Postpartum Depression

Background

• Postpartum depression refers to mood disorders, minor depressive symptoms, or unipolar major depressive disorder which occur in the postpartum period (the first 12 months after delivery).
• Incidence of postpartum depression is 6.5%-20% of all postpartum women.
• Risk factors include a personal or family history of perinatal depression or mood or anxiety disorders, adolescence, an antecedent pregnancy which resulted in premature delivery, and residence in an urban area.
• Postpartum depression is thought to occur as a result of a rapid decline in estrogen and progesterone during the postpartum period, triggering mood disorders in susceptible women.
• Major professional organizations recommend screening at least once during the perinatal period (at the comprehensive postpartum visit or at the 2-month well-child visit) with the Edinburgh Postnatal Depression Scale or other validated screening tool.
• For women at high risk of postpartum depression, consider preventive therapy with prenatal and postpartum counselling or psychotherapy, and/or antidepressant medication.

Evaluation

• Postpartum depression is diagnosed clinically. Key diagnostic criteria include anhedonia and a depressed mood.
• Evaluate the patient using a validated depression screening tool, perform mental health assessment for features of major or minor depression, and assess psychosocial history.
• Consider other diagnoses such as postpartum blues, postpartum psychosis, bipolar disorder, and hypo- or hyperthyroidism.
• Consider assessing levels of thyroid-stimulating hormone and free thyroxine to evaluate for thyroid disorders.

Management

• Psychosocial and psychological treatments are often first-line treatments for mild-to-moderate depression.
• Interpersonal therapy or cognitive behavioral therapy may be preferred by women concerned about using pharmacotherapy when breastfeeding.
• Brexanolone (allopregnanolone) is the only medication currently FDA-approved for the treatment of postpartum depression.
• Antidepressant medication may be indicated for postpartum major depression.
  • If the patient has previously responded positively to a specific antidepressant, consider restarting that medication.
  • Selective serotonin reuptake inhibitors should be considered as first-line antidepressant medications for postpartum depression due to relatively low concentrations in breastmilk and limited evidence of adverse effects for breastfed infants.
  • A psychiatric consultation or referral is indicated for patients who have not improved despite 6 weeks of antidepressant use.
• Postpartum depression may be associated with poorer mother-infant bonding and difficulties with breastfeeding.
• Mean duration of untreated depression is about 7 months, but prognosis with appropriate treatment is excellent with full recovery; however, affected women remain at increased risk of further depressive episodes.