Peripartum Depression

Risks from untreated major depression during pregnancy

Decreased prenatal care
Insufficient weight gain
Increased use of addictive substances
Increased risk of being a victim of violence
Decision to abort due to depression
Suicide (although risk may be lower than in non-pregnant women

Obstetric & neonatal complications of depression
Fetal growth retardation
Pre-eclampsia
Premature labor
Placental abruption
Newborns more inconsolable (independently of addictive substance use, weight gain, length of labor, method of delivery and Apgar scores)


Types of postpartum mood disorders
Postpartum “blues”
Postpartum depression
Postpartum psychoses

Postpartum “blues”
Central features: tearfulness, lability, reactivity
Peaks 3-5 days after delivery
Present in 50-80% of women
Present in all cultures studied
Unrelated to environmental stressors
Unrelated to psychiatric history

Postpartum “blues” : hormone withdrawal hypothesis
Ovarian steroid receptors in CNS are heavily concentrated in the limbic system
The magnitude of the postpartum drop in estrogens and progesterone correlates with presence of “blues”; absolute levels don’t
Neuroactive steroids (pregnanolone, allopregnanolone) decrease postpartum, affecting GABA

Postpartum “blues”: biological attachment hypothesis
Neurobiological systems foster attachment between mammalian mothers & infants
Oxytocin activates limbic structures (e.g. the ACG) that mediate the interface between attention & emotion
Postpartum reactivity may stem from this
With stressors, depression may result

“I couldn’t snap out of it. I was so down. I had a knot in my stomach. I kept wringing my hands. Sometimes I held my head, knowing that at any second, it was going to explode. I was petrified to get up with my baby. I would cry at the drop of a hat. I was afraid I’d lose my temper. I felt guilty because I couldn’t control myself. I couldn’t bring myself to eat. I had to force myself to chew. I couldn’t sleep even though I was exhausted.” (from Dalton)

Clinical features of postpartum depression
Despondency
Sleep disturbance, fatigue, irritability
Anorexia
Poor concentration
Feelings of inadequacy
Ego-dystonic thoughts of harming the baby

Characteristics of postpartum depression
Begins within 4 weeks of baby’s birth
Clinical presentation peaks 3-6 months after delivery
Present in 10% of new mothers in U.S.
Much less prevalent in some cultures
Related to psychiatric history
Related to environmental stressors

Consequences of untreated postpartum depression
Disturbed mother-infant relationship (elevated cortisol found in both)
Psychiatric morbidity in children later (depression, conduct disorder, lower IQ)
Marital tension
Vulnerability to future depression
Suicide/homicide

Postpartum cultural influences
Ceremonies
Cleansing rituals
Seclusion
Rest
Solicitude
Return to home of origin

Postpartum psychoses
Usually related to a mood episode
More disorientation, agitation, lability
Peaks within 3 weeks of birth
Affects 1/1000 women overall, but 25 - 35% of women with bipolar diathesis
Predicted by absence of depression/anxiety in third trimester
Unrelated to environmental stressors

Treating postpartum mood disorders
Psychotherapy
Interpersonal psychotherapy
Couples therapy
Somatic treatments
Antidepressant medication
Hormone therapy
ECT
Self help networks

Interpersonal psychotherapy for postpartum depression
Focus on role transition
Integrate new role with established roles
Explore feelings & ambivalence about roles
Assess satisfaction with relationships
Define patient’s expectations of others
Renegotiate relationships
Maintain specific problem focus

Couples therapy for postpartum depression: evaluation
Evaluation begins with family, then each parent individually, then couple together
Relevant history
parents’ families of origin
history of parents’ relationship
parents’ expectations about the baby
circumstances surrounding becoming pregnant, pregnancy, labor, delivery, postpartum

Couples therapy for postpartum depression
Create accepting atmosphere
Educate about wide range of normal feelings postpartum
Establish common ground
Articulate “ideal family”
Find compromises to approximate the ideal and replace fantasies with a real family

Antidepressants: teratogenicity
Morphologic: none for SSRI’s, tricyclics & venlafaxine; not enough systematic data about newer agents (e.g. nefazodone, bupropion, mirtazapine)
Behavioral
none for fluoxetine, tricyclics
fluoxetine protects against brain effects of maternal separation in rats

Antidepressants: fetal & neonatal side effects
SSRI’s: “colic”, decreased weight gain; tremor; tachypnea; motor automatisms; increased bleeding diathesis
Tricyclics: tachycardia; (rare) tachyarrhythmia, urinary retention
All antidepressants:
neonatal withdrawal
questionable association with prematurity

Guidelines for antidepressants during pregnancy
Consider better-studied agents
Agents to avoid during pre-eclampsia: bupropion, maprotiline
Vitamin C with SSRI’s
Dosing considerations
increase sometimes needed in 2nd trimester
consider reduction during last month

Postpartum pharmacotherapy: side effect concerns
Sedation
Insomnia
Weight gain
Decreased sexual desire
Effects on breastfeeding infant

Antidepressants & lactation: relative doses to nursing
Sertraline: 0.4% - 1.0%
Fluvoxamine 0.5% - 1.6%
Paroxetine: 0.1% - 4.3%
Fluoxetine: 1.2% - 12.0%
Venlafaxine: 5.2% - 7.4%
Citalopram: 0.7% - 9.0%
(% of weight-adjusted maternal doses)

Antidepressants & lactation: reported side effects
Usually none
Fluoxetine case report of “colic” -- e.g. crying, restlessness, decreased sleep, vomiting, watery stools
Citalopram case report of uneasy sleep
Doxepin case report of pallor, hypotonia, respiratory depression

Prescribing during lactation
Explain potential risks & benefits, ideally to both parents
Obtain description of baby’s baseline behavior
For possible infant side effects, check serum level & confer with pediatrician
Some mothers pump breast milk prior to each dose & use pumped milk after dose

Postpartum estrogen treatment
Effective in placebo-controlled studies
Dose: 200 micrograms as transdermal patch, changed twice weekly, or sublingual 1mg QID
Contraindications: breast cancer, hypercoagulability, pregnancy
Efficacy & safety relative to antidepressants not yet established

Preventing peripartum depression
Discuss family planning & reproduction
Identify women at risk during pregnancy
Psychosocial prevention
Mood stabilizer prophylaxis for bipolar disorder
Antidepressant prophylaxis for depression
Estrogen prophylaxis (experimental)