Postpartum Depression: Diagnostic and Treatment Issues PDF

Women’s Health Postpartum Depression: Diagnostic and Treatment Issues Verinder Sharma, MBBS,1,2,3 Priya Sharma, HBHSc4 1 Department of Psychiatry, University of Western Ontario, London ON 2 Department of Obstetrics and Gynaecology, University of Western Ontario, London ON 3 Consultant P...

Women’s Health Postpartum Depression: Diagnostic and Treatment Issues Verinder Sharma, MBBS,1,2,3 Priya Sharma, HBHSc4 1 Department of Psychiatry, University of Western Ontario, London ON 2 Department of Obstetrics and Gynaecology, University of Western Ontario, London ON 3 Consultant Psychiatrist, Women’s Clinic, London Health Sciences Centre, London ON 4 Wyckoff Heights Medical Center, Brooklyn, New York NY Abstract INTRODUCTION C Postpartum depression is the most common psychiatric complication hildbirth can trigger a variety of psychiatric illnesses of child-bearing. Despite the potentially deleterious effects of postpartum depression on the mother and her infant, the disorder including mood disorders. The term “postpartum is often unrecognized and untreated. Women may be reluctant to mood disorders” generally refers to the baby blues, seek professional help because of the stigma of mental illness, or postpartum depression, and puerperal psychosis. The baby they may be unwilling to try medication because of concerns about safety during lactation. In this review of postpartum depression, we blues affect 30% to 75% of women shortly after childbirth, discuss its clinical presentation, diagnosis, differential diagnosis, and with symptoms of mood lability, tearfulness, anxiety, treatment. insomnia, and irritability. Because of the mild and transient nature of symptoms, no treatment is required; however, Résumé the blues may sometimes be the early manifestation of postpartum depression or puerperal psychosis. Puerperal La dépression postpartum est la complication psychiatrique la plus psychosis, on the other hand, is a rare condition (1 in 500 courante de l’accouchement. Malgré les effets potentiellement délétères de la dépression postpartum sur la mère et son to 1000 deliveries) but serious because of its association enfant, ce trouble passe souvent inaperçu et demeure non with maternal suicide and infanticide.1 traité. Les femmes peuvent hésiter à chercher à obtenir une aide professionnelle en raison de la stigmatisation qui entoure Postpartum depression is the most common psychiatric la maladie mentale; il est également possible qu’elles ne soient complication of childbirth, affecting 10% to 15% of pas disposées à faire l’essai de médicaments en raison de préoccupations au sujet de leur innocuité pendant l’allaitement. women who have recently given birth.2 If left untreated, Dans le cadre de cette analyse de la dépression postpartum, postpartum depression is associated with potentially nous discutons de son tableau clinique, de son diagnostic, de son adverse consequences for the mother, her infant, and her diagnostic différentiel et de sa prise en charge. family. Postpartum depression has been associated with disruptions in maternal–infant interactions, and lower cognitive functioning and behavioural problems in children.3 Persistence of maternal depression can increase the risk J Obstet Gynaecol Can 2012;34(5):436–442 of children developing emotional problems including anxiety, disruptive disorders, and depressive disorders, while remission of depression has a positive effect on both mothers and their children.4 Maternal depression can also Key Words: Antidepressants, bipolar disorder, depression, increase the risk for negative infant feeding outcomes and lactation, postpartum, psychotherapy screening lower rates of initiating or maintaining breastfeeding. Competing Interests: See Acknowledgements. Received on November 15, 2011 Despite its common occurrence, there are many barriers Accepted on January 24, 2012 to the provision of optimal clinical care to women with postpartum depression. Because of the stigma of mental 436 l MAY JOGC MAI 2012 Downloaded for Anonymous User (n/a) at McMaster University from ClinicalKey.com by Elsevier on December 03, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.  Postpartum Depression: Diagnostic and Treatment Issues illness and feelings of guilt, women may fail to seek help in Table 1. Symptoms of postpartum major depression a timely manner.5 Breastfeeding women may be reluctant Depressed mood to try medications because of concerns about their safety Lack of pleasure or interest during lactation. Finally, physicians may fail to inquire Sleep disturbance (insomnia or hypersomnia) about the symptoms of postpartum depression or may Weight loss dismiss the symptoms as clinically non-significant, causing Loss of energy under-diagnosis or under-treatment. Agitation or retardation Feelings of worthlessness or inappropriate guilt METHODS Diminished concentration or indecisiveness On April 30, 2011, three electronic databases, Medline Frequent thoughts of death or suicide (1966 to 2010), PsycInfo (1840–2010), and EMBASE were searched using the combinations of the following search items: “postpartum,” “postnatal,” “depression,” “risk not; however, there is often a focus on mothering or infant factors,” “screening,” “breastfeeding,” “pharmacotherapy,” care issues in postpartum depression. and “psychotherapy.” The reference lists of articles Women with postpartum depression can have comorbid identified were also searched to select other relevant symptoms such as panic attacks, obsessions, compulsions, publications. The search yielded a total of 648 articles. All or psychotic features. The psychiatric comorbidity can relevant papers published in English were included. also occur at the syndromal level in the form of anxiety or substance use disorders. Women with postpartum CLINICAL PRESENTATION depression commonly experience comorbid obsessive- Postpartum depression is usually defined as an episode compulsive thoughts (41% to 57%), which are ego-dystonic of depression with an onset of symptoms during the in nature, but there is preservation of rational judgement first four weeks after delivery; however, women remain and reality testing.1 at risk for developing depression for several months An episode of postpartum depression is considered mild following delivery.2 According to the DSM-IV diagnostic if few symptoms are present beyond what is required to criteria, the postpartum onset specifier can be applied to make a diagnosis and the person can function normally, the current major depressive episode of major depressive although with extra effort. The severity of symptoms is disorder, bipolar I disorder, or bipolar II disorder.6 Some between mild and severe in moderate depression. In severe women have a recurrence of depression after childbirth, depression most symptoms are present, and a person clearly while others experience first onset of depression in the has little or no ability to function.6 Although symptoms of postpartum period. depression may remit spontaneously, many women are still A diagnosis of a major depressive episode requires that at depressed one year after childbirth.7 The DSM-IV criteria least five of the symptoms (Table 1) must be present, one for the two types of postpartum depression (unipolar and of which must be depressed mood or diminished pleasure bipolar) are the same, but certain clinical characteristics or interest in activities.6 The symptoms must be present such as presence of psychosis, diurnal mood variation, most of the day, nearly every day, for two weeks and there hypersomnia, hyperphagia, and a greater number of must be an associated decline in social and/or occupational shorter depressive episodes are more likely to be associated functioning. A depressed mood caused by substances (such with a bipolar course. Distinguishing between unipolar and as drugs, alcohol, or medications) or which is part of a general bipolar postpartum depression is important because there medical condition is not considered towards a diagnosis of are differences in the optimal management and treatment major depressive episode. Further, it is important to rule out of these disorders. Antidepressants are the cornerstone of uncomplicated bereavement. The symptoms of depression unipolar postpartum depression but their use in women are usually the same, whether experienced postpartum or with bipolar postpartum depression can cause treatment- emergent mania or hypomania, accelerated cycle frequency, and treatment resistance. In one study, bipolar disorder ABBREVIATIONS had the highest diagnosis-specific relative risk of first-time DSM-IV Diagnostic and Statistical Manual of Mental Disorders hospital admission in the first 30 postpartum days among Fourth Edition primiparous women (RR = 23.33) versus an RR of 2.79 EPDS Edinburgh Postnatal Depression Scale for unipolar depression.8 A previous diagnosis of bipolar RR relative risk disorder was the strongest predictor of readmissions 10 to MAY JOGC MAI 2012 l 437 Downloaded for Anonymous User (n/a) at McMaster University from ClinicalKey.com by Elsevier on December 03, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved. Women’s Health 19 days postpartum (RR = 37.22), and the increased risk DIFFERENTIAL DIAGNOSIS of hospital admissions for bipolar disorder persisted for two months postpartum.8 These findings underscore the Symptoms of early-onset postpartum depression may be difficult to differentiate from those of the baby blues, need for obstetricians to assess patients for a history of which generally appear within three to four days after psychiatric disorders, particularly bipolar disorder, and, delivery, peak on the seventh postpartum day, and disappear with psychiatric colleagues, to optimize the treatment of within two weeks.17 Anxiety disorders, including obsessive– mothers through childbirth.9 compulsive disorder or panic disorder, are also common in the postpartum period and need to be differentiated from IDENTIFICATION AND postpartum depression. SCREENING OF WOMEN AT RISK Postpartum depression should also be differentiated from Women who are at risk for postpartum depression should puerperal psychosis, a psychiatric emergency that requires be identified as soon as possible during pregnancy so immediate medical attention and is characterized by rapid that appropriate follow-up and care can be initiated. Risk mood changes, confusion alternating with periods of factors for postpartum depression include depression lucidity, and psychotic features. Puerperal psychosis has a during pregnancy, anxiety during pregnancy, stressful life sudden onset, with symptoms rapidly reaching a climax of events during pregnancy or the early puerperium, low severity. Manic forms invariably start within the first two levels of social support, and a personal or family history postpartum weeks, but depressive psychosis may develop of depression.10 Women with a history of postpartum somewhat later.18 Risk factors include a personal history depression are also at increased risk of recurrence.11 of puerperal psychosis or bipolar disorder,19 family history of puerperal psychosis or bipolar disorder, primiparity,20 Screening for postpartum depression should be strongly longer duration of labour,21 sleep loss,22 and obstetric considered, although evidence in support of universal complications.20 Although there is some confusion about screening tools is lacking.12 Patients with known risk factors the diagnostic status of puerperal psychosis, it is generally may be selected for screening with the EPDS.13 The EPDS considered a psychotic episode of bipolar disorder. is a 10-item self-rated instrument that has been used widely to screen for postpartum depression. A reasonable cut-off Hypothyroidism can mimic symptoms of postpartum depression and can affect the clinical response to on the EPDS is a score of 13 or greater, even though the antidepressants.23,24 A recent study observed a strong sensitivity and specificity varies across languages and cultures. association between low serum ferritin and postpartum Patients with a score of 13 or greater should be assessed depression.25 Careful history-taking and appropriate for depression; however, a special note should be made of laboratory testing are essential to avert misdiagnosis of positive responses on item 10 regarding suicidal ideation.13 physical disorders as postpartum depression. Women with postpartum depression should also be assessed for manic features.13 Women with first onset TREATMENT of depression in the postpartum period, occurrence of The treatment of postpartum depression can be divided depression immediately after delivery, treatment-resistant into acute and maintenance phases. The goal of acute postpartum depression, depression with psychotic features, treatment is the remission of symptoms of depression or a family history of bipolar disorder should be screened and prevention of an episode, whereas the goal of for bipolar disorder. Recently the Bipolar Disorders: maintenance treatment is to prevent recurrence of Improving Diagnosis, Guidance and Education study symptoms and achieve a return to baseline levels of reported high rates of bipolar disorders (15% to 50%) functioning and quality of life. The duration of acute among women experiencing onset of major depressive treatment is eight to 12 weeks, and the maintenance disorder in the postpartum period.14 Screening instruments treatment should last six to 24 months or longer.26 The such as the Mood Disorder Questionnaire may aid in the options for treatment of unipolar postpartum depression detection of manic features.15 A recent study reported a are shown in Table 2. Selective serotonin reuptake sensitivity of 75.44% and a specificity of 86.76% with inhibitors are the mainstay of pharmacological treatment. the traditional criteria (symptoms and supplementary In general the pharmacotherapy of unipolar postpartum questions). The optimal cut-off score was eight or more depression is similar to that of major depressive endorsed symptoms without the supplementary questions disorder occurring outside the postpartum period. If an (a sensitivity of 87.72% and a specificity of 85.29%).16 antidepressant was previously effective in a patient, it 438 l MAY JOGC MAI 2012 Downloaded for Anonymous User (n/a) at McMaster University from ClinicalKey.com by Elsevier on December 03, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.  Postpartum Depression: Diagnostic and Treatment Issues Table 2. Options for treatment of unipolar postpartum Table 3. Treatment of bipolar postpartum depression depression Refer to a psychiatrist Mild to moderate Treatment follows guidelines for non-postpartum bipolar Individual or group psychotherapy alone or adjunctively with depression50 antidepressants Due to the risk of inducing mania or rapid cycling, antidepressant Cognitive-behavioural therapy monotherapy should be avoided in bipolar postpartum depression in favour of mood stabilizers51 Interpersonal therapy27 Women who are already receiving antidepressants should be Psychodynamic psychotherapy28 monitored for cycle acceleration or a mood switch to hypomania or Psychosocial interventions, such as nondirective counselling29 mania Moderate to severe Treatment options include lithium, lamotrigine, divalproex, lithium Fluoxetine34 or divalproex plus antidepressant, lithium plus divalproex, and antidepressant plus atypical neuroleptic52 Sertraline31 Nortriptyline31 Paroxetine52 (may have a higher risk for cardiac malformations51) should be considered as the first choice in that patient’s In a double-blind study of fluoxetine versus placebo in treatment. The dose of antidepressant used should begin 87 women, Appleby et al. reported that significantly more at the low end of the dose range. Hospitalization should women improved in the fluoxetine group than in the placebo be considered for women who are at imminent risk for group.34 A double-blind trial comparing sertraline and harming themselves or their baby or who have psychotic nortriptyline showed no differences between medications features. The treatment of bipolar postpartum depression in response rates (sertraline 56% and nortriptyline 69%), is outlined in Table 3. or remission rates (sertraline 46% and nortriptyline 48%) by the eighth week of treatment.31Another study compared Because suicide is a leading cause of maternal death, paroxetine monotherapy for 12 weeks with paroxetine plus physicians should ask women about thoughts of suicide. It cognitive behaviour therapy in postpartum depression is also important to inquire about thoughts of harming the with comorbid anxiety.32 Both groups showed significant newborn and to determine whether infanticidal thoughts improvement in depressive and anxiety symptoms are obsessional or psychotic in nature.1 (response rates 87.5% in the paroxetine group and 78.9% Psychotherapeutic and Psychosocial Interventions in the combination therapy group) without significant Some women with postpartum depression prefer non- differences between groups. Because of the absence of a pharmacological interventions because they do not placebo arm in the study, it is difficult to determine the involve exposure to medications. Despite the paucity of specific effect of either intervention. A study comparing studies that have systematically studied the role of non- paroxetine and placebo found both groups improving pharmacologic treatment modalities for postpartum over time, but not differing significantly at follow-up.33 depression, the existing research supports the use of There was a high attrition rate, as only 31 of 70 (17 in the psychological treatments, especially interpersonal therapy,27 paroxetine group and 14 in the placebo group) participants cognitive-behavioural therapy, and psychodynamic completed the study. The response rates and remission rates therapy,28 as well as psychosocial interventions such as in trials of treatment for moderate to severe postpartum nondirective counselling.29 A recent meta-analysis did depression (Table 2) ranged from 43% to 87% and 27% to not find any differences in the effectiveness of different 48%, respectively. There is no evidence for superiority of types of psychological interventions.30 Other non- any single antidepressant in the treatment of postpartum pharmacological interventions, including acupuncture, depression. exercise, phototherapy, and massage, have been studied, but there are limited data on their effectiveness. Estrogen supplementation has also been studied in the treatment of postpartum depression,38 but because of the Pharmacotherapy methodological flaws of these studies it is not currently Support for the use of antidepressants in the treatment recommended as a treatment option. Similarly, the mixed of postpartum depression comes from four randomized results on the effectiveness of omega-3 fatty acids do controlled trials31–34 and four open trials including not support their use in the treatment of postpartum sertraline,31 fluvoxamine,35 bupropion,36 and venlafaxine.37 depression.39 MAY JOGC MAI 2012 l 439 Downloaded for Anonymous User (n/a) at McMaster University from ClinicalKey.com by Elsevier on December 03, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved. Women’s Health PREVENTION OF POSTPARTUM DEPRESSION Since sleep disruption can worsen symptoms of depression, the benefits of breastfeeding need to be The recurrence rate of postpartum depression during the balanced against the reduction of the mother’s opportunity first year after birth has been estimated at 25% to 41%, with for uninterrupted sleep.49 a clustering of cases near delivery and the great majority of episodes occurring within six months after childbirth.40 MAINTENANCE TREATMENT OF Women with bipolar disorder, especially those who have a POSTPARTUM DEPRESSION depressive episode after their first delivery, are at a very high risk for recurrence of postpartum depression. One study Women who are at risk for non-postpartum recurrences of reported the recurrence rate at 100% following delivery depression should be evaluated for maintenance treatment. among women who had a bipolar depressive episode after The risk factors that support the need for maintenance their first delivery.41 treatment are a history of recurrent episodes (3 or more), chronic episodes, psychotic episodes, severe episodes, There have been two placebo-controlled studies of episodes that are difficult to treat, significant comorbidity the role of antidepressants in preventing recurrent (psychiatric or medical), residual symptoms (lack of postpartum depression.42,43 In the first, a study with 22 remission) during the current episode, and a history of participants, sertraline started immediately after delivery recurrence during discontinuation of antidepressants.49 for non-depressed women with a history of at least one prior episode of postpartum depression was effective in CONCLUSION preventing recurrence and prolonging time to relapse.44 However, in the second, no difference was found in the Postpartum depression is a common public health problem rate of recurrence in women treated after delivery with among women who have recently given birth. Given the nortriptyline and those treated with placebo.45 potentially serious consequences of untreated depression for the woman and her family, it is important that health There have been no randomized controlled trials in the care professionals strive for early identification and prophylaxis of bipolar postpartum depression. Data from treatment of postpartum depression. Because of the high retrospective studies and open trials support the use of rates of psychiatric comorbidity, women with depression lithium, carbamazepine, and olanzapine. A single-blind, should be screened for other psychiatric disorders such as non-randomized clinical trial comparing valproate plus obsessive–compulsive disorder and panic disorder. The symptom monitoring and monitoring without medication extant literature has focused almost exclusively on unipolar showed no significant differences between groups in the postpartum depression, but a postpartum depressive proportion of women who developed mania, depression, episode can also occur in the patients with bipolar or mixed states.41 disorder. A depressive episode after childbirth may also herald bipolar disorder. Pregnant women with a history ANTIDEPRESSANTS AND BREASTFEEDING of postpartum depression or non-puerperal depression should be assessed regarding the need for preventive Some breastfeeding mothers may favour psychological treatment of a recurrence of depression after childbirth. interventions over pharmacological treatment. The decision The available evidence suggests that antidepressants for a breastfeeding mother to take medication involves a typically used to treat non-postpartum depression are careful consideration of the potential effectiveness of drugs also effective in the acute, maintenance, and preventive for postpartum depression and the potential risks of exposure treatment of postpartum depression. Women with mild of her infant to antidepressant medication. All medications to moderate depression may benefit from psychotherapy, pass into breast milk, but the extent of passage varies including cognitive behavioural therapy, interpersonal considerably between drugs.46 Citalopram, nortriptyline, therapy, psychodynamic psychotherapy, or non-directive sertraline, and paroxetine are first-line antidepressants counselling. because these medications in therapeutic doses are associated with low to undetectable serum concentrations in breastfed ACKNOWLEDGEMENTS babies.46 Infants should be monitored for symptoms such as persistent irritability, sedation, decreased feeding, or poor Dr Verinder Sharma has received grant support from, weight gain.42,47 Routine laboratory testing of infant blood participated on scientific advisory boards for, or served levels is not currently recommended because blood levels do on the speakers’ bureaus of AstraZeneca, Bristol-Myers not correlate with adverse effects.43,48 Squibb, Cephanol, Eli Lilly, Janssen, Lundbeck, the Ontario 440 l MAY JOGC MAI 2012 Downloaded for Anonymous User (n/a) at McMaster University from ClinicalKey.com by Elsevier on December 03, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.  Postpartum Depression: Diagnostic and Treatment Issues Mental Health Foundation, Pfizer, Servier, and the Stanley 17. Nonacs R, Cohen LS. Postpartum mood disorders: diagnosis and treatment guidelines. J Clin Psychiatry 1998;59:34–40. Foundation. This research supported by a grant from the Ontario Mental Health Foundation. 18. Brockington IF, Cernik K, Schofield E, Downing AR, Francis AF, Keelan C. Puerperal psychosis: phenomena and diagnosis. Arch Gen Psychiatry 1981;38:829–33. We thank Carley Pope for her help in the preparation of 19. Jones I, Craddock N. Familiality of the puerperal trigger in bipolar this manuscript. disorder: results of a family study. Am J Psychiatry 2001;158:913–7. 20. Kendell RE, Chalmer JC, Platz C. Epidemiology of puerperal psychoses. REFERENCES Br J Psychiatry1987;150:662–73. 21. Sharma V, Smith A, Khan M. The relationship between duration of 1. 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