Postpartum Depression

Robert Kennedy, Kelley Suttenfield

Robert Kennedy is Editor, Medscape Psychiatry & Mental Health; Kelley Suttenfield is
Assistant Editor, Medscape Psychiatry & Mental Health
Kennedy RS, Suttenfield K. Postpartum Depression. MedGenMed 3(4), 2001 [formerly
published in Medscape Psychiatry & Mental Health eJournal 6(4), 2001]. Available at:
http://www.medscape.com/viewarticle/408688
Postpartum blues, also known as "baby blues," affect approximately 50% to 80%
of new mothers. Symptoms may include mood swings with times of feeling
anxious, irritable, or tearful interspersed with times of feeling well. Sleeping
difficulties may also occur. The symptoms usually begin 3-4 days after delivery,
worsen by days 5-7, and tend to resolve by day 12. For symptoms that last
longer than 2 weeks, it is important for the individual to seek medical attention,
since approximately 1 in 5 women with postpartum blues develop postpartum
major depression.[1]

According to a Medscape Treatment Update on reproductive psychiatry by Misri and

Kostaras,[3] "during pregnancy, depressive symptoms such as changes in sleep and appetite
are often difficult to distinguish from the normal experiences of pregnancy."[4] Although up to
70% of women report experiencing negative mood symptoms during pregnancy, the
prevalence of pregnant women who actually fulfill the diagnostic criteria for major
depression is between 10% and 16%.[5] The course of depression varies throughout
pregnancy; most studies report a symptom peak during the first trimester, improvement
during the second trimester, and an increase again during the third trimester.[6,7]
Several controlled studies have reported that between 12% and 16% of women experience a
postpartum depressive episode,[8] and this rate is as high as 26% in adolescent mothers.[9]
However, there is some disagreement over the defined time frame of the postpartum period.
Although the DSMIV-TR defines PPD as a major depressive episode occurring within 4
weeks of childbirth, other studies of PPD report that symptoms manifest themselves most
often in the 6-12 weeks following delivery,[10] and several researchers have defined the
postpartum period as extending from 6-12 months after the birth. PPD can also be
precipitated by a miscarriage.
Postpartum psychosis is a rare condition that occurs in approximately 1-2 per
1000 women after childbirth.[11,12] The presentation can be dramatic, with onset
as early as the first 48-72 hours postpartum. For the majority of women with
postpartum psychosis, symptoms develop within the first 2 weeks after delivery.
The earliest symptoms are typically restlessness, irritability, and sleep

disturbance. In general, postpartum psychosis evolves rapidly and is

characterized by depressed or elated mood, disorganized behavior, mood lability,
and delusions and hallucinations. [13] Postpartum psychosis of the bipolar type is
characterized by elated mood, disorganized behavior, mood lability, and the
presence of hallucinations or delusions. In extreme cases, the risks of suicide
and/or infanticide are high, thus these women often require hospitalization. [14]

Biological risk factors that contribute to the development of PPD include:

1. A history of depression in previous pregnancies or postpartum period. Women with
previous pregnancy-related depressive episodes are at a 50% to 62% increased risk of
recurrent episodes with subsequent pregnancies.[5]
2. A previous history of depression. Up to 30% of women who have experienced a major
depressive episode prior to conception will develop PPD.[15]
3. A history of depression in blood relatives. The risk of depression is higher with a
positive family history and is greatest if a relative experienced a PPD.[7,8]
4. There are several other psychosocial risk factors that may contribute to a heightened
risk of depression in both pregnancy and the postpartum period. These include poor
social support, adverse life events, marital instability, and ambivalence towards the
pregnancy.[7,8,11,15]
In an often-cited study by Kendall
[11]

concerning affective disorder in the puerperium, a sharp increase in psychiatric admissions

during the first 3 months after delivery was demonstrated. Women at highest risk were those
with a history of a mood disorder or those who experienced depression during pregnancy.
There are many factors that may contribute to the increase in pregnancyassociated affective syndromes. Hormonal factors play a major role in influencing
central nervous functioning. Women who develop PPD may be particularly
sensitive to the marked hormonal changes associated with the pregnancy. Of
course, other factors are also important such as genetics, socioeconomic issues,
stress, and emotional support system for the new mother. [1,2]

The criteria used to diagnose depression is the same in postpartum states. In addition to these
criteria, other symptoms may include fear or feelings of guilt about being a "bad" mother, or
possibly extreme fear that some harm will come to the baby. These thoughts help distinguish
postpartum from other kinds of depression (Table 1).
Women with postpartum major depressive episodes may also have severe anxiety, panic
attacks, spontaneous crying long after the usual duration of "baby blues" (ie, 3-7 days

postpartum), disinterest in the new infant, and insomnia (manifested as difficulty falling
asleep).
When assessing whether a symptom is a sign of depression or a normal postpartum reaction,
the individual's circumstances need to be considered. A woman's level of exhaustion or
irritability may be quite normal when her infant is 2 weeks old and nursing frequently, but
may not be normal when her baby is 4 months old and sleeping soundly through the night.
Sleep deprivation can cause fatigue and poor concentration, but the degree of these symptoms
needs to be carefully assessed.
Although there are a number of rating scales for depression, one that has been validated in the
postpartum population is the Edinburgh Postnatal Depression Scale (EPDS) (Table 2).[17] A
new instrument called the Postpartum Depression Screening Scale (PDSS)[18,19] also shows
promise as a screening tool.
Less severe presentations of depressive illness are often missed and frequently dismissed by
patients and healthcare professionals as normal after childbirth. It is generally advised that
screening for postpartum affective disorders should become routine. The suggested ideal time
to screen is at the standard postpartum medical visit at 6 weeks and at subsequent pediatric
visits.[2]
Treatment of PPD generally depends on the type and severity of the symptoms. With
postpartum blues, additional emotional support or extra help caring for the newborn may be
the only intervention necessary. Patient education is important and women should be directed
to contact their physicians if symptoms persist beyond the second postpartum week. If
symptoms persist or become more severe then professional treatment may be warranted. In
mild cases in which the depression does not interfere with the mother's functioning,
psychotherapy may be of benefit. If the symptoms are of a more severe major depression then
carefully selected antidepressant medication may be needed and this should be combined
with counseling and support as well.
As in non-postnatal depression, there is great variability in the type of symptoms as well as in
the intensity of depressed mood. Treatment should be guided by these parameters as well as
the degree of functional impairment.
In general, there are too few studies on the most effective treatment of PPD, and "postpartum
major depression demands the same course of treatment as nonpuerperal major depression."[2]
There is a tendency to treat women with PPD less intensely than those with non-pregnancyrelated affective episodes. The dose of medication may be suboptimal or the duration of
treatment too short. Women who are breastfeeding must be informed that all psychotropic
medications, including antidepressants, are secreted in the breast milk at varying
concentrations.[20] "Data do not suggest that one antidepressant is safer than another for
women who breastfeed. Choices of medications should be based as usual on prior response to
antidepressants and side effect profile."[2]

Some studies have suggested that progesterone and estrogen may be effective agents for
treatment of PPD.[21,22] These studies are preliminary, however, and additional research is
required to clarify these issues. Also, for severe depression in which medication is either not
an option or problematic, electroconvulsive treatment may be a viable alternative.
It is estimated that approximately 40% of births occurring annually in the United States are
complicated by some form of postpartum mood disorder.[10] Since "baby blues" are estimated
to occur after 40% to 80% of deliveries, both practitioners and patients tend to view this as a
"normal" phenomenon.[23] Postpartum disorders occur on a spectrum from mild to severe.
Between these 2 extremes is PPD, a major depression that is unique and can become a serious
complication following childbirth. Unfortunately, many of these patients suffer from PPD for
more than 6 months and, if untreated, approximately 25% are still depressed after 1 year.[21]
Awareness of the impact of these disorders is only the beginning, and attention needs to be
directed toward prevention. The traditional "wait and see" attitude may be appropriate for
women with postpartum blues or those who have low risk, but women with high-risk factors
need to be educated and closely monitored by their physician and healthcare professionals.
Prophylactic treatments such as psychotherapy, counseling, and support groups could make a
significant difference in the well-being of the mother, the child, and the family.
The editors of Medscape Psychiatry have put together a collection of resources (see sidebar
for Related Resources) with clinicians and consumers in mind. Included are links to
organizations such as the National Women's Health Information Center, Postpartum Support
International, as well as related Medscape articles.