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Updated: Apr 23 2020

Major Depressive Disorder with Peripartum Onset (Postpartum Depression)

  • 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
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