Peripartum depression: Early recognition improves outcomes
ABSTRACT
Depression is highly prevalent in women of childbearing age, especially during the postpartum period. Early recognition and treatment improve outcomes for mother, developing fetus, and infant. Caution is warranted when prescribing antidepressants to pregnant and breastfeeding mothers, but evidence is mounting that the risks of untreated maternal depression outweigh those of pharmacologic treatment for it.
KEY POINTS
- Depression occurs in up to 13% of pregnant women, a prevalence similar to that in nonpregnant women, but the incidence rises postpartum.
- Depressed pregnant women are more likely to engage in behaviors that pose a risk to the fetus.
- Depression in pregnancy is associated with adverse pregnancy outcomes such as preterm birth, low birth weight, gestational diabetes, and hypertensive disorders of pregnancy.
- Risk factors for depression in pregnancy include past episodes of depression, poor social support, unwanted pregnancy, and domestic violence.
DIFFERENTIATING ‘POSTPARTUM BLUES’ FROM MAJOR DEPRESSION
Primary care providers are often the first point of contact for depressed women. The diagnosis of major depression in pregnant and postpartum women is challenging because of changes in sleep, appetite, and energy brought on by pregnancy, complications of delivery, and demands of caring for a newborn.36 Many pregnant and postpartum women are reluctant to disclose their symptoms due to a sense of shame and guilt for being depressed during a time in their life that society commonly regards as joyful, and this contributes to under-detection.
In the first few days postpartum, fatigue, emotionality, irritability, and worry over the infant’s well-being affect up to 75% of women. This period, typically referred to as the “baby blues” or “postpartum blues,” is not considered a disorder and responds well to support, reassurance, and adequate sleep, and it typically resolves within 2 weeks.37,38 Table 1 lists features that help distinguish postpartum blues from major depression.
Signs of major depressive disorder
Major depressive disorder is a serious and disabling condition. To meet criteria for major depressive disorder, women must report depressed mood and loss of interest or pleasure in normally pleasurable activities for at least 2 weeks. Completing the symptom profile, at least 5 of the following must be present: sleep disturbance (insomnia or hypersomnia), lack of energy, feelings of worthlessness or low self-esteem, guilt, difficulty concentrating, indecisiveness, psychomotor retardation or agitation, and thoughts of suicide or death.
The Diagnostic and Statistical Manual of Mental Disorders (5th edition) recognizes that postpartum depression commonly begins during pregnancy, and now uses “peripartum onset” as the specifier for major depressive disorder that occurs during pregnancy, postpartum, or both.39 Other hallmark symptoms with peripartum onset include a lack of interest in or attachment to the pregnancy or infant, and anxiety and worry often accompanied by intrusive, unwanted thoughts of harm befalling the infant.40
Postpartum psychosis
Postpartum psychosis is a far less common presentation, occurring in 1 to 2 per 1,000 births, but it constitutes a psychiatric emergency requiring immediate referral to a psychiatric care setting. Women at highest risk are those with a personal or family history of bipolar disorder.
The clinical presentation is most commonly characterized by confusion, agitation, hallucinations, delusional beliefs, and disorientation. Suicide and infanticide, while rare, are more likely to occur in the context of a psychotic episode.41
SCREENING RECOMMENDATIONS
Screening for depression is routine in primary care settings and is no less important for peripartum women.
In 2016, the US Preventive Services Task Force issued a recommendation that all pregnant and postpartum women be screened for depression,42 highlighting the need for all medical providers to be alert to the potentially serious consequences of unrecognized and untreated maternal psychiatric illness.
The American College of Obstetricians and Gynecologists (ACOG) recommends screening for depression and anxiety at least once during the peripartum period,43 and the American Academy of Pediatrics recommends screening mothers for depression at the 1-, 2-, and 4-month well-baby visits.44
The peripartum period is associated with changes in sleep, appetite, and energy levels, but these are also typical of depression. Taking this into account, the Edinburgh Postnatal Depression Scale (EPDS) was developed to screen for depression specifically in this population.45 The EPDS is a validated and widely used 10-item self-reporting questionnaire with a high degree of sensitivity and specificity; it is easily administered and quickly scored. A cutoff score of 13 (of a maximum of 30) is considered indicative of depressed mood and signals the need for further assessment.
ACOG, the American Academy of Pediatrics, and the US Preventive Services Task Force recommend a standardized validated tool and cite both the EPDS (https://psychology-tools.com/epds/) and the Patient Health Questionnaire-9 (PHQ-9) (Figure 1) as appropriate to screen for peripartum depression.42–44 Primary care providers tend to be most familiar with the PHQ-9, a highly sensitive and specific 9-item depression screen that has been validated in primary care and obstetric clinic patients.46 A score on the PHQ-9 ranging from 5 to 10 indicates mild depression, 10 to 14 moderate depression, 15 to 19 moderate to severe depression, and greater than 19 severe depression.
