Identification and Management of Peripartum Depression

 

Am Fam Physician. 2016 May 15;93(10):852-858.

  Related editorial: Opportunities to Detect and Manage Perinatal Depression in Men.

  Patient information: See related handout on depression during and after pregnancy, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Peripartum depression affects up to one in seven women and is associated with significant maternal and neonatal morbidity if untreated. A history of depression is the strongest risk factor for developing peripartum depression. The U.S. Preventive Services Task Force recommends screening pregnant and postpartum women for depression. Both two-step and one-step screening strategies are effective in identifying peripartum depression. Peripartum depression should be distinguished from the baby blues, which is characterized by short duration, mild symptoms, and minimal impact on functioning. Women with peripartum depression should be evaluated for bipolar disorder, postpartum psychosis, and suicidal risk. For first-time mothers, adolescent mothers, and mothers who have experienced a traumatic delivery, home health visits, telephone-based peer support, and psychotherapy may help prevent peripartum depression. Mild to moderate depression should be treated with psychotherapy or selective serotonin reuptake inhibitors, whereas moderate to severe depression should be treated with a combination of psychotherapy and medication. Citalopram, escitalopram, and sertraline appear to be the safest selective serotonin reuptake inhibitors during pregnancy, whereas fluvoxamine, paroxetine, and sertraline are preferred in breastfeeding women because they lead to the lowest serum medication levels in breastfed infants. Patients with psychosis, active suicidal thoughts, or thoughts of harming their newborns should receive same-day psychiatric consultation and referral for possible inpatient treatment.

Major or minor depression during or immediately after pregnancy occurs in up to one in seven women.1 Peripartum depression is associated with significant neonatal morbidity, such as failure to thrive, attachment disorder, and developmental delay at one year of age2; treatment improves functioning in these children.3 Peripartum depression is also associated with significant maternal morbidity, including decreased energy, poor concentration,4 sleep disturbances,5 and disruption of maternal-infant bonding and healthy family dynamics. Maternal suicide is a more common cause of peripartum mortality than postpartum hemorrhage or hypertensive disorders.6 Family physicians are in a vital position to identify and treat patients with peripartum depression.

WHAT IS NEW ON THIS TOPIC: PERIPARTUM DEPRESSION

First-time mothers, adolescent mothers, and mothers who have experienced a traumatic delivery may benefit from home health visits, telephone-based peer support, and psychotherapy to prevent peripartum depression.

View/Print Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Women may be screened for peripartum depression using a single tool, such as the Edinburgh Postnatal Depression Scale, or using a two-step process, such as the Patient Health Questionnaire-2 followed by a more comprehensive screening test if the initial screen is positive.

C

1820

All women should be screened for depression during pregnancy and the postpartum period.

B

27, 28

Women with peripartum depression should be evaluated for bipolar disorder, postpartum psychosis, and suicide risk and referred for emergent psychiatric evaluation when appropriate.

C

29, 30, 64

There is insufficient evidence to recommend selective serotonin reuptake inhibitors, estrogen, or docosahexaenoic acid for the prevention of peripartum depression.

C

37, 45, 46

There is insufficient evidence to recommend one selective serotonin reuptake inhibitor over another in the treatment of moderate to severe postpartum depression.

C

55


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Women may be screened for peripartum depression using a single tool, such as the Edinburgh Postnatal Depression Scale, or using a two-step process, such as the Patient Health Questionnaire-2 followed by a more comprehensive screening test if the initial screen is positive.

C

1820

All women should be screened for depression during pregnancy and the postpartum period.

B

27, 28

Women with peripartum depression should be evaluated for bipolar disorder, postpartum psychosis, and suicide risk and referred for emergent psychiatric evaluation when appropriate.

C

29, 30, 64

There is insufficient evidence to recommend selective serotonin reuptake inhibitors, estrogen, or docosahexaenoic acid for the prevention of peripartum depression.

C

37, 45, 46

There is insufficient evidence to recommend one selective serotonin reuptake inhibitor over another in the treatment of moderate to severe postpartum depression.

C

55


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality

The Authors

show all author info

ROBERT C. LANGAN, MD, FAAFP, is program director at St. Luke's University Hospital Family Medicine Residency, Bethlehem, Pa....

ANDREW J. GOODBRED, MD, is a faculty member at St. Luke's University Hospital Family Medicine Residency.

Address correspondence to Robert C. Langan, MD, St. Luke's Hospital, 2830 Easton Ave., Bethlehem, PA 18017 (e-mail: robert.langan@sluhn.org). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

show all references

1. Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G, Swinson T. Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol. 2005;106(5 pt 1):1071–1083....

2. Earls MF; Committee on Psychosocial Aspects of Child and Family Health American Academy of Pediatrics. Incorporating recognition and management of perinatal and postpartum depression into pediatric practice. Pediatrics. 2010;126(5):1032–1039.

3. Pilowsky DJ, Wickramaratne P, Talati A, et al. Children of depressed mothers 1 year after the initiation of maternal treatment: findings from the STAR*D-Child Study. Am J Psychiatry. 2008;165(9):1136–1147.

4. Swain AM, O'Hara MW, Starr KR, Gorman LL. A prospective study of sleep, mood, and cognitive function in postpartum and nonpostpartum women. Obstet Gynecol. 1997;90(3):381–386.

5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.

6. Palladino CL, Singh V, Campbell J, Flynn H, Gold KJ. Homicide and suicide during the perinatal period: findings from the National Violent Death Reporting System. Obstet Gynecol. 2011;118(5):1056–1063.

7. Maurer-Spurej E, Pittendreigh C, Misri S. Platelet serotonin levels support depression scores for women with postpartum depression. J Psychiatry Neurosci. 2007;32(1):23–29.

8. Ahokas A, Kaukoranta J, Aito M. Effect of oestradiol on postpartum depression. Psychopharmacology (Berl). 1999;146(1):108–110.

9. Magiakou MA, Mastorakos G, Rabin D, Dubbert B, Gold PW, Chrousos GP. Hypothalamic corticotropin-releasing hormone suppression during the postpartum period: implications for the increase in psychiatric manifestations at this time. J Clin Endocrinol Metab. 1996;81(5):1912–1917.

10. Bunevicius R, Kusminskas L, Mickuviene N, Bunevicius A, Pedersen CA, Pop VJ. Depressive disorder and thyroid axis functioning during pregnancy. World J Biol Psychiatry. 2009;10(4):324–329.

11. Doornbos B, Dijck-Brouwer DA, Kema IP, et al. The development of peripartum depressive symptoms is associated with gene polymorphisms of MAOA, 5-HTT and COMT. Prog Neuropsychopharmacol Biol Psychiatry. 2009;33(7):1250–1254.

12. Räisänen S, Lehto SM, Nielsen HS, Gissler M, Kramer MR, Heinonen S. Risk factors for and perinatal outcomes of major depression during pregnancy. BMJ Open. 2014;4(11):e004883.

13. Lancaster CA, Gold KJ, Flynn HA, Yoo H, Marcus SM, Davis MM. Risk factors for depressive symptoms during pregnancy: a systematic review. Am J Obstet Gynecol. 2010;202(1):5–14.

14. Howard LM, Oram S, Galley H, Trevillion K, Feder G. Domestic violence and perinatal mental disorders: a systematic review and meta-analysis. PLoS Med. 2013;10(5):e1001452.

15. Sutter-Dallay AL, Giaconne-Marcesche V, Glatigny-Dallay E, Verdoux H. Women with anxiety disorders during pregnancy are at increased risk of intense postnatal depressive symptoms: a prospective survey of the MATQUID cohort. Eur Psychiatry. 2004;19(8):459–463.

16. Abbasi S, Chuang CH, Dagher R, Zhu J, Kjerulff K. Unintended pregnancy and postpartum depression among first-time mothers. J Womens Health (Larchmt). 2013;22(5):412–416.

17. Kozhimannil KB, Pereira MA, Harlow BL. Association between diabetes and perinatal depression among low-income mothers. JAMA. 2009;301(8):842–847.

18. Gaynes BN, Gavin N, Meltzer-Brody S, et al. Perinatal depression: prevalence, screening accuracy, and screening outcomes. Evidence report/technology assessment no. 119. Rockville, Md.: Agency for Healthcare Research and Quality; 2005. http://archive.ahrq.gov/downloads/pub/evidence/pdf/peridepr/peridep.pdf. Accessed January 15, 2016.

19. Zubaran C, Schumacher M, Roxo MR, Foresti K. Screening tools for postpartum depression: validity and cultural dimensions. Afr J Psychiatry (Johannesbg). 2010;13(5):357–365.

20. Committee on Obstetric Practice. The American College of Obstetricians and Gynecologists committee opinion no. 630. Screening for perinatal depression. Obstet Gynecol. 2015;125(5):1268–1271.

21. Gjerdingen DK, Yawn BP. Postpartum depression screening: importance, methods, barriers, and recommendations for practice. J Am Board Fam Med. 2007;20(3):280–288.

22. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782–786.

23. Chae SY, Chae MH, Tyndall A, Ramirez MR, Winter RO. Can we effectively use the two-item PHQ-2 to screen for postpartum depression? Fam Med. 2012;44(10):698–703.

24. Jones I, Shakespeare J. Postnatal depression. BMJ. 2014;349:g4500.

25. Miller LJ. Postpartum depression. JAMA. 2002;287(6):762–765.

26. Hirst KP, Moutier CY. Postpartum major depression. Am Fam Physician. 2010;82(8):926–933.

27. Siu AL, Bibbins-Domingo K, Grossman DC, et al. Screening for depression in adults: US preventive services task force recommendation statement. JAMA. 2016;315(4):380–387.

28. Howard LM, Megnin-Viggars O, Symington I, Pilling S; Guideline Development Group. Antenatal and postnatal mental health: summary of updated NICE guidance. BMJ. 2014;349:g7394.

29. Hirschfeld RM, Williams JB, Spitzer RL, et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Am J Psychiatry. 2000;157(11):1873–1875.

30. Sit D, Rothschild AJ, Wisner KL. A review of postpartum psychosis. J Womens Health (Larchmt). 2006;15(4):352–368.

31. Gamble J, Creedy D, Moyle W, et al. Effectiveness of a counseling intervention after traumatic childbirth. Birth. 2005;32(1):11–19.

32. Hiscock H, Cook F, Bayer J, et al. Preventing early infant sleep and crying problems and postnatal depression: a randomized trial. Pediatrics. 2014;133(2):e346–e354.

33. Stremler R, Hodnett E, Kenton L, et al. Effect of behavioural-educational intervention on sleep for primiparous women and their infants in early postpartum: multisite randomised controlled trial. BMJ. 2013;346:f1164.

34. Howell EA, Balbierz A, Wang J, Parides M, Zlotnick C, Leventhal H. Reducing postpartum depressive symptoms among black and Latina mothers: a randomized controlled trial. Obstet Gynecol. 2012;119(5):942–949.

35. Phipps MG, Raker CA, Ware CF, Zlotnick C. Randomized controlled trial to prevent postpartum depression in adolescent mothers. Am J Obstet Gynecol. 2013;208(3):192.e1–192.e6.

36. Dennis CL. Psychosocial and psychological interventions for prevention of postnatal depression: systematic review. BMJ. 2005;331(7507):15.

37. Howard LM, Hoffbrand S, Henshaw C, Boath L, Bradley E. Antidepressant prevention of postnatal depression. Cochrane Database Syst Rev. 2005;(2):CD004363.

38. Ross LE, Grigoriadis S, Mamisashvili L, et al. Selected pregnancy and delivery outcomes after exposure to antidepressant medication: a systematic review and meta-analysis. JAMA Psychiatry. 2013;70(4):436–443.

39. U.S Food and Drug Administration. FDA drug safety communication: selective serotonin reuptake inhibitor (SSRI) antidepressant use during pregnancy and reports of a rare heart and lung condition in newborn babies. December 14, 2011. http://www.fda.gov/Drugs/DrugSafety/ucm283375.htm. Accessed July 31, 2015.

40. Grigoriadis S, Vonderporten EH, Mamisashvili L, et al. Prenatal exposure to antidepressants and persistent pulmonary hypertension of the newborn: systematic review and meta-analysis. BMJ. 2014;348:f6932.

41. Clements CC, Castro VM, Blumenthal SR, et al. Prenatal antidepressant exposure is associated with risk for attention-deficit hyperactivity disorder but not autism spectrum disorder in a large health system. Mol Psychiatry. 2015;20(6):727–734.

42. Skurtveit S, Selmer R, Roth C, Hernandez-Diaz S, Handal M. Prenatal exposure to antidepressants and language competence at age three: results from a large population-based pregnancy cohort in Norway. BJOG. 2014;121(13):1621–1631.

43. Reefhuis J, Devine O, Friedman JM, Louik C, Honein MA; National Birth Defects Prevention Study. Specific SSRIs and birth defects: Bayesian analysis to interpret new data in the context of previous reports. BMJ. 2015;351:h3190.

44. Boukhris T, Sheehy O, Mottron L, Bérard A. Antidepressant use during pregnancy and the risk of autism spectrum disorder in children. JAMA Pediatr. 2016;170(2):117–124.

45. Dennis CL, Ross LE, Herxheimer A. Oestrogens and progestins for preventing and treating postpartum depression. Cochrane Database Syst Rev. 2008;(4):CD001690.

46. Miller BJ, Murray L, Beckmann MM, Kent T, Macfarlane B. Dietary supplements for preventing postnatal depression. Cochrane Database Syst Rev. 2013;(10):CD009104.

47. Deligiannidis KM, Freeman MP. Complementary and alternative medicine therapies for perinatal depression. Best Pract Res Clin Obstet Gynaecol. 2014;28(1):85–95.

48. Sado M, Ota E, Stickley A, Mori R. Hypnosis during pregnancy, childbirth, and the postnatal period for preventing postnatal depression. Cochrane Database Syst Rev. 2012;(6):CD009062.

49. Yonkers KA, Vigod S, Ross LE. Diagnosis, pathophysiology, and management of mood disorders in pregnant and postpartum women. Obstet Gynecol. 2011;117(4):961–977.

50. Rahman A, Malik A, Sikander S, Roberts C, Creed F. Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. Lancet. 2008;372(9642):902–909.

51. Scope A, Leaviss J, Kaltenthaler E, et al. Is group cognitive behaviour therapy for postnatal depression evidence-based practice? A systematic review. BMC Psychiatry. 2013;13:321.

52. Misri S, Kostaras X, Fox D, Kostaras D. The impact of partner support in the treatment of postpartum depression. Can J Psychiatry. 2000;45(6):554–558.

53. Daley A, Jolly K, MacArthur C. The effectiveness of exercise in the management of post-natal depression: systematic review and meta-analysis. Fam Pract. 2009;26(2):154–162.

54. Morrell CJ, Warner R, Slade P, et al. Psychological interventions for postnatal depression: cluster randomised trial and economic evaluation. The PoNDER trial. Health Technol Assess. 2009;13(30):iii–iv, xi–xiii, 1–153.

55. Molyneaux E, Howard LM, McGeown HR, Karia AM, Trevillion K. Anti-depressant treatment for postnatal depression. Cochrane Database Syst Rev. 2014;(9):CD002018.

56. Sharp DJ, Chew-Graham C, Tylee A, et al. A pragmatic randomised controlled trial to compare antidepressants with a community-based psychosocial intervention for the treatment of women with postnatal depression: the RESPOND trial. Health Technol Assess. 2010;14(43):iii–iv, ix–xi, 1–153.

57. Wisner KL, Parry BL, Piontek CM. Clinical practice. Postpartum depression. N Engl J Med. 2002;347(3):194–199.

58. Costantine MM. Physiologic and pharmacokinetic changes in pregnancy. Front Pharmacol. 2014;5(5):65.

59. Weissman AM, Levy BT, Hartz AJ, et al. Pooled analysis of antidepressant levels in lactating mothers, breast milk, and nursing infants. Am J Psychiatry. 2004;161(6):1066–1078.

60. Fortinguerra F, Clavenna A, Bonati M. Psychotropic drug use during breastfeeding: a review of the evidence. Pediatrics. 2009;124(4):e547–e556.

61. ACOG Committee on Practice Bulletins—Obstetrics. ACOG practice bulletin: clinical management guidelines for obstetrician-gynecologists number 92, April 2008 (replaces practice bulletin number 87, November 2007). Use of psychiatric medications during pregnancy and lactation. Obstet Gynecol. 2008;111(4):1001–1020.

62. Sachs HC; Committee On Drugs. The transfer of drugs and therapeutics into human breast milk. Pediatrics. 2013;132(3):e796–e809.

63. Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #18: use of antidepressants in nursing mothers. Breastfeed Med. 2008;3(1):44–52.

64. Mitchell J, Trangle M, Degnan B, et al; Institute for Clinical Systems Improvement. Adult depression in primary care. Updated September 2013. https://www.icsi.org/_asset/fnhdm3/Depr-Interactive0512b.pdf. Accessed January 18, 2016.

65. Gelenberg AJ, Freeman MP, Markowitz JC, et al.; American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder. Third edition. 2010. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf. Accessed October 26, 2015.

66. Klinger G, Stahl B, Fusar-Poli P, Merlob P. Antipsychotic drugs and breastfeeding. Pediatr Endocrinol Rev. 2013;10(3):308–317.


 

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