Peripartum Depression
Peripartum Depression (PD)
Peripartum depression is described as depression that begins during pregnancy, and up to four weeks after the baby is born. It can have significant health risks to the mother and baby if not treated. PD has been linked to maternal suicide, and neonatal complications such as failure to thrive, developmental delays, disruption of maternal-infant bonding, and disruption of family dynamics.
The development of PD is unknown. But, there are theories such as: abnormalities in the mother’s neurotransmitters, fear of childbirth, tobacco use, adolescence, single status, lower socioeconomic status, domestic violence, mothers over forty, maternal anxiety, history of depression or anxiety, social isolation, genetic predisposition, and dysfunction of the pituitary and/or thyroid gland. Women with a history of depression prior to pregnancy are at greatest risk.
Diagnosis and Criteria
PD is diagnosed as a major depressive disorder identified during pregnancy or within four weeks postpartum per The Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
According to the DSM-5, the patient must display five or more of the following criteria: depressed mood most of the day, decreased ability to perform daily activities, significant weight loss, unable to sleep or sleeping too much, psychomotor agitation or retardation, fatigue or loss of energy every day, feelings of worthlessness, decreased cognitive abilities, and recurrent thoughts of death. These characteristics or symptoms cannot be attributed to a physiologic cause or other medical condition.
PD also has the following characteristics in comparison to something often called the “baby blues”: Duration is for more than two weeks unlike the “baby blues”, onset is often during pregnancy unlike post “baby blues” which often occurs 2-3 days after delivery, severity of symptoms in women with PD can be moderate to severe, and suicidal ideation may also be present.
It is recommended that first-time mothers, adolescent mothers, and mothers who have experienced a traumatic event, or traumatic past delivery, be screened for PD. This can be done using a variety of screening tools for depression. Some examples of peripartum depression screening tools that can be utilized are the Edinburgh Postnatal Depression Scale and the Postpartum Depression Screening Scale. Neither scale so far has tested as the preferred scale to use. These tools are for postpartum screening, but there is one other Patient Health Questionnaire that is a short ten-question tool to screen for depression that can be used for any patient.
As with other forms of depression, women should be assessed for suicide and homicide ideation. Evidence of either would warrant emergency psychiatric evaluation and intervention.
Treatment Approaches
Treatment for PD can include pharmacological and nonpharmacological interventions, and is again based on the severity of the patient’s symptoms.
Nonpharmacological treatment can consist of psychotherapy for mild to moderate symptoms, and can be added to pharmacological therapy for more severe cases. Selective Serotonin Reuptake Inhibitors or SSRI’s are the treatment of choice when medications are necessary. Dosages will need to be addressed and titrated during pregnancy and after pregnancy. Celexa, Lexapro, and Zoloft are the safest SSRI’s to take during pregnancy, while Luvox, Paxil, and Zoloft are preferred in breastfeeding women because they lead to the lowest serum medication levels in breastfed infants. It is understood that patients should be followed up with in one to two weeks and then four to six weeks or sooner. Again, medications may need to be adjusted or changed to another medication within the SSRI class. It is also recommended that patients be screened after treatment for major depression, and that treatment for PD continues for at least six months even after “remission” is achieved.
There are safety concerns with the use of SSRI medications during pregnancy and its effect on the newborn. There have been cases of lower APGAR scores, developmental and speech delays, hyperactivity, and even autism in newborns whose mothers were on these medications.
There is some use of electroconvulsive therapy in severe cases that do not respond to medication and other therapies.
In addition to psychotherapy and medication therapy, cognitive behavioral therapy has also been recommended for the treatment of PD.
Emergency treatment of patients with active suicidal thoughts or thoughts of harming their newborn should be considered for same-day psychiatric treatment for possible inpatient care.
Prevention of PD is of primary importance as its effects on the family unit can be far-reaching. It has also been studied that first-time mothers, adolescent mothers, and mothers who have experienced a traumatic delivery have benefited from home visits, telephone support, talk therapy, and cognitive behavioral therapy.