Postpartum Depression Project Newsletter - January 26, 2010
This is the first of a quarterly newsletter aimed at promoting recognition, education
and updates on psychiatric treatment of women during pregnancy and the postpartum
period. We will try to provide a summary of the most recent pertinent publications and address one
frequently asked question.
This newsletter is created by members of the MAPP PPD Project, which is a statewide project funded by a
grant from the APA for the purpose of collaborating with other medical specialties and other members of
the mental health community to promote understanding of postpartum depression as a psychiatric illness
with serious consequences to mothers and infants, decrease stigma and increase recognition and
treatment of PPD.
Why the MAPP PPD Project?
-Depression is the leading cause of disease-related disability in women
-1 of 8 new mothers experience depression
-The most common complication of childbirth is depression
-10-20% of women will experience significant depression during pregnancy
-The peak lifetime prevalence for psychiatric disorders and hospital admissions for women occurs in the
first 3 months after childbirth
-The most significant factor in the duration of postpartum depression is delay in receiving treatment
APA/ACOG Guidelines
A recent report with joint guidelines from the American Psychiatric Association and the American College
of Obstetricians and Gynecologists on the management of depression during pregnancy was published in
the September/ October 2009 issue of General Hospital Psychiatry.
The article describes the rate of depression in pregnancy (14%-23%) and the difficulty in interpreting the
literature on the use of antidepressants during pregnancy. The article describes the correlation of
maternal depression and adverse obstetrical outcomes. It provides a good summary of the impact of
antidepressants on birth outcomes.
Treatment guidelines include flowcharts for the following:
Patient considering pregnancy and on medications for depression
-for women with mild or no symptoms, can consider taper and discontinuation of medication
-if possible recommended reasonable period of stability before attempt to conceive
-for women with history of severe and recurrent depression, consider continuation of medication unless
the patient has responded to psychotherapy alone in the past
Pregnant patient in an episode of Major Depression (no SI and no psychotic sx) and not taking
medications
-psychotherapy may be indicated as first line of treatment if woman wants to avoid antidepressants
-if medication preferred, evaluate and discuss risks and benefits (including stage of gestation, history of
depression, maternal and infant impact)
Pregnant patient with Major Depression currently taking antidepressants
-women who are not experiencing depression, have no history of relapse with discontinuation and
request discontinuation of medication, may attempt taper
- women with continued depressive symptoms may benefit from addition of therapy
- women with a history of recurrent severe depression should remain on medication
A full copy of the article is available on line at www.sciencedirect.com
Q. Should valproate medications be prescribed to women of reproductive age?
Considering the number of unplanned pregnancies, up to 49 in one study, valproate should be prescribed
with great caution or not at all in women with reproductive potential.
First trimester exposure to valproate has been associated with a 3-5% risk of neural tube defects. In the
general population, neural tube defects occur in 1 in 1,000-2,000 births. Valproate increases the risk of
other malformations affecting the heart, limbs and genitals. Fetal hepatic failures have been reported in
newborns of mothers who used valproate while pregnant.
A 2009 New England Journal of Medicine article based on a prospective study of 309 women found that
at age 3 years, children exposed to valproate in utero had significantly lower IQs compared with other
antiepileptic medications. On average, children exposed to valproate had an IQ score 9 points lower than
those exposed to lamotrigine, The association between valproate use and IQ was dose dependent.
Children's IQs were significantly related to maternal IQ among children exposed to other antiepileptic
medications but not among those exposed to valproate.
All women should supplement their diets by taking prenatal multivitamins (containing 0.8mg to 1.0mg of
folate). A woman taking valproate (or other anitepileptic) should receive 3.0mg of folate in addition to
other prenatal vitamins. If a woman becomes pregnant while on valproate, she should be offered
screening for neural tube defects.
For more information about the MAPP PPD Project or to get involved please contact us at:
plopsymd@myfairpoint.net or rabinl@mmc.org
Postpartum Depression Project Newsletter Committee
Leora Rabin, MD, Maine Medical Center
Maya Rydewski, MD, Maine Medical Center
P. Lynn Ouellette MD, PPD Project Director, Private Practice, Brunswick Maine