1
Florida Heart CPR*
Postpartum Depression
1 hour
Objectives: After completing this course, the student will have an understanding of
AntePartum and Postpartum Depression, its causes, diagnoses, and treatments.
Psychiatric mood disorders can and do occur in pregnant women. Women with
antepartum depression have a risk of poor nutrition, substance abuse, and prenatal
noncompliance. Careful assessment of risk and benefits to the pregnant woman and to
the unborn child must be made before pharmacologic therapy is initiated. The three
postpartum mood disorders--postpartum "blues," postpartum depression, and
postpartum psychosis--are common, and education is an important instrument in the
treatment of these disorders.
Pregnancy-related psychiatric disorders were described by Hippocrates in the 4th
century BC.1 Once stricken from the American psychiatric nomenclature, postpartum
disorders have recently been incorporated into the fourth revision of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV).2 Although the criterion for symptom
onset is limited to the fourth postpartum week, many clinicians consider symptom onset
within six to 12 months after delivery as temporally related to childbirth. It is a wellknown fact that mood disorders are two times more common in women than in men,
particularly during childbearing years.3 These mood changes are more likely to occur
during rapid shifts in reproductive hormones, such as pregnancy, premenstruum, and
perimenopause. Nevertheless, these affective states do not correlate with either genetic
or psychosocial factors. In addition, research has failed to demonstrate a direct
relationship between the gonadal steroids and mood.4
During gestation, estrogen and progesterone rise to peak levels, then rapidly decline
within the first 24 to 48 hours after delivery.5,6 Alterations in brain monoamine
transmission are correlated with affective disorders.7 The neurohormonal hypothesis
suggests that the gonadal hormones trigger changes in brain neurotransmitter function,
which in turn precipitate psychiatric symptoms.8 This precipitous hormonal decline
appears to alter central nervous system activity and to cause psychiatric disorders in
vulnerable women at childbirth.9
ANTEPARTUM DEPRESSION
It was once thought that women were protected against psychiatric disorders during
gestation. Although society's expectation is one of maternal bliss during pregnancy, the
prevalence of antepartum depression is similar to that of depression in postpartum
women and nonchildbearing women.10,11 One in 10 women suffers from antepartum
depression. This depression often remains unrecognized because many discomforts of
pregnancy are similar to symptoms of depression.12
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Post-Partum Depression
2
Pregnant women with depression are at risk for poor nutrition, substance abuse, and
noncompliance with prenatal care.13 Also, they have a greater potential for child abuse
and neglect.14 Because depression during pregnancy is a strong predictor of postpartum
depression, the antepartum period is an optimum time for screening, diagnosis, and
treatment.15
RISKS AND BENEFITS OF TREATMENT
The decision to treat the pregnant depressed woman presents a dilemma for both the
patient and the physician. Few guidelines exist primarily because antepartum
depression has been underdiagnosed. Therefore, few treatment trials have been
conducted. Recent controlled clinical treatment trials provide some information about
fetal teratogenic and neurobehavioral effects,16-18 but there is a paucity of information to
reassure the mother of absolute safety.19 The risk–benefit assessment of
pharmacotherapy must be done by the patient, significant other, and treating physician.
In addition, the unknown effects of stress, depression, and anxiety on the fetus must be
considered and may contribute substantially to fetal distress or neonatal outcome.
Therefore, the decision to treat depression during gestation must be determined by
balancing maternal well-being with fetal safety.
Recent data suggest that depression during pregnancy increases perinatal risk. 19
Therefore, the seriousness of the mother's illness, the likelihood of recurrence, and the
available support systems all must be considered by the physician, patient, and
significant other.
METHODS OF TREATMENT
Although electroconvulsive therapy (ECT) is indicated for psychotic mood disorders,
clinical guidelines also exist for gestation depression.20 Another treatment alternative is
psychotherapy, which is an appropriate choice as an initial noninvasive treatment
modality. Interpersonal psychotherapy (IPT) is a brief, focused therapy designed to treat
nonpsychotic major depression. It has been shown to be effective in decreasing the
neurovegetative symptoms of depression and improving interpersonal skills.21
The role of the pregnant woman changes rapidly in both family and society. IPT for
antepartum depression (IPT-P) is a modified version of interpersonal psychotherepy,
that addresses the role transition and developmental stages of pregnancy. 22
An open trial pilot study of IPT-P has illustrated its efficacy in 13 pregnant women who
met DSM-III-R criteria for major depression.22,23 Both physician- and patient-rated
depression scales decreased significantly from entry week zero to termination week 16.
Of the 10 subjects located in the third postpartum month, none suffered a postnatal
depression. A controlled clinical trial of IPT-P funded by the National Institute of Mental
Health (NIMH) is presently underway at the Columbia University College of Physicians
and Surgeons.
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Post-Partum Depression
3
POSTPARTUM MOOD DISORDERS
Three syndromes have been identified in the postpartum period. Postpartum "blues,"
postpartum depression, and postpartum psychosis are believed to represent a spectrum
of mood disorders.24
Postpartum "Blues"
Postpartum "blues" is a self-limited syndrome of mood lability, euphoria, tearfulness,
confusion, and insomnia, that is experienced by 39% to 85% of new mothers.25,26 This
subsides without treatment by postpartum day 14. Because the "blues" may represent a
prodrome of depression, the practitioner should monitor symptoms, particularly in
women with a personal or family history of mood disorder.
A recent New York State law27 stipulates that postpartum women must be advised of
the possibility that one in 10 women will begin motherhood with a depressive episode,
and that one or two in 1000 will suffer postpartum psychosis.11,28 This recognition may
signify the beginning of improved awareness of and education about psychiatric
disorders. Education is a valuable instrument, which enables the new parents and
family to seek treatment if postpartum depression symptoms appear.
Postpartum Depression
Psychiatric hospital admissions are more likely to occur at childbirth than at any other
time of life.29 Eighty percent receive a diagnosis of affective disorder. Women with
postpartum depression are more likely to have infants who are withdrawn and
inconsolable.13 Weissman et al30 found that these children are themselves predisposed
to depression.
Puerperal depression is treated with standard psychopharmacologic interventions. 28 If
the mother wishes to breast-feed, the risks and benefits of psychotropic medications
must also be considered. Recent data indicate that some psychotropic medications
pass only minimal or undetectable amounts of drug or metabolite from breast milk to the
infant serum.31,32However, even small doses of medication may have unknown adverse
effects on the infant's developing central nervous system.
Inadequate response to antidepressant treatment is often due to inadequate dosing for
an insufficient period of time.33 Consequently, medication should be continued for six
months to one year. The likelihood of recurrence after a postpartum affective episode is
30% to 50%.34,35 Affected women are estimated to be 300 times more likely to
experience a recurrence of postpartum depression.6
POSTPARTUM PSYCHOSIS
Postpartum psychosis begins precipitously and is associated with hallucinations and
delusional beliefs about the infant.36 Because puerperal psychosis frequently represents
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Post-Partum Depression
4
a bipolar spectrum disorder, mood stabilization and antipsychotic intervention are often
necessary.29 Puerperal psychosis is a psychiatric emergency requiring hospitalization.
Therefore, the infant must be protected from the psychotic mother and her infanticidal
impulses. The mother must be evaluated and the family informed of the potential
dangers. In addition, the risk of postpartum psychosis for subsequent pregnancies
increases 100-fold.35,37
Prophylactic pharmacologic therapy in women with a history of postpartum psychosis
may prevent recurrence. Antipsychotics, antidepressants, and mood stabilizers are
excellent methods of prophylaxis in women who were successfully treated during a
previous postpartum episode.37-39 Medication should be started soon after delivery, and
the dosage should be selected according to the history of previous remission.38
LEGAL CONSEQUENCES
Most Western countries consider childbirth a time of increased vulnerability to mental
illness.9 However, the U.S. medical system has been slow to identify these illnesses. In
fact, the United States is the only Western country to incarcerate postpartum psychotic
mothers who have killed their infants. These mothers are charged with homicide and
incarcerated without treatment. In other countries, such as England and Italy, a woman
is considered vulnerable because of childbirth with preference for psychiatric
treatment.40
New advances in American research have increased the trend toward public
awareness, better-educated physicians, and well-informed patients. Yet, as long as
postpartum illness remains unrecognized in the psychiatric community, our judicial
system will fail to validate its existence in postpartum mothers who commit infanticide.
Thus, the identification and treatment of psychiatric illness associated with childbirth
constitute a method of both primary and secondary prevention by treating parents of
children at risk and reducing family morbidity.
References
1. Hamilton JA. The identity of postpartum psychosis. In: Brockington IF, Kumar R, eds. Motherhood and
Mental Illness. Vol 1. London, England: Academic Press; 1982:1-17.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed.
Washington, DC: American Psychiatric Press; 1994.
3. Robins LN, Helzer JE, Weissman MK, et al. Lifetime prevalence of specific psychiatric disorders in
three sites. Arch Gen Psychiatry 1984;41:949-958.
4. Wisner K, Stowe Z. Psychobiology of postpartum mood disorders. Semin Reprod Endocrinol
1997;15:77-89.
5. George A, Sandler M. Endocrine and biochemical studies in puerperal mental disorders. In:
Brockington IF, Kumar R, eds. Motherhood and Mental Illness. Vol 1. London, England: Academic Press;
1982:78-105.
6. Hamilton JA, Sichel DA. Postpartum measures. In: Hamilton JA, Harberger PN, eds. Postpartum
Psychiatric Illness: A Picture Puzzle. Philadelphia, PA: University of Pennsylvania Press; 1992:219-254.
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7. Mann JJ, McBride P, Stanley M. Neurochemical correlates of suicide: Postmortem serotonergic and
adrenergic receptor binding to frontal cortex: Correlations with suicide. Psychopharmacol Bull 1986;22:
647-743.
8. Pajer K. New strategies in the treatment of depression in women. J Clin Psychiatry 1995;56:30-37.
9. Hamilton JA. The issue of unique qualities. In: Hamilton JA, Harberger PN, eds. Postpartum Psychiatric
Illness: A Picture Puzzle. Philadelphia, PA: University of Pennsylvania Press; 1992:15-32.
10. Gotlib IH, Whiffen VF, Mount JH. Prevalence rates and demographic characteristics associated with
depression in pregnancy and the post partum. J Consult Clin Psychol 1989;57:269-274.
11. O'Hara M, Zekoski EM, Philipps LH, et al. Controlled prospective study of postpartum mood disorders:
Comparison of childbearing and nonchildbearing women. J Abnorm Psychol 1990;99:3-15.
12. Klein MH, Essex MJ. Pregnant or depressed? The effect of overlap between symptoms of depression
and somatic complaints of pregnancy on rates of major depression in the second trimester. Depression
1994;2:1994-1995.
13. Zuckerman A, Bauchner H, Parker S, et al. Maternal depressive symptoms during pregnancy, and
newborn irritability. Developmental and Behavioral Pediatrics 1990;114:190-194.
14. Scott D. Early identification of maternal depression as a strategy in the prevention of child abuse.
Child Abuse Negl 1992;16:345-358.
15. Bridge LR, Little BC, Hayworth J, et al. Psychometric antenatal predictors of postnatal depressed
mood. J Psychosom Res 1985;29:325-331.
16. Pastuszak A, Schick-Boschetto B, Zuber C, et al. Pregnancy outcome following first-trimester
exposure to fluoxetine. JAMA 1993;269:2246-2248.
17. Jacobson SJ, Jones K, Johnson K, et al. Prospective multicenter study of pregnancy outcome after
lithium exposure. Lancet 1992;39:530-533.
18. Altshuler L, Cohen L, Szuba MP, et al. Pharmacological management of psychiatric illness during
pregnancy: Dilemmas and guidelines. Am J Psychiatry 1996;153:592-606.
19. Nulman I, Rovet J, Stewart DE, et al. Neurodevelopment of children exposed in utero to
antidepressant drugs. N Engl J Med 1997;336:258-262.
20. Stewart DF, Robinson GK. Psychotropic drugs and electroconvulsive therapy during pregnancy and
lactation. In: Stewart DE, Stotland NL, eds. Psychological Aspects of Women's Health. Washington, DC:
American Psychiatric Press; 1993:71-95.
21. Klerman GL, Weissman MM, Rounsaville BH, et al. Interpersonal Psychotherapy of Depression. New
York, NY: Basic Books; 1984.
22. Spinelli M. Interpersonal psychotherapy in antepartum depression: A pilot study. Am J Psychiatry
1997;154(7):1028-1030.
23. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed rev.
Washington, DC: American Psychiatric Press; 1980.
24. Hapgood CC, Elkind GS, Wright JJ. Maternity blues: Phenomena and relationship to later post partum
depression. Aust N Z J Psychiatry 1988;22:299-306.
25. O'Hara MD, Schlechte JA, Lewis DA, et al. Prospective study of postpartum blues: Biologic and
psychosocial factors. Arch Gen Psychiatry 1991;48:801-806.
26. Kennerly R, Gath D. Maternity blues I: Detection and measurement by questionnaire. Br J Psychiatry
1989;155:356-362.
Florida Heart CPR*
Post-Partum Depression
6
Florida Heart CPR*
Postpartum Depression Assessment
1. Women with antepartum depression have a risk of
a. Poor nutrition
b. Substance abuse
c. Prenatal noncompliance
d. All of the above
2. It is a well-known fact that mood disorders are ____ times more common in
women than in men, particularly during childbearing years.
a. Two
b. Three
c. Four
d. Five
3. A syndrome that has been identified in the postpartum period is
a. Postpartum “blues”
b. Postpartum depression
c. Postpartum psychosis
d. All of the above
4. ________is a self-limited syndrome of mood lability, euphoria, tearfulness,
confusion, and insomnia, that is experienced by 39% to 85% of new mothers.
a. Postpartum “blues”
b. Postpartum depression
c. Postpartum psychosis
d. None of the above
5. Women with ________ are more likely to have infants who are withdrawn and
inconsolable.
a. Postpartum “blues”
b. Postpartum depression
c. Postpartum psychosis
d. All of the above
6. _______begins precipitously and is associated with hallucinations and delusional
beliefs about the infant. Mood stabilization and antipsychotic intervention are
often necessary.
a. Postpartum “blues”
b. Postpartum depression
c. Postpartum psychosis
d. None of the above
Florida Heart CPR*
Post-Partum Depression
7
7. Although the criterion for symptom onset is limited to the fourth postpartum week,
many clinicians consider symptom onset within ____ months after delivery as
temporally related to childbirth.
a. 3-6
b. 6-9
c. 6-12
d. 9-12
8. This type of depression often remains unrecognized because many discomforts
of pregnancy are similar to symptoms of depression.
a. Postpartum “blues”
b. Postpartum depression
c. Postpartum psychosis
d. Antepartum depression
9. Because depression during pregnancy is a strong predictor of______, the
antepartum period is an optimum time for screening, diagnosis, and treatment.
a. Postpartum depression
b. Postpartum “blues”
c. Postpartum psychosis
d. None of the above
10. The decision to treat depression during gestation must be determined by
balancing
a. Maternal well being with fetal safety
b. Maternal mental status with physical side effects
c. Fetal side effects with maternal physical side effects
d. Fetal mental status with maternal well being
Florida Heart CPR*
Post-Partum Depression