Keywords
Key points
- •Postpartum depression incidence is increasing and should be screened for at antepartum, postpartum, and pediatric visits.
- •Therapeutic counseling should be used as a first step in all peripartal people who are at risk of postpartum depression.
- •Good informal social support may help prevent and may decrease the symptoms of postpartum depression.
- •There are multiple treatment modalities available for postpartum depression, including counseling, medication, social support, repeated transcranial magnetic stimulation, and electroconvulsive therapy.
- •The rare complication of postpartum psychosis is a medical emergency and requires emergent hospitalization and treatment.
Introduction
Postpartum depression (PPD) is a relatively common depressive disorder that occurs after the delivery of a baby. Previously thought to have an onset only after delivery, postpartum depression is now considered to be a form of peripartal depression, as approximately half of cases have an onset of affective symptoms during pregnancy [
1
]. PPD is a major depressive disorder (MDD) that can be managed with nonpharmaceutical therapeutic care in less serious cases, but often requires more extensive treatment [1
,2
].Peripartum depression is defined by the American Psychiatric Association as depression that occurs during pregnancy or after delivery and includes symptoms of sadness, changes in energy that may include reduced capacity for pleasure, sleep issues, appetite changes, and anxiety [
1
, 2
, 3
]. Patients may exhibit loss of interest, reduced capacity to think clearly, and an inability to concentrate. (PPP), a severe form of PPD, is a condition that may include suicidal or infanticidal ideation and requires emergency psychiatric evaluation [2
]. Symptoms of PPD may begin as early as the third trimester of pregnancy or may start as late as 4 weeks to 1 year postpartum [2
, 3
, 4
].Peripartal depression is a common complication of childbearing. Although estimates vary, it is suspected that as many as 1 in 7 childbearing women may be affected, and recent work suggests that the incidence may be increasing [
1
, 2
, 3
, 4
, 5
, 6
]. Although part of the increase is suspected to be related to increased awareness and diagnosis, there was a 30% increase in peripartal depression between 2014 and 2018, possibly related to income inequality, women’s long working hours, older maternal age, and decreased social connections [6
,7
]. The childbearing parent, newborn, and entire family unit are likely to suffer long-term effects from perinatal depression [1
, 2
, 3
, 4
, 5
].Estimates of the incidence of PPD vary greatly, from 6% to 20% of childbearing women [
3
,7
]. Although there is regional variation, an increased incidence in PPD exceeding 20% has been found in women who were adolescents, smokers, those who had a history of intimate partner violence or a prior history of depression, those who suffered the death of an infant, or those who were of Native American or Alaskan Native heritage [8
]. Half of the depressive episodes in the peripartal period are diagnosed during pregnancy, and 50% of cases are diagnosed up to 1 year postpartum [3
,8
].Types of depression postpartum
PPD, the subset of peripartum depression that occurs after delivery, has been divided into categories, each of which has its own incidence, risk factors, prognosis, and outcomes. These categories include “baby blues,” PPD, and PPP.
Baby blues
“Baby blues” is a common short-lived phenomenon lasting only several days within the first 2 weeks following birth. Characterized by sadness or moodiness, “baby blues” do not require treatment, resolve spontaneously, and are estimated to be experienced by up to 70% of childbearing women [
4
]. “Baby blues” are not PPD, as they are related to the changes in hormonal levels, fatigue, and relationship changes. “Baby blues” occur in 39% to -85% of women, typically improve spontaneously within 3 to 5 days, and require no treatment [9
, 10
, 11
].Postpartum depression
PPD, a subset of peripartal depression, typically occurs later after the birth of a baby and may have some of the same symptoms as postpartum blues. However, PPD lasts longer than 2 weeks and is likely to require treatment [
2
]. Although the underlying cause is not known, PPD may be related to a sudden drop in estrogen and progesterone or thyroid hormones following delivery, fatigue from labor and delivery, sleep disruption, or relationship changes. Changes in home life, work, unscheduled time, unrealistic expectations, and being overwhelmed may also be related. PPD is associated with poor bonding with the newborn and later disruptions in cognitive, emotional, and physical development in children. PPD is disruptive to the patient and their family and is a serious illness [11
].Symptoms of PPD are similar to other MDD and include sadness, hopelessness, restlessness, moodiness, low energy, and difficulty focusing or with memory (Table 1). The postpartum person may have multiple other symptoms that do not dissipate spontaneously, and the patient or family members may notice symptoms worsening [
2
,4
,10
,11
].Table 1Symptoms of postpartum depression
Data from Beck CT. A checklist to identify women at risk for developing postpartum depression.J Obstet Gynecol Neonatal Nurs. 1998;27(1):39-46
| Common symptoms of PPD | Less common symptoms of PPD |
|---|---|
|
|
Postpartum psychosis
PPP is rare, occurring in 1 to 4 out of 1000 postpartum women, and occurs within the first 2 days to 4 weeks postpartum [
11
,12
]. In addition to other symptoms of PPD, people with PPP may suffer from hallucinations, paranoia, agitation, reckless behavior, confusion, and very rapid mood swings. The patient, the newborn, and other children are at high risk of injury or death, as the patient may become suicidal or consider infanticide [4
,11
]. Frequently related to a past personal or family history of bipolar disorder, PPP is considered a medical emergency and is frightening for the patient and their family.Women who have the preexisting mental health conditions, such as bipolar disorder or schizoaffective disorder, are at higher risk of PPP [
13
,14
]. Furthermore, bipolar disorder may emerge during pregnancy in birthing parents who have a personal or family history of mood disorders [4
]. Patients may suffer from severe sadness, high energy, elevated mood, rapid speech, poor judgment, minimal sleep, and hallucinations or delusions [4
].History
Mental health disorders attributable to or coinciding with events in female lives have been recognized for centuries. From nearly 4000 years ago when Romans diagnosed hysteria, from the root word hystera, or uterus, PPD was suggested to be a type of female mental illness through “puerperal melancholia.” In the 1800s, women were vulnerable to mental illnesses related to childbearing [
15
,16
]. Treatments over the ages included ice baths, restraint, bleeding, purging, food, rest, and institutionalization of affected women. During the early part of the twentieth century, motherhood was extolled, and little mention was made of PPD or other negative emotions that might be related to childbearing [16
].However, in the 1950s, some articles in the popular press had started to mention PPD, although it went against the narrative of joyous motherhood embraced in the first part of the century for white middle-class women, the societal standard to which all women were compared at the time [
17
]. By the mid-1980s, PPD was recognized as a poorly understood distinct illness that not only affected the postpartum mother but also negatively affected the newborn and the family constellation [10
,15
]. Little screening was done for PPD [10
,15
].At the end of the twentieth century, researchers had recognized the need for screening and intervention for PPD. Several models were developed to evaluate postpartum women for PPD. Two widely used scales developed for this purpose were the Beck Postpartum Depression Screening Scale and the Edinburgh Postnatal Depression Scale, both of which helped care providers evaluate the need for intervention in postpartum patients [
10
,12
].Interest in PPD has accelerated since the turn of the century. The US Preventative Services Taskforce (USPSTF) updated its screening recommendations for depression in adults to include screening of pregnant and postpartum women and in 2019 recommended counseling intervention for all pregnant or postpartum women who showed symptoms of depression [
5
].Effects of the coronavirus disease 2019 pandemic on postpartum depression
It is estimated that only about 50% of women who had PPD were diagnosed as such before the coronavirus disease 2019 (COVID-19) pandemic [
18
]. The Kaiser Family Foundation has reported that the baseline rate of depression and anxiety in the adult population of the United States has increased precipitously since the onset of the COVID-19 pandemic in early 2020 [19
]. Although approximately 11% of the population reported symptoms of anxiety and depression in a survey done in the first half of 2019, the Kaiser survey showed an incidence of anxiety and depression of approximately 41% in 2021 [19
]. Because a prior history of depression and anxiety is associated with PPD, it is unsurprising that anxiety and depression in pregnant and postpartum women may also have become more prevalent during the pandemic. Of concern, the continuing isolation from friends and family that the COVID-19 pandemic has required could further increased PPD.Diagnosis
Diagnosis of PPD is made via the persistence of troubling depressive symptoms that affect thinking, mood and emotions, and daily activities, including care of self and others, sleep, eating, and work, for 2 weeks or longer [
2
]. Diagnosis of PPD is dependent on the presence of 5 or more signs and symptoms that last more than 2 weeks (Box 1) [20
]. As with other diagnoses, PPD should be considered against the individual’s complete evaluation, which should include thyroid levels and a complete physical examination.Box 1
Postpartum depression symptoms from Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition)
- Feeling of depression most of day, most days for greater than 2 weeks
- Decreased pleasure or interest in usual pastimes for greater than 2 weeks
- Eating more or less than usual; gaining or losing weight, appetite changes
- Sleeping more or less than usual
- Agitation, fidgeting, slower movements, or slower talking than usual
- Feeling tired or run down most of day, most days for greater than 2 weeks
- Difficulty concentrating
- Memory loss
- Difficulty making decisions
- Feeling worthless, guilty, or overwhelmed
- Thoughts of death or suicide or current suicidal ideation
- Inability to take care of self (hygiene, meals, food)
- Inability to take care of baby or feeling detached from baby
- Detachment from family and friends
- Inability to work, study, or maintain household
- Inability to problem solve or cope with problems
Risk factors
Risk factors for PPD may include a past history of depression, anxiety, or PPD in the patient or their family, current life stress, a history of sexual or physical abuse, pregnancy complications including preterm or traumatic deliveries, or difficulty during labor [
1
, 2
, 3
,21
,22
]. Young maternal age, poor or limited social support, low economic status, substance use disorder, and unplanned pregnancy may also be risk factors [2
,3
,22
,23
]. Although most women experience some stress during pregnancy, there is evidence that black and Hispanic women, particularly those experiencing relational and financial stress, and Asian/Pacific Islander women experiencing high levels of physical stress have higher rates of PPD [18
,21
]. Impoverished women have rates of PPD that are nearly double those of the general population of childbearing women [22
].Screening tools
Although there have been several tools developed to assist in screening for PPD, two are commonly used. The Beck Postpartum Depression Screening Scale is based on risk factors for PPD and is designed to be used as a tool that promotes discussion between a patient and their provider [
8
]. Beck’s scale helps patients, and their providers, consider specific risk factors for PPD in the context of length of time symptoms have occurred (Box 2) [8
]. In the Beck screening tool, although a higher score indicates greater risk of PPD, it is not diagnostic. Furthermore, Beck recommended the continued use of the tool to screen throughout the first year of the infant’s life, so that women with later-onset PPD could be screened in for further workup [8
].Box 2
Primary screening topics in the Beck Postpartum Depression Scale
- Antenatal depression
- Antenatal anxiety
- History of previous depression
- Lack of social support
- Marital/partner relationship dissatisfaction
- Life stress (major life changes, family or partner issues, financial issues, death in family)
- Childcare issues
- “Baby blues”
The Edinburgh Postnatal Depression Scale is a shorter, 10-question screening tool that can be completed in approximately 5 minutes by patients or providers [
11
,18
,19
]. Although there are no universally accepted cutoff markers diagnostic for depression in this scale, a score of greater than 12 is frequently considered to be indicative of probable PPD and requires further patient evaluation [11
,18
,19
,24
].A 2018 study showed that approximately 80% of women were screened during pregnancy, and 87% were screen postpartum for risk factors related to PPD [
15
]. However, there is some evidence that screening for PPD has significantly declined during the COVID-19 pandemic. As the need to curtail face-to-face visits to protect healthy patients and health care workers increased, the in-person visit schedule for pregnant and postpartum people has significantly decreased, and screening opportunities have lessened [18
].Prevention
Little is known about prevention of PPD. The American College of Obstetricians and Gynecologists recommends early screening for all postpartum patients [
23
]. The USPTF recommends counseling for those at risk for depression and anxiety during pregnancy, as evidence supports moderate beneficial effects for this group [5
].Exercise and diet
There is limited information on the utility of exercise, dietary changes or supplements, or education as preventives of PPD [
2
]. Although there are recommendations encouraging regular exercise, low-quality evidence and limited studies on exercise and PPD have found modest benefits, although other work has found no benefit [25
,26
]. High dropout rates among participants in these studies may speak to the difficulty new mothers have with time management owing to disrupted sleep schedules and multiple role demands [25
].Dietary supplements are currently being reviewed in the prevention of peripartum depression by the USPSTF, although recommendations are not yet available [
2
]. There is exploratory work on the use of vitamin D and selenium as dietary supplements that may have the potential to prevent PPD [27
]. Other dietary areas of exploration in prevention of PPD may include combination dietary supplements, or tryptophan, tyrosine, fish oil supplementation, vitamin D, calcium, selenium, blueberries, or combination dietary supplements [27
]. Although evidence remains elusive, there may be some role for dietary supplements or hormones in the future.Social support
There is good evidence that adequate social support is strongly protective against PPD in diverse populations. Informal support from families and friends is instrumental in the postpartum period, particularly for first-time parents, and families should be coached to help with housework, emotional support, and childcare throughout the first year. Partners should be coached to encourage good nutrition and exercise, as well as support women in gaining regular time for themselves [
28
,29
].In summary, preventative strategies include screening for PPD and referrals for counseling from care providers and the promotion of good social support for all postpartum women. During a time of pandemic, when social interaction outside of a family circle is difficult, it is especially important that all care providers should assess the postpartum patient’s mood and affect during all interactions, including during pediatric visits through the first year of the newborn’s life. Providers must be prepared to discuss concerning findings and take appropriate action.
Web-based prevention
A newer approach to the prevention of PPD in women at risk for the disorder is the use of Web-based cognitive behavioral therapy (WCBT) emphasizing emotional regulation and self-compassion. Some early explorations of this method in PPD suggest that WCBT shows significant improvement in intervention groups in the short term, particularly when guided by a therapist or therapeutic group of health care providers [
30
,31
]. Further study may elucidate increased applicability of this technique to women with active PPD, particularly with the increased use of teletherapy during the pandemic.Treatment of postpartum depression
Lifestyle changes
Several lifestyle changes are recommended for those diagnosed with PPD [
2
]. Instituting or reinstating social support from the patient’s own network or support groups for new parents may be helpful. After the initial recovery from delivery, maintaining good nutrition and starting moderate exercise may also be useful. Increasing sleep times when the baby sleeps may mitigate the fatigue of new parents, and time for the new parent to go out or see friends may contribute to recovery [4
].Barriers to care include scarcity of resources and supports for the postpartum patient, even under the best of circumstances. Furthermore, patients with PPD and their families may not feel comfortable reaching out to others for support because of the stigma of mental illness, which may worsen their situation.
Worsening or severe cases of PPD and PPP require more intense treatment. All health care providers should be aware of current treatments, including psychotherapy, medications, homeopathy, transcranial magnetic stimulation, electroconvulsive therapy (ECT), and supplements and hormones.
Psychotherapy
Although there has been some controversy about the efficacy of psychotherapy with a mental health care provider in the treatment of PPD, it is now widely recommended as both initial and adjunct treatment [
5
,31
, 32
, 33
, 34
]. Counseling appears to be effective with or without medications in diminishing depressive symptoms for at least the first 12 weeks postpartum, whether in person or via telehealth [35
]. Cognitive behavioral therapy has been shown to be efficacious in treating PPD up to 6 months postpartum [30
,31
,36
].Psychotherapeutic treatments tend to suffer from high dropout rates among patients with PPD. Individuals with PPD may struggle to obtain childcare and transportation, and psychotherapy may be expensive if not covered by insurance. A potential solution to several of these obstacles is psychotherapy delivered via the Internet. Brief, Internet-delivered, interpersonal psychotherapy showed promising results when used with patients suffering from PPD, particularly in low-income populations [
35
,37
]. Other alternatives to individual psychotherapy include group psychotherapy and mindfulness-based cognitive behavioral therapy, which have shown significant improved mental health outcomes [38
].Medications as treatment for postpartum depression
Although psychotherapy and lifestyle changes are the first choices in the treatment of mild PPD, medication should be considered in the initial treatment of moderate to severe PPD. It should be noted that the USPSTF has found insufficient data to recommend or withhold recommendations on the use of antidepressant medication, on the basis that benefits, and harms, were not well studied [
5
]. The risk/benefit ratio for both the patient with PPD and the newborn must be evaluated, particularly as many medications are found in human breastmilk.Providers have used combinations of antidepressant medications, psychotherapy, and other modalities to treat MDDs, including PPD. Treatments have included ECT and hormonal treatments, and repeated transcranial magnetic stimulation (rTMS) as adjuncts to treatment [
39
,40
].Medications in common use for the treatment of PPD include selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors, and hormone metabolite analogues (Table 2). Tricyclic antidepressants, although still listed as treatments for PPD, are in less common use related to the limited information on the effects on the newborn.
Table 2Medications used to treat postpartum depression
Data from Limandri BJ. Postpartum Depression: When the Stakes Are the Highest. J Psychosoc Nurs Ment Health Serv 2019; 57(11): 9-14.
| Medication classification | Example | Comments |
|---|---|---|
| Selective serotonin reuptake inhibitors∗ (SSRIs) ∗Note: Paroxetine is not used because of potential side effects on the fetus or newborn [ 4 ]. | Citalopram (Celexa) Fluoxetine (Prozac) | Excreted in human breastmilk, breastfeeding not recommended, or if used, use caution |
| Selective norepinephrine reuptake inhibitors (SNRIs) | Bupropion (Wellbutrin) Venlafaxine (Effexor) | Excreted in human breast milk. Potential for serious adverse reaction in infants. Breastfeeding contraindicated |
| Hormone metabolite analogue | Zulresso (Brexanolone) | Food and Drug Administration approved. Given intravenously, requires hospitalization, careful clinical oversight required |
Although there is limited understanding of the underlying causes of PPD, hormonal changes have been a focus of causative theories. In 2019, Zulresso (Brexanolone), an exogenous analogue of a major metabolite of progesterone, was approved for the treatment of moderate to severe PPD [
39
]. An important limitation is that Brexanolone, given via a 60-h continuous intravenous infusion, requires inpatient care and can result in dizziness and sudden loss of consciousness [39
].Transcranial magnetic stimulation
A recent addition to the range of treatments for depression is rTMS, approved for treatment for use with MDD. The treatments involve directing an electromagnetic pulse to a specific brain region daily over the course of multiple weeks. Anesthesia is not necessary; there is no pain involved, and the patient remains awake during treatments. These treatments pose no exposure risk to breastfeeding infants. Application of rTMS to treat PPD appears to show sustained improvement in mood at 3 and 6 months after treatment [
41
]. Previous work has shown that a combination of SSRI and rTMS can be effective in treating PPD [42
]. However, drawbacks include the need for limited availability and limited insurance coverage for this new therapy.Electroconvulsive therapy
ECT is known to be effective for treating MDD. However, it is associated with several adverse effects, including headaches, memory deficits, and recovery from general anesthesia, with each treatment. Therefore, ECT is a less desirable treatment choice for PPD [
41
]. Although women treated with ECT had a somewhat lower risk of relapse, the negative image of ECT from films and reports can prevent appropriate patients with PPD from agreeing to this treatment. It can be difficult for appropriate patients to agree to this treatment. Insurance coverage, babysitting needs, and transportation issues also can play a part in dissuading likely candidates to this treatment.Homeopathy
Homeopathy is a therapeutic system based on the theory that a disease can be successfully treated by administering a substance that produces similar symptoms in healthy people. However, despite some interest, there is little information on this method in the treatment of PPD [
42
].Supplements and hormones
Considering that the exact biological cause of PPD is yet unknown, identifying supplements or hormones that will decrease this disorder may be unfounded. However, many studies have focused on these areas of research. There has been some research on treating PPD with replacement hormones (progesterone and allopregnanolone), thyroxine, and dietary supplements, including docosahexaenoic acid, essential fatty acids, selenium, calcium, zinc, magnesium, vitamin D and tryptophan, tyrosine, and blueberry [
27
]. However, the research on this area is preliminary, and recommendations are elusive.Postpartum psychosis treatment
PPP is the least common, yet the most devastating of all the subcategories of perinatal affective disorders. It occurs in less than 3 per 1000 women and is characterized by an abrupt onset of severe symptoms that may begin immediately after delivery until 4 weeks postpartum, and that deteriorate rapidly, including hallucinations, delusions, and suicidal and infanticidal urges [
43
]. The severity and rapid onset of symptoms of PPP require all practitioners to understand the potential for danger to the mother and infant, and to be prepared to act immediately should symptoms arise. No patient with PPP should be left alone with an infant or child from the onset of symptoms. Immediate assessment and transfer to inpatient psychiatric services are indicated, where antipsychotic medication is the treatment of choice. Family members will need support during this challenging time and should be involved as the patient improves with medication in care and discharge planning.Discussion
PPD and related disorders are conditions that all providers should be aware of and assessing for in all pregnant and parenting patients for a full year following birth. Patients whose screens indicate that they are at risk should be referred for group or individual psychotherapy, whether in person or via telehealth. Patients and their family members should receive clear, matter-of-fact information on PPD and be encouraged to contact their provider should symptoms worsen.
Family members or friends should be coached to encourage supportive care of the birth parent to prevent or ameliorate the effects of PPD. Supportive care may include helping with childcare, helping with household tasks, and allowing the patient to talk and have weekly free time away from the baby. The patient’s informal support network also may help provide good nutrition and rest time and may encourage regular, moderate exercise after the first few days or weeks postpartum.
Patients should be coached toward realistic expectations of early postpartum and newborn care and should be encouraged to think through resources they may have for help before such resources are needed. Parenting groups for parents of infants, online or in person, may be used for some support.
Patients who have moderate to severe or worsening symptoms of PPD should be started on an approved antidepressant after considering risks and benefits to the patient and the baby and referred to psychiatric care. Any patients with PPP should be referred for acute care at once, and the baby or other children kept in a safe, supervised situation.
Summary
PPD, a subset of peripartal depression, is a major mental health disorder that affects a significant proportion of postpartum patients. Screening for PPD is an important part of antepartum and postpartum care, and through the first year following delivery. Good informal support from family, friends, or social groups may prevent some PPD and may ameliorate the effects on the family constellation. However, patients whose screens may indicate PPD should be referred promptly for psychotherapy and medication, and other adjunct therapies should be considered.
Clinics care points
- •PPD impacts the entire family constellation, particularly the birthing parent and the newborn. Support and monitoring of all family members including the infant is essential.
- •Symptoms of PPD may look like other types of depression and may include anxiety symptoms. Additional symptoms may include sleeplessness, lack of appetite, and panic in addition to typical depressive symptoms.
- •PPD may occur longer than the initial 6 weeks postpartum. Affective disorders can manifest during pregnancy and through the first year of newborn life.
- •Symptoms of psychosis in the postpartum patient is a crisis situation. Patients require emergency evaluation, and newborns and children must not be left alone with patients under any circumstances.
Disclosure
K. Green has no disclosures of any commercial or financial conflicts of interest and no funding sources related to this work. M. Low has no disclosures of any commercial or financial conflicts of interest and no funding sources related to this work.
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