Continuing Education Activity

Postpartum “blues” is defined as low mood and mild depressive symptoms that are transient and self-limited and are extremely common in the perinatal period. This activity describes the diagnostic criteria for postpartum blues and highlights the interprofessional team's role in its evaluation and management.

Objectives:

• Identify the etiology of postpartum blues.
• Review the diagnostic criteria for postpartum blues.
• Outline the treatment modalities available for postpartum blues.
• Summarize some interprofessional strategies that can contribute to better outcomes for patients suffering from postpartum blues.

Introduction

Psychiatric illnesses that are non-psychotic are one of the most common morbidities of pregnancy and the perinatal period. These disorders include depressive disorders (postpartum blues, postpartum depression), anxiety, post-traumatic stress disorder (PTSD), and personality disorders. Postpartum “blues” are defined as low mood and mild depressive symptoms that are transient and self-limited.[1] The depressive symptoms include sadness, crying, exhaustion, irritability, anxiety, decreased sleep, decreased concentration, and labile mood. These symptoms typically develop within two to three days of childbirth, peak over the next few days, and resolve by themselves within two weeks of their onset.

Etiology

Several risk factors can lead to the development of postpartum blues. These include a history of menstrual cycle-related mood changes or mood changes associated with pregnancy, a history of major depression or dysthymia, a larger number of lifetime pregnancies, or a family history of post-partum depression.[1][2] The factors that, when present, do not predispose a patient to the development of postpartum blues: low economic status, ethnic or racial background, gravidity status (primiparous vs. multiparous), planned vs. unplanned pregnancy, spontaneous pregnancy vs. IVF, type of delivery (vaginal vs. cesarean), family history of mood disorders, or history of postpartum depression in the past.[1]

Pathogenesis is largely unknown. However, hormonal changes have long been suggested as one of the primary causative factors in developing postpartum mood changes. Typically, there is a drastic decrease in estradiol, progesterone, and prolactin in the time following delivery. The decrease in these hormones is also noted in the mood changes that occur during the various phases of the menstrual cycle, such as those noted in premenstrual dysphoric disorder.[3]

According to one particular study, the three predisposing factors most often found in women who developed postpartum blues were higher levels of depressive symptoms during pregnancy, at least one previous episode of diagnosed depression, and a history of premenstrual depression or other menstrual-related mood changes.[3]

Other studies have also proposed that elevated monoamine oxidase levels or decreased serotoninergic activity in the immediate postpartum period are also significant risk factors or etiological characteristics that could predispose a woman to the development of postpartum blues.[4][5]

Epidemiology

Postpartum blues are extremely common and are estimated to occur in about 50% or more of women within the first few weeks after delivery.[1] Postpartum major depression is approximately 4 to 11 times more common among women who have postpartum blues.

History and Physical

As with all psychiatric diagnoses, the most important diagnostic tool is the interview. In the setting of a female patient who presents immediately after or within two weeks of delivery, a low mood and depressive symptoms that do not meet the major depressive disorder criteria can point to a diagnosis of postpartum blues. If the criteria for major depressive disorder are met or if the mood disturbances persist beyond two weeks after delivery, a diagnosis of postpartum blues should not be made.

Evaluation

Symptoms of postpartum blues include crying, dysphoric affect, irritability, anxiety, insomnia, and appetite changes.[3] These symptoms, when present, should not meet the criteria for major depressive disorder or, when occurring in the postpartum period, of postpartum depression. To fully meet the criteria for a diagnosis of postpartum blues, the symptoms usually develop within two to three days of delivery and resolve within two weeks. If the symptoms persist beyond two weeks, the diagnostic criteria for postpartum depression are then fulfilled. A clinical tool that can be useful to screen for postpartum depression is the Edinburgh Postpartum Depression Scale, which has been validated to have adequate sensitivity and specificity across population groups, even when assessing changes in depression over time.[6]

Under the updates proposed in the fifth edition of the new Diagnostic and Statistical Manual of Mental Disorders, postpartum depression is re-defined as “depressive disorder with peripartum onset.”[7] In rare cases, psychotic features may accompany the primary symptoms of depression. This symptomatic presentation used to formerly be referred to under its own diagnostic classification as postpartum psychosis. Postpartum depression and postpartum psychosis are now classified as one diagnosis, namely "depressive disorders with peripartum onset" and differentiated with the classifier “with psychotic features” if psychotic features are present. This DSM-5 does not recognize postpartum blues as its own separate diagnosis. Instead, it is clinically differentiated from the depressive disorder with peripartum onset by being labeled either "adjustment disorder with depressed mood" or "depressive disorder not otherwise specified." For coding purposes, it is recognized by the ICD-10 diagnostic manual as "postpartum depression, not otherwise specified."

Treatment / Management

Peripartum mood disorders can be viewed as occurring on a spectrum of severity, with postpartum “blues” being milder and self-limited and postpartum depression more disabling. By its diagnostic criteria, postpartum blues are transient and self-limited. Therefore, it resolves on its own and requires no treatment other than validation, education, reassurance, and psychosocial support.[8] Patients diagnosed with postpartum blues should be carefully evaluated to see if the diagnostic criteria for postpartum depression are met. This would entail ensuring both that symptoms do not meet the criteria for a depressive episode at the time of presentation and that symptoms do not persist beyond two weeks. If a diagnosis of postpartum depression, or depression with peripartum onset, is finalized, the clinician should initiate a treatment regimen with supportive psychotherapy and antidepressants. Concurrently, with a diagnosis of postpartum depression, antipsychotics should be considered if psychotic features are present. 

While postpartum blues symptoms are mild, transient, and self-limited, patients should still be carefully screened for suicidal ideation, paranoia, or homicidal ideation towards the infant. Moreover, home help should be sought to help the patient in getting enough sleep. If insomnia persists, cognitive therapy and/or pharmacotherapy can be recommended.

Differential Diagnosis

Sleep disturbances decreased energy, and some mood changes can normally occur in the peripartum period. These can be differentiated from postpartum blues by assessing if the mood and activity levels are normal peripartum-related changes or determining if the symptoms cause impairment or distress in the individual’s life.

Postpartum blues requires differentiation from postpartum depression or, in concordance with the new DSM-5, a depressive disorder with peripartum onset. In the latter case, symptoms must meet the criteria for a depressive episode, and mood disturbances must persist beyond two weeks. According to the DSM-5, the criteria for a depressive disorder include depressed mood, anhedonia, weight or appetite changes, sleep disturbances or insomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or guilt, difficulty concentrating, and recurrent thoughts of death or suicidal ideation. The diagnosis for depressive disorder with a peripartum onset uses the same diagnostic criteria but with the added criteria that symptoms must occur in the context of pregnancy or within four weeks after delivery.

Prognosis

Postpartum blues involve mood changes that are typically mild, transient, and self-limited. However, a diagnosis of postpartum blues can predispose an individual to postpartum depression or postpartum anxiety disorders. According to the DSM-5, the risk of postpartum depression developing in an individual with “baby blues” significantly increases in those who had mood or anxiety symptoms during pregnancy.

Complications

Individuals who are diagnosed with postpartum blues are at increased risk for developing postpartum depression or postpartum psychosis. One particular study completed in Africa demonstrated that women diagnosed with “postpartum blues” on the fifth day after delivery were twelve times more likely to be diagnosed with postpartum depression one month after delivery and ten times more likely to be diagnosed with postpartum depression two months after delivery.[9]

While postpartum depression, which is the most common and widely recognized complication of postpartum “blues,” has many of the same characteristics and is diagnosed using the same criteria as major depressive disorder, women with postpartum depression tend to have higher levels of co-morbid anxiety. These women are also more likely to convert to bipolar disorder in the future than women with major depressive disorder without a peripartum onset.[10]

According to the DSM-5, psychotic features are estimated to occur in 0.1% to 0.2% of women in the peripartum period. The DSM further states that this risk is more common in primiparous women, those with a prior history of depressive or bipolar disorders, and those with a family history of bipolar disorder. The DSM further states that once an individual has had one peripartum-onset depressive episode with psychotic features, the risk of recurrent with subsequent pregnancies and deliveries is 30% to 50%.

Deterrence and Patient Education

Like all psychiatric disorders, the prevention of postpartum blues would involve mediation of the major risk factors. Unlike most other psychiatric disorders, however, most of the risk factors for postpartum blues – such as parity, delivery status, history of depression or bipolar disorder, or history of menstrual-related mood changes – are nonmodifiable. However, the most important factor in managing postpartum blues is the early identification of symptoms, prompt intervention, facilitation of open discussions with patients and their families, and access to mental health resources and professionals. It is also important that patients are screened for suicidal ideation, homicidal ideation towards the infant, paranoia, or psychotic features. It is also essential if symptoms were to develop and be identified that resources are in place to ensure that new mothers feel adequately supported.

Enhancing Healthcare Team Outcomes

Postpartum “blues,” though not formally recognized as a diagnosis by the DSM-5, is a phenomenon that is extremely prevalent in the immediate time period after delivery. As postpartum blues are, by definition, mild, transient, and self-limited, they do not cause significant distress or disability in an individual’s life. However, the need for prompt identification and intervention, namely the access to social support systems and other mental health resources like counseling, is underscored by the significant risk of developing postpartum depression or psychosis in those with postpartum blues.

As with most mental health disorders, the primary care setting is usually the predominant location in which these symptoms are brought to healthcare providers' attention. Therefore, primary care providers, including obstetricians, must be knowledgeable in the symptoms of postpartum blues and adept in its diagnosis and treatment. Obstetric nurses should watch for signs and symptoms of the disorder and provide patient education. If the patient requires antidepressant therapy, a pharmacist consult is to verify agent selection, appropriate dosing, and medication reconciliation to preclude drug-drug interactions. Both nursing and pharmacy need to report any concerns to the prescriber/treating clinician. Employing these interprofessional strategies will optimize patient outcomes. [Level 5]

It is also of extreme importance that individuals diagnosed with postpartum blues are screened for suicidal ideation, paranoia, para- or pre-psychotic thoughts, or homicidal ideation towards the infant.

Though all mental health diagnoses are most effectively managed through a comprehensive and inter-disciplinary model, peripartum mood disorders are naturally predisposed to this modality of management. According to a review article published in the American Journal of Obstetrics and Gynecology, a combination of various hormonal, biologic, and psychologic factors are responsible for many perinatal and postnatal complications, including preterm delivery, low birth weight in the infant, and mood disorders. Therefore, an interprofessional process that allows healthcare providers to collaborate on mitigating these interrelated risk factors would be most effective in reducing the rates of these outcomes.[11]