Depression: Postpartum
INTRODUCTION
Description: Postpartum depression is a cluster of
symptoms characterized by disturbance of mood; a loss
of sense of control; intense mental, emotional, and
physical anguish; and a loss of self-esteem associated
with childbirth.
Prevalence: Eight percent to ten percent of delivering
women, true psychosis1 to 2 of 1000 deliveries.
Predominant Age: Reproductive.
Genetics: No genetic pattern, although there is a
proposed family tendency.
ETIOLOGY AND PATHOGENESIS
Causes: Unknown.
Risk Factors: History of major depression, premenstrual
syndrome, prior postpartum depression, perinatal loss,
early childhood loss (parent, sibling), physical or sexual
abuse, socioeconomic deprivation, family predisposi-
tion, lifestyle stress, preterm delivery, unplanned preg-
nancy. There is a 50% recurrence rate for subsequent
pregnancies.
CLINICAL CHARACTERISTICS
Signs and Symptoms
Five of the following must be presentdepressive mood
most of the time; diminished interest in normal or
pleasurable activities; signicant involuntary change in
weight; insomnia or hypersomnia; psychomotor agita-
tion or retardation; fatigue or loss of energy; feelings of
worthlessness or guilt; diminished ability to think or
concentrate; recurrent thoughts of death
Begins 2 to 12 months after delivery; lasts 3 to 14
months
DIAGNOSTIC APPROACH
Dierential Diagnosis
Normal grief reaction
Transient mood change (postpartum blues)
Substance abuse
Eating disorders or other nonmood psychiatric
disorders
Associated Conditions: None.
Workup and Evaluation
Laboratory: No evaluation indicated.
Imaging: No imaging indicated.
Special Tests: Beck Depression Inventory may be used to
screen for depression.
Diagnostic Procedures: History, suspicion.
Pathologic Findings
None.
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205
MANAGEMENT AND THERAPY
Nonpharmacologic
General Measures: Support, reassurance, and assistance
with transition to motherhood. Postpartum exercise has
been associated with a lower rate of depression.
Specic Measures: Psychotherapy, antidepressants, elec-
troshock therapy.
Diet: No specic dietary changes indicated.
Activity: No restriction.
Patient Education: Reassurance, family support;
American College of Obstetricians and Gynecologists
Patient Education Pamphlet AP091 (Postpartum
Depression).
Drug(s) of Choice
Selective serotonin reuptake inhibitors (uoxetine
[Prozac] 10 to 40 mg daily, paroxetine [Paxil] 20 to
50 mg daily, sertraline [Zoloft] 50 to 150 mg daily).
For symptoms of appetite loss; loss of energy or interest
in pleasure; psychomotor retardation; thoughts of
hopelessness, guilt, or suicide: cyclic antidepressants
(e.g., amitriptyline, clomipramine, doxepin, imipramine,
nortriptyline, bupropion, and others).
For symptoms of increased appetite, sleepiness,
high levels of anxiety, phobias, obsessive-compulsive
disorders: monoamine oxidase (MAO) inhibitors (e.g.,
isocarboxazid, phenelzine, tranylcypromine).
Contraindications: See individual agents.
Precautions: Use in pregnancy must be carefully weighed
versus the potential effects (teratogenic) on the fetus.
Some agents are associated with delayed cardiac conduc-
tion and disturbances in rhythm. Tricyclic agents,
paroxetine, sertraline, and venlafaxine must be tapered
over 2 to 4 weeks to discontinue.
Interactions: Virtually all agents may produce fatal
interactions with monoamine oxidase inhibitors or anti-
arrhythmic medications. Monoamine oxidase inhibitors
can also adversely interact with vasoconstrictors, decon-
gestants, meperidine, and other narcotics.
Alternative Therapy
Electroshock therapy may still play a role in the treatment
of major depression and mania in those who do not
respond to other therapies or are at high risk for
suicide.
FOLLOW-UP
Patient Monitoring: Follow up at 6 weeks, 3 and 6
months, and as needed.
Prevention/Avoidance: None for primary occurrence.
For those with a history of prior postpartum depression,
prophylactic treatment with antidepressants is associ-
ated with a reduced rate of recurrence. Postpartum
513
514 SECTION 11 Obstetric Conditions and Concerns
Patient may have prior history of depression or premenstrual
tension, or prior postpartum depression
Diagnostic Criteria
(must meet five of the following factors)
1) Depressed mood for majority of time
2) Decreased interest in pleasurable activities
3) Significant involuntary weight loss
4) Psychomotor agitation or retardation
5) Feelings of guilt or worthlessness
6) Decreased concentration
7) Recurrent thoughts of death Decreased concentration or retardation
exercise has been associated with a lower rate of
depression.
Possible Complications: Progressive loss of function,
suicide.
Expected Outcome: Generally good response for mild to
moderate depression with psychotherapy and medica-
tion; severe depression in 45% to 65% of patients
responds to medication. Recurrence rates are approxi-
mately 50% after a single episode, 70% after two epi-
sodes, and 90% with three or more episodes.
MISCELLANEOUS
Pregnancy Considerations: Tends to recur with subse-
quent pregnancies. Prophylactic treatment after delivery
should be considered for these patients.
ICD-9-CM Code: 648.4.
REFERENCES
Level I
Hagan R, Evans SF, Pope S: Preventing postnatal depression in
mothers of very preterm infants: a randomised controlled trial.
BJOG 2004;111:641.
Wisner KL, Perel JM, Peindl KS, et al: Prevention of postpartum
depression: a pilot randomized clinical trial. Am J Psychiatry
2004;161:1290.
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Condition begins 212 months
postdelivery and may last 314 months
Postpartum depression is characterized by a
disturbance of mood; a loss of sense of control;
intense mental, emotional, and physical anguish;
and a loss of self-esteem associated with childbirth
with
E. Hatton
Feelings of
Depressive worthlessness
mood or guilt
Recurrent thoughts
Psychomotor agitation of death
Level II
Dennis CL: Psychosocial and psychological interventions for preven-
tion of postnatal depression: systematic review. BMJ 2005;331:15.
Gavin NI, Gaynes BN, Lohr KN, et al: Perinatal depression:
a systematic review of prevalence and incidence. Obstet Gynecol
2005;106:1071.
Level III
American College of Obstetricians and Gynecologists: Exercise
during pregnancy and the postpartum period. ACOG Committee
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American College of Obstetricians and Gynecologists: Psychosocial
risk factors: perinatal screening and intervention. ACOG Commit-
tee Opinion 343. Obstet Gynecol 2006;108:469.
American College of Obstetricians and Gynecologists: Treatment
with selective serotonin reuptake inhibitors during pregnancy.
ACOG Committee Opinion 354. Obstet Gynecol 2006;108:1601.
Beck A: Depression Inventory. Philadelphia, Center for Cognitive
Therapy, 1991.
Brockington I: Postpartum psychiatric disorders. Lancet 2004;
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Clay EC, Seehusen DA: A review of postpartum depression for the
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Suri R, Burt VK, Altshuler LL, et al: Fluvoxamine for postpartum
depression. Am J Psychiatry 2001;158:1739.
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