the postpartum period, which is distinguished by a fluctuating level of awareness or attention. The postpartum period is unique with respect to the degree of neuroendocrine alterations and psychosocial adjustments, the potential impact of breast-feeding on treatment planning, and the long-term implications of a history of postpartum mood disorder on subsequent family planning.


Screening

The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item self-report questionnaire that identifies patients at risk for perinatal depression, but is not diagnostic on its own. 

An abbreviated version of the EPDS known as the EPDS-3 is also available, and may have higher sensitivity, although more data is needed. 


Management

  1. Consult psychiatry in presence of features suggesting psychosis
    • Rhode Island Maternal Psychiatry Resource Network (RI MomsPRN): 401-430-2800 (consultation service for providers only)
  2. Consider psychotherapy
    • Interpersonal, CBT, and psychodynamic therapy have similar efficacy rate
  3. Consider pharmacologic therapy
    • SSRIs
    • TCAs: limited data except for nortriptyline
    • Omega-3 fatty acids: controversial
  4. Discuss infant feeding goals and consider lactation consultant
  5. Discuss additional resources–there are many!

Pro tip: Check out the shared dot phrase for the above resources (.MPPCCPostpartumDepressionResources)


Blog post based on Med-Peds Forum talk by Madeleine Ward, PGY2