creation date: 2025-12-04 15:00
tags: Pathologies
Postpartum Depression
Background
Definitions
Postpartum depression refers to major unipolar depression that occurs in relation to the postpartum period. This is grouped under peripartum depression which refers to the duration of pregnancy to 12 months following delivery.
The estimated prevalence of PPD is 10-15% globally.
Etiology and Pathogenesis
The pathogenesis is unknown. It is also unclear whether postpartum depression is distinct from nonperinatal depression and the level of difference.
Several factors are hypothesized to be involved:
Genetics
- Heritability estimated to be 40%
- Partial overlap with genetic susceptibility of perinatal and nonperinatal depression
Hormonal changes
- Decreases in estrogen/progesterone
- Cortisol, melatonin, oxytocin, thyroid hormone
- Fluctuations paired with increased sensitivity (eg. due to genetics) may precipitate depression
Clinical Presentation
Signs & Symptoms
The manifestations typically mimic those of nonperinatal major depressive episodes.
The classic symptoms are listed using the MSIGECAPS mnemonic:
- Mood: depressed, can manifest as irritable
- Sleep: insomnia or hypersomnia
- Interest: reduced, anhedonia
- Guilt: unrealistic
- Energy: mental and physical fatigue
- Concentration: easily distractible
- Appetite: decreased or increased
- Psychomotor: retardation or agitation
- Suicide: thoughts, plans, behaviours
It should be noted that certain symptoms may simply be a manifestation of parenthood (eg. fatigue, poor sleep due to infant waking)
Postpartum manifestations may include the following symptoms:
- Anxiety about infant health, including concerns about one’s ability to care for infant
- Negative perception of infant temperament and behaviour
- Despondency for ≥2 weeks
- Lack of interest in infant activities
- Lack of response to support and reassurance
- Use of alcohol, illicit drugs, or tobacco
- Nonadherence to postnatal care
- Frequent nonroutine visits to obstetrician or pediatritian
Severe episodes are distinguished by:
- Onset during pregnancy
- Symptoms of anxiety and suicidal ideation
- Obstetric complications
Comorbid mental illness is common (66%, comparable to nonperinatal depression) and patients may present with such symptoms, with the most common being anxiety disorders.
History & Physical Exam
Suspicion of postpartum depression from observation and history taking should elicit screening
Routine screen can be completed with two simpler questions (PHQ-2):
- “During the last month, have you often been bothered by feeling down, depressed, or hopeless?”
- “During the last month, have you been bothered by having little interest or pleasure in doing things?”
Endorsement of the above questions should be followed by screening with the Edinburgh Postnatal Depression Scale (EPDS), of which cutoffs are discussed below.
It should be noted that routine screening is not universally recommended (eg. CTF Preventative Health Care guidelines).
Risk factors
The epidemiology showed 50% of patients with postpartum depression had onset prior to delivery. In those who had onset following delivery:
- Month 1: 54%
- Month 2-4: 40%
- Month 5-12: 6%
Primary risk factors (consistently associated) include:
- Depression during pregnancy
- Prior history of depression (either perinatal or nonperinatal)
Secondary risk factors (frequently associated) include:
- Stressful life events (eg. marital conflict, emigration, pandemics) during pregnancy or after delivery
- Poor social and financial support
Other possible risk factors include (non-exhaustive):
- Perinatal anxiety symptoms and disorders
- Young age
- Single marital status
- Multiparity
- Family history of postpartum depression or other psychiatric illness
- Intimate partner violence or history of physical/sexual abuse
- Unintended pregnancy
- Body image dissatisfaction
- Adverse pregnancy and neonatal outcomes (eg. preterm birth)
- Childcare stress (eg. difficult infant temperament)
Diagnosis
Criteria
Screening
The 10-item EPDS has a maximum score of 30. A cutoff score of 11 is typically recommended to maximize sensitivity and specificity.
A score of ≥20 is considered severe.
Diagnosis
Diagnosis of postpartum depression is made using the DSM-5 critiera for major depression along with the specifier “with peripartum onset”.
The peripartum onset specifier is applicable for episodes that arrive during pregnancy or within 4 weeks of delivery. Beyond 4 weeks, no modifier is used although in clinical practice, the term postpartum depression is often used for 12 months following childbirth.
Five or more of the following symptoms have been present in a two-week period that is different from previous functioning. At least one symptom must be depressed mood (1) or loss of interest (2).
- Depressed mood most of the day, nearly every day, as indicated by either subjective report (eg. feels sad, empty, hopeless) or observations made by others (eg. appears tearful). In children and adolescents, can be irritable mood.
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (subjective account or observation).
- Significant weight loss when not dieting or weight gain (eg, a change of more than 5% of body weight in a month), or decrease/increase in appetite nearly every day. In children, consider failure to make expected weight gain.
- Insomnia or hypersomnia nearly every day.
- Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
- Fatigue or loss of energy nearly every day.
- Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
- Diminished ability to think or concentrate, or indecisiveness, nearly every day (either subjective account or observed by others)
- Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
The symptoms must also cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The episodes must also not be attributable to a substance or another medical condition.
Work-up
Differential
Normal postpartum changes
A number of symptoms of major depression overlap with normal changes postpartum (eg. energy changes, sleep, appetite). Clinicians should evaluate if changes are within normal expectations.
Postpartum blues
Same symptoms as postpartum major depression but postpartum blues does not require a minimum number of symptoms. Symptoms are also:
- Mild and self-limited
- Develop within 2-3 days of delivery
- Peaks a few days following onset
- Resolves within 2 weeks
Bipolar depression
23% of patients who screened positive for depression postpartum were diagnosed with bipolar depression. This is distinguished by:
- Past history of hypomania and/or mania
- Agitation (more prevalent in bipolar depression than postpartum depression)
Red Flags / Complications
A number of adverse consequences may result from postpartum depression impairing maternal functioning:
- Increased risk of not breastfeeding
- Impaired bonding with infant
- Poorer health care of children (improper sleep, out of date vaccinations)
- Abnormal infant and child development
- Cognitive impairment of psychopathology in child
- Marital discord
- Suicide and/or infanticide
Management
Mild-to-moderate
Non-pharmacological
For mild to moderate depression, psychotherapy alone is the preferred initial treatment. This is particularly useful for lactating patients who do not want to expose their infants to antidepressants.
Options include:
- CBT
- Interpersonal psychotherapy
A number of reasonable alternatives may be available. Administration may also vary including remote or in person, and individual or group format.
Supplemental interventions may include:
- Exercise (eg. aerobic, strength, stretching)
- Social/peer support
- Parental education (to address infant behaviours)
Follow-up and monitoring
Routine monitoring using the EPDS is recommended as an indicator of response to treatment. A response is defined as a reduction of ≥50% of baseline depressive symptoms.
Additional management
For patients with no response to initial treatment consider:
- Incorrect diagnosis
- Adherence to plan
- Life stressors that needs to be addressed before improvement can be seen
- Cormobid conditions requiring treatment
Patients may need to switch to other forms of psychotherapy if current choice is not effective. In cases where the patient is refractor to treatment, consider adjunctive antidepressants (see below).
Severe
Pharmacological / Interventional
For patients with severe depression, treatment consist of psychotherapy in addition to pharmacotherapy. Choice of treatment typically depends on:
- Clinical history
- Treatment preference of patient
- Availability of treatments
Patients treated with antidepressants during pregnancy or prior to pregnancy
In these patients, resuming the same antidepressant is consistent with guidelines. For patients who were treated for depression prior to pregnancy, a change in regimen may be necessary if prior pharmacotherapy is not compatible with breastfeeding.
Patients not previously treated for depression
In patients with no prior history of pharmacotherapy for depression, a step-wise approach is used, moving to the next step if patient does not respond to treatment.
Note that there are no head-to-head trials comparing each option and thus it is reasonable to use any for initial treatment based on availability, affordability, and patient preference.
Step-wise options are as follows:
- SSRIs (eg. sertraline for antepartum, paroxetine for postpartum)
- SNRIs
- Mirtazipine (good if weight gain and sedation is preferred) or other atypicals
- Electroconvulsive therapy (ECT) after all antidepressants have been trialed and refractory
Adjunctive medications may be necessary for specific symptom management.
- Anxiety - clonazepam or lorazepam
- Agitation - aripiprazole, olanzapine, or haloperidol
Medications contraindicated in pregnancy are bupropion, TCAs, paroxetine
(Unavailable in Canada) - Zuranolone (Zurzuvae) 50 mg PO qPM for 14 days with fat-containing food OR brexanolone IV over 60 hours at a healthcare facility
Follow-up and monitoring
Routine monitoring using the EPDS is recommended as an indicator of response to treatment. A response is defined as a reduction of ≥50% of baseline depressive symptoms.
Addressing concerns with breastfeeding safety with antidepressant use
Counselling points to emphasize include:
- While there are some risk for patients who are breastfeeding, the benefits outweigh said risks
- Untreated depression pose risk to mother and infant
- Impaired bonding
- Poor self and infant care
- Abnormal child development
- Cognitive impairment and psychopathology in the children
- Relatively low amounts are excreted in the breast milk and generally regarded as safe to infant
- Uncommon side effects include sedation and difficulties with feeding and sleeping
- Antidepressant-induced sedation can interfere with ability to care for infant