Continuing Education Activity
Around one in seven women can develop postpartum depression (PPD). While women experiencing baby blues tend to recover quickly, PPD tends to last longer and severely affects women's ability to return to normal function. PPD affects the mother and her relationship with the infant. Maternal brain response and behavior are compromised in PPD. According to Beck in 2006, as many as half of PPD in new mothers go undiagnosed because of conflict in privacy and not wanting to disclose to close family members. There is also a stigma around new mothers in that disclosure may lead to abandonment and fear of lack of support. This activity reviews the evaluation, treatment, and complications of postpartum depression and underscores the importance of an interprofessional team approach to its management.
- Describe common symptoms of postpartum depression.
- Articulate the reasons that women may not seek care for postpartum depression.
- Review management strategies for postpartum depression.
- Plan a discussion amongst interprofessional, interprofessional team members regarding the detection, evaluation, and management of postpartum depression so that this condition is detected quickly and appropriate management can be implemented immediately, enhancing patient outcomes.
Childbirth is a difficult and exhausting process. A female goes through a lot of hormonal, physical, emotional, and psychological changes throughout pregnancy. Tremendous changes occur in the mother's familial and interpersonal world. After childbirth, a mother can experience varied emotions ranging from joy and pleasure to sadness and crying bouts. These feelings of sadness and tearfulness are called "baby blues," and they tend to decrease over the first 2 weeks after delivery.
Around one in seven women can develop postpartum depression (PPD). While women experiencing baby blues tend to recover quickly, PPD tends to be longer and severely affects women's ability to return to normal function. PPD affects the mother and her relationship with the infant. Maternal brain response and behavior are compromised in PPD. According to Beck in 2006, as many as half of PPD in new mothers go undiagnosed because of conflict in privacy and not wanting to disclose to close family members. There is also a stigma around new mothers in that disclosure may lead to abandonment and fear of lack of support. 
PPD can occur in females having depression and anxiety in any trimester of pregnancy.
Psychological: History of depression and anxiety, premenstrual syndrome (PMS), Negative attitude towards the baby, the reluctance of baby gender, history of sexual abuse are perpetual factors for developing postpartum depression.
Obstetric risk factors: Risky pregnancy which includes emergency cesarean section and hospitalizations during pregnancy. Meconium passage, umbilical cord prolapse, preterm or low birth infant, and low hemoglobin are associated with PPD.
Social factors: Lack of social support can cause postpartum depression. Domestic violence in the form of spouse sexual and physical and verbal abuse can also be a causative factor in the development of the disease. Smoking during pregnancy is a risk factor for developing PPD.
Lifestyle: Eating habits, sleep cycle, physical activities, and exercise may affect postpartum depression. Vitamin B6 has known to be involved in postpartum depression via its conversion to tryptophan and later on serotonin, which, in turn, affects mood. The sleep cycle is among the factors influencing the risk of depression. It is evident that decreased sleep is associated with postpartum depression. Physical activity and exercise decrease depressive symptoms. Exercise decreases low self-esteem caused by depression. Exercise increases endogenous endorphins and opioids which brings positive effects on mental health. This also improves self-confidence and increases problem-solving capacity and helps in focusing on their surrounding environment. 
Postpartum depression most commonly occurs within 6 weeks after childbirth. PPD occurs in about 6.5% to 20% of women. It occurs more commonly in adolescent females, mothers who deliver premature infants, and women living in urban areas. African American and Hispanic mothers reported onset of symptoms within 2 weeks of delivery, unlike white mothers, who reported onset of symptoms later as one study reports.
The pathogenesis of postpartum depression is currently unknown. It has been suggested that genetics, hormonal and psychological, and social life stressors play a role in the development of PPD.
The role of reproductive hormones in depressive behavior suggests neuroendocrine pathophysiology for PPD. There is ample data to advocate that changes in the reproductive hormones stimulate the dysregulation of these hormones in sensitive women. The pathophysiology of PPD can be caused by alterations of multiple biological and endocrine systems, for example, the immunological system, the hypothalamic-pituitary-adrenal axis (HPA), and lactogenic hormones. The Hypothalamic-pituitary-adrenal axis (HPA) is known to be involved in the disease process of post-partum depression. HPA axis causes the release of cortisol in trauma and stress, and if the HPA axis function is not normal, then the response decreases the release of catecholamines leading to the poor stress response. HPA-releasing hormones increase during pregnancy and remain elevated up to 12 weeks after childbirth.
The rapid changes in reproductive hormones like estradiol and progesterone following delivery can be the potential stressor in susceptible women, and these changes can lead to the onset of depressive symptoms. Oxytocin and prolactin also play an important role in the pathogenesis of PPD. These hormones regulate the milk let-down reflex as well as the synthesis of breast milk. It is often observed that failure to lactate and the onset of PPD occur at the same time. Low levels of oxytocin are particularly observed in PPD and unwanted early weaning. During the third trimester, lower levels of oxytocin are associated with increased depressive symptoms during pregnancy and following delivery. 
History and Physical
Postpartum depression is diagnosed when at least five depressive symptoms are present for at least 2 weeks. In the Diagnostic and Statistical Manual of Mental Disorders (DSM–5), postpartum depression is considered when a patient has a major depressive episode along with the peripartum-onset, and it is not mentioned as a separate disease. By definition, it is defined as a major depressive episode with the onset of pregnancy or within 4 weeks of delivery. The nine symptoms are present almost every day and represent a change from the previous routine. The diagnosis should include either depression or anhedonia (loss of interest), in addition to the five symptoms to be diagnosed.
- Depressed mood (subjective or observed) present most of the day
- Loss of interest or pleasure, most of the day
- Insomnia or hypersomnia
- Psychomotor retardation or agitation
- Worthlessness or guilt
- Loss of energy or fatigue
- Suicidal ideation or attempt and recurrent thoughts of death
- Impaired concentration or indecisiveness
- Change in weight or appetite (weight change 5% over 1 month)
These symptoms can lead to significant distress and/or impairment. Furthermore, these symptoms are not attributable to a substance or medical condition. A psychotic disorder does not cause the episode, nor has been a prior manic or hypomanic episode.
In the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10), a postpartum onset is defined to be within 6 weeks after delivery. ICD-10 describes a depressive episode as follows:
- In typical mild, moderate, or severe depressive episodes, the patient has a depressed mood with a decrease in activity and energy.
- Capacity for enjoyment, interest, and concentration is reduced. The patient feels very tired after the minimum effort along with sleep disturbance and a decreased appetite. Guilt or worthlessness are commonly present, along with reduced self-esteem and self-confidence.
- Somatic symptoms, such as anhedonia, unusual walking in the very early morning, along with agitation, weight loss, loss of libido, decreased appetite, and marked psychomotor retardation. These symptoms vary little from day-to-day, and not responsive to circumstances.
- A depressive episode may be classified as mild, moderate, or severe and it depends on the severity and number of the symptoms.
The signs and symptoms of PPD are identical to non-puerperal depression with an additional history of childbirth. Symptoms include depressed mood, loss of interest, changes in sleep patterns, change in appetite, feelings of worthlessness, inability to concentrate, and suicidal ideation. Women may also experience anxiety. Patients having PPD may also have psychotic symptoms which include delusions and hallucinations (voices saying to harm infant).
PPD may lead to poor maternal-infant bond, failure of breastfeeding, negative parenting practices, marital discord, as well as worse outcomes concerning child physical and psychological development. The remission of symptoms will reduce the risk of behavioral and psychiatric problems in the offspring.
A prior episode of PPD increases the future risk of major depression, bipolar disorder, and PPD.
Past personal and family histories of postpartum depression and postpartum psychosis should also be noted.
During the evaluation, it is important to include drug and alcohol history, smoking habits, and all prescription and over-the-counter-drug medications. Screening for PPD can be done 2 to 6 months after childbirth. There are several screening tools available, and one of the most frequently used is the Edinburgh Postnatal Depression Scale (EPDS). It is a 10-item questionnaire filled out by patients and takes a few minutes to complete. An EPDS cutoff score equal to or greater than 13 is required to determine if patients are at risk for developing PPD.
This screening test provides the basis for additional clinical tests. The objectives of the clinical evaluation are to constitute the diagnosis, assess suicidal and homicidal risks, in this case usually infanticide, and to rule out other psychiatric illnesses. 
Treatment / Management
First-line treatment for peripartum depression is psychotherapy and antidepressant medications. Psychosocial and psychological psychotherapy is the first-line treatment option for women with mild to moderate peripartum depression especially if mothers are hesitant about starting on medications and are going to nurse the newborn. A combination of therapy and antidepressant drugs is recommended for women with moderate to severe depression. Selective serotonin reuptake inhibitors (SSRI) are the first choice. Consider switching to serotonin-norepinephrine reuptake inhibitors (SNRIs) or mirtazapine if SSRI is ineffective. Once an effective dose reached, continue treatment for 6 to 12 months to prevent relapse of symptoms.
Pharmacologic recommendations for women who are lactating should include discussing the benefits of breastfeeding, the risks of antidepressant use during lactation, and the risks of untreated illness. Repetitive transcranial magnetic stimulation (TMS) is a treatment that may provide an alternative option for women who breastfeed and are concerned about their babies being exposed to medication. There is the most data for the use of sertraline for the prevention and treatment of postpartum depression. The risk of breastfeeding while taking a serotonin reuptake inhibitor is relatively low and women can be encouraged to breastfeed while on antidepressants. After 12 weeks CBT mono-therapy was found to be remarkable to both sertraline mono-therapy and combination therapy. The CBT mono-therapy group found the most accelerated initial gains after treatment startup. An important factor in the duration of postpartum depression is delayed treatment.
Transcranial Magnetic Stimulation (TMS) is a procedure that is non-invasive and uses magnetic waves to stimulate and activate nerve cells. These cells are underactive in people with major depression. It is usually done five times a week for 4 to 6 weeks to be effective. It is done in patients who are not responding to anti-depressants and psychotherapy. Generally, TMS is safe and well-tolerated, but there can be some side effects which include headaches, lightheadedness, scalp discomfort, and facial muscle twitching. Some serious side effects are rare including seizures, hearing loss if ear protection is not adequate, and mania in people with bipolar disorder. 
Patients with severe postpartum depression may not respond to psychotherapy and pharmacotherapy. For patients refractory to four consecutive medication trials, ECT is recommended. ECT is particularly useful in patients with psychotic depression, with intent or plans on committing suicide or infanticide, and refusal to eat, leading to malnutrition and dehydration.  Several observational studies have suggested ECT as a safer option for lactating mothers as there are fewer adverse effects on both the mother and the infant. 
Patients with severe postpartum depression that decline or don't respond to ECT; for these patients, intravenous Brexanolone is recommended. Brexanolone received FDA approval in March 2019, and it is the first drug to be specifically approved for postpartum depression. Brexanolone is an aqueous formulation of allopregnanolone, a progesterone metabolite. Brexanolone is only recommended if patients do not improve on antidepressants or ECT due to its restricted availability and limited clinical experience. In the United States, Brexanolone is only available at certified healthcare facilities, and patients are required to enroll in the Risk Evaluation and Mitigation Strategy Program. Through this program, patients are continuously monitored by a clinician during their IV infusion for increased sedative effects, sudden loss of consciousness, and hypoxia. Brexanolone is administered intravenously as a continuous 60hr infusion, which lasts approximately 2.5 days. Multiple clinical trials demonstrate Brexanolone is usually well-tolerated in women with moderate to severe postpartum depression and can provide a rapid beneficial response.  More clinical trials are needed to further access the long-term safety and efficacy of Brexanolone in the treatment of postpartum depression.
Most commonly occurs around 2 to 5 days after delivery and resolves around 10 to 14 days. Women experience crying bouts, sadness, anxiety, irritability, sleep disturbance, appetite changes, confusion, and fatigue. It does not affect daily functioning or the ability to take care of the baby.
Hyperthyroidism or Hypothyroidism
These conditions can also lead to mood disorders. They can be assessed by testing TSH and free T4 levels.
Postpartum psychosis is a psychiatric emergency with a potential suicide and infanticidal risk. A female can experience hallucinations, lack of sleep for several nights, agitation, unusual behavior, and delusions. It is an acute onset of manic or depressive psychosis within the first few days or weeks after delivery.
Postpartum depression has repercussions beyond physical harm to the child. Data reveal that the condition also affects mother-infant bonding. Often the child is treated inappropriately with a very negative attitude. This can have a significant impact on the growth and development of the child. Children born to mothers with postpartum depression have been found to exhibit marked changes in behavior, altered cognitive development, and early onset of depressive illness. More important, these children are often obese and have dysfunction in social interactions.
Postpartum depression affects the mother, father, and infant.
Mother: It can lead to chronic depressive disorder if not treated on time. Even if treated, PPD can be a risk for future episodes of major depression.
Father: This can be a precipitating factor for depression in the father as this will be a stressful event for the entire family.
Infant: Children of mothers who have untreated depression can develop behavioral and emotional problems. More commonly seen are delays in language development. They can also suffer from sleeping problems, eating difficulties, excessive crying, and attention-deficit/hyperactivity disorder (ADHD).
Pearls and Other Issues
Before delivery, many females who are at risk of developing PPD can be identified. These females, along with their families, should be provided with information and education regarding PPD prenatally. The information should be reinforced during postpartum hospitalization and after discharge. 
Childbirth education classes teach new mothers to seek help and support that they might need for childbirth. By teaching women and their spouses about the signs and symptoms of PPD, educators can increase the chance that the woman suffering will receive proper management and treatment.
Screening for depressive symptoms can be done during pregnancy. This screening can identify women who are at increased risk for developing PPD.
Exclusive breastfeeding has a positive effect on reducing depressive symptoms from childbirth to 3 months.
Postpartum depression can be prevented when parents are given positive parenting lessons and when the maternal-infant bond is promoted and increased. This can be achieved through social support from family and healthcare providers. Along with this, good maternal sleep can also help in preventing PPD.
Enhancing Healthcare Team Outcomes
Because of the high morbidity of postpartum depression, the focus today is now on prevention. Unlike the psychiatrist, the nurse is in a primary position to identify women at high risk for postpartum mood disorders before delivery. During the admission, the nurse may identify the female with a prior history of depression or postpartum blues. Further, any female who develops depression during pregnancy should be identified and closely followed by the postpartum nurse or primary care provider. These women need education and support on available treatments. Some of these women may benefit from a consult with a therapist and others may need a referral to a psychiatrist for treatment with an antidepressant after delivery. Both pharmacological and nonpharmacological prophylaxis has been used in such settings with variable success. There is also a large body of evidence that postpartum women with depression who are treated have a much better mother-infant bonding experience than those women who forego treatment. More important, infants of mothers who are depressed may also develop a variety of mood and behavior problems, as well as obesity later in life. Despite awareness of postpartum depression, many women miss out on treatment because they are simply not followed after pregnancy. Thus, the role of the postpartum visiting nurse is critical.  [Level 5]
Unfortunately, there are no good randomized clinical trials that show that screening postpartum women for depression is of any benefit. While the topic remains debatable, there are many small case series revealing that the treatment of postpartum women for depression is of some benefit. As to which type of therapy is ideal for these women is still not known.  [Level 3]