Snapshot A 25-year-old woman presents to the clinic 3 days after delivery of her newborn son. She experiences the following situations (3 separate vignettes are presented): Occasional tearfulness and feeling sad several days out of the week. She still takes good care of her baby and has no thought of hurting the baby. (Postpartum blues) Loss of pleasure and a severely depressed mood most days of the week. She takes care of her baby but sometims has thoughts of hurting the baby. (Major depressive disorder with peripartum onset (postpartum depression) Is hearing voices telling her to drown the baby so that the world will be safe. (Peripartum psychosis) Introduction Overview postpartum depression is a mood disorder that can affect women after childbirth postpartum blues temporary condition characterized by mild depressive symptoms and labile mood that develops 2-3 days following delivery and resolves within 2 weeks of onset major depressive disorder with peripartum onset (postpartum depression) syndrome of major depression that persists beyond 2 weeks following delivery peripartum psychosis psychosis with hallucinations and delusions that presents within 2 weeks of delivery Epidemiology Postpartum blues incidence 50-85% of postpartum women Major depressive disorder with peripartum onset incidence 10-15% of postpartum women Peripartum psychosis incidence 0.1-0.2% of postpartum women Risk factors history of premenstrual mood changes (postpartum blues) depressive syndromes pre-pregnancy family history of depression or psychiatric illness stressful life events during pregnancy or after delivery Presentation Symptoms postpartum blues mild depressive symptoms sadness crying irritability anxiety insomnia fatigue mood lability generally diagnosed if 3 or 4 depressive symptoms present major depressive disorder with peripartum onset depressed mood Sleep disturbance, loss of Interest, Guilt or feelings of worthlessness, Energy loss and fatigue, Concentration problems, Appetite/weight changes, Psychomotor retardation or agitation, and Suicidal ideations (mnemonic: SIG E CAPS) diagnostic criteria are same as those used to diagnose non-postpartum major depression postpartum depression begins within 12 months of childbirth peripartum psychosis rapid onset of psychotic symptoms, including hallucinations and delusions typically accompanied by manic and/or depressed mood peripartum onset onset of current episode during pregnancy or within 4 weeks postpartum Treatment Lifestyle no treatment required for postpartum blues, which generally resolves spontaneously evaluate for postpartum depression if symptoms worsen or persist beyond 2 weeks suicidal ideation develops Medical treatment of postpartum major depression antidepressant medications along with psychotherapy SSRIs (i.e., paroxetine and sertraline) recommended for patients who are breastfeeding and were not treated with antidepressants prior to pregnancy resume same antidepressant drug used prior to pregnancy if previously on pharmacotherapy psychotherapy alone is reasonable if depressive syndrome does not include suicidal ideation treatment of peripartum psychosis hospitalization of mother until stable mother should not be left alone with the infant antipsychotic medications second-generation antipsychotics (i.e., quetiapine, risperidone, and olanzapine) recommended over first-generation antipsychotics a benzodiazepine, a mood stabilizer, and/or an antidepressant medication may be used in conjunction with an antipsychotic medication depending on patient's symptoms