A 12-day-old male came to clinic for his 2 week health maintenance examination. He was doing well according to his mother who was breastfeeding every 2-4 hours and was having numerous wet and stool-filled diapers. Previously he had been monitored closely during the first few days of life for hyperbilirubinemia but did not require hospitalization or treatment. His skin color looked better by her report. The mother appeared sad during the interview and was crying when she said that her mother had left the day before after helping out with the baby. The mother’s Patient Health Questionnaire-2 score was 3.
The past medical history showed the product of a 39 weeks gestation born to a 23 year old G1P1 married female who had no problems during the pregnancy or delivery. The family history was non-contributory. The social history showed a family who had recently moved to the area for the father’s new business job. He had returned to work several days ago. The mother did not know other people in the area yet. The pertinent physical exam showed an alert male with minimal jaundice around his face. His weight was 3.578 kg which was 130 grams above birth weight. His length and head circumference were around the 50%. The rest of his examination was normal with a well-healing circumcision. A transdermal bilirubin was 7.8 mg/dl.
The diagnosis of a healthy newborn male was made. The physician discussed with the mother how obviously she wasn’t feeling very well about life. The mother was able to verbalize that she felt exhausted, sad, and overwhelmed. “My husband is gone all day and I don’t really know anybody else that I can talk to,” she said. The pediatrician offered to have the mother referred to the obstetrical psychological clinic but the mother refused, however she was willing to talk with the clinic social worker. The social worker helped the mother work out some strategies for getting some rest and doing her own self-care along with taking care of the baby. The social worker phone number was given to the mother and a followup was arranged for 1 week later.
The patient’s clinical course found that the mother returned with the infant for a rash 3 days later that turned out to be erythema toxicum, but during that visit the mother endorsed feeling worse despite having support from her husband. The PHQ-2 was now 4. She again refused referral to the psychological clinic but did meet with the social worker again. At 3 weeks of life the infant was physically doing well, but the mother continued to have postpartum depressive symptoms and again had a PHQ-2 score of 4. She did allow referral to the obstetrical psychological clinic, which initiated cognitive behavioral therapy. At 6 weeks of life, the infant was still doing well, and the mother was doing somewhat better. She felt that having someone on a regular basis to talk with was helpful, and “the social worker is so helpful in knowing where to go in the community and just to talk to,” she said. With each subsequent visit the mother seemed somewhat better and she continued her therapy for 4 months.
Postpartum depression affects 10 to 20% of women after delivery, but less than half of these women are detected. Postpartum depression is defined as major depressive episodes with symptom onset during pregnancy or in the first four weeks following delivery. There is recognition that symptoms may begin later after delivery but the mother would not be diagnosed with PPD.
PPD is distinct from postpartum blues which occur in 50 to 80% of new mothers. They occur within 1 to 2 days of delivery and resolve within 10-14 days of delivery. Symptoms include anxiety, depression, irritability, tearfulness, poor sleep, and appetite. Postpartum psychosis is a rare but extremely serious condition that occurs within 1 to 4 weeks after delivery and carries a high risk of infanticide and maternal suicide. Symptoms include “…delusions, hallucinations, severe and rapid mood swings, sleep disturbances, and obsessive preoccupation about the baby.” Women who experience termination or loss of pregnancy or neonatal death may also have bereavement and experience symptoms such as grief, poor appetite and sleep which may look like PPD.
Risk factors for PPD include: previous depression including PPD, anxiety, relationship problems with partner, inadequate or absent home support, ongoing life stresses, low socioeconomic status, adolescent mother, preterm delivery, substance abuse (alcohol, tobacco, other medications or illicit drugs), and possibly depressive symptoms when taking oral contraceptives or premenstrual dysphoric disorder. Fathers are at risk for depression if their partner has PPD.
Common screening tests for PPD are the Edinburgh Postnatal Depression Scale (EPDS) which has 10 items and takes 10-15 minutes to complete. Items are scored 0-3 with a cut-off of = or > 13 for identification of possible PPD. The PHQ-9 (Patient Health Questionnaire-9) has 9 items which are scored 0-3 with a cut-off of = or > 10. A 10th question is used if any of the first 9 are positive and asks how difficult the symptoms are for the patient to do their work, activities of daily living and getting along with others. The PHQ-2 is a shortened version of PHQ-9 using its first 2 items. A cut-off of = or > 3 for further evaluation is used. The 2 questions rate symptomatic emotions in the past 2 weeks and the items are having “little interest or pleasure in doing things” and “feeling down, depressed or hopeless.” Ratings are by the number of days the symptoms occur with 0 = no days, 1 = several days, 2 = more than half the days and 3 = nearly every day.
The use of antidepressant medications for PPD has increased to over 7% in 2008. A recent Cochrane Review said that its review was the limited by small number of studies and little information about important outcomes. It notes, “There was insufficient evidence to conclude whether, and for whom, antidepressant or psychological/psychosocial treatments are more effective, or whether some antidepressants are more effective or better tolerated than others. There was also inadequate evidence on whether the benefits of antidepressants persists beyond eight weeks or whether they have short- or long term adverse affects on breast-feeding infants.”
A 2014 summary of antidepressant use in pregnant and postpartum women found that research showed
- “…[M]odestly elevated risk of clinically recognized spontaneous abortion”
- Limited data on fetal death but probably no association with maternal antidepressant use
- Selective serotonin reuptake inhibitors (SSRIs) did not appear to be major teratogens with the exception of paroxetine that has been associated with cardiovascular malformations
- Preterm births occurring at a higher rate
- Data on fetal growth is mixed
- Small or no association with persistent pulmonary hypertension of the newborn
- Associated with neonatal behavioral syndrome with SSRI exposure most often reported with fluoxetine, paroxetine and venlafaxine.
Neonatal behavior syndrome includes symptoms of “…irritability, jitteriness, trouble feeding, tremor, agitation, hypotonia, hyperreflexia, respiratory distress, seizures, vomiting, excessive crying.”
PPD treatment depends on several factors including severity, patient preference, breastfeeding practices, response to previous treatment, co-morbidities and other risk factors and local mental health services availability. Mild PPD usually are patients who meet diagnostic criteria and who are able to overcome the negative impacts with extra effort. Moderate PPD are patients who cannot overcome the impacts with extra effort but are not incapacitated. Severe PPD are patients that are incapacitated by the symptoms.
- Patients with mild to moderate PPD usually start with cognitive behavioral therapy or interpersonal therapy.
- Patients with moderate to severe PPD who are not breastfeeding often are prescribed antidepressant medication with or without psychotherapy. Psychotherapy alone can be used but because of the increased risks requires close tracking of patient symptoms. In patients who are not improving or worsening, antidepressant medication is often a higher priority.
- Patient with moderate to severe PPD who are breastfeeding often are prescribed prescribed antidepressant medication with or without psychotherapy. Psychotherapy alone can be used but because of the increased risks requires close tracking of patient symptoms. In patients who are not improving or worsening, antidepressant medication is often a higher priority or if depressive symptoms are severe to begin with.
- For patients who have psychotic symptoms, hospitalization, antipsychotic medications and/or electroconvulsive therapy is needed.
Choice of antidepressant depends on the risk factors above but may be influenced by the mother’s own response to previously used antidepressants or family members response to these medications.
Mothers also need other supports such as parenting support, case management, community support groups and access to access meet physical needs such as food, clothing or shelter.
Other types of counseling may be needed depending on patient needs and availability including group therapy, couples therapy, non-directive counseling and community supports.
Questions for Further Discussion
1. What resources do you use to check for possible medication warnings for use during pregnancy or breastfeeding?
2. What local resources do you have for treatment of postpartum depression?
3. How do you treat major depressive disorder?
- Disease: Postpartum Depression
- Symptom/Presentation: Health Maintenance and Disease Prevention | Depression
- Specialty: General Pediatrics | Obstetrics / Gynecology | Psychiatry and Psychology | Social Services
- Age: Newborn | Fetus and Mother
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Postpartum Depression
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Liberto TL. Screening for depression and help-seeking in postpartum women during well-baby pediatric visits: an integrated review. J Pediatr Health Care. 2012 Mar;26(2):109-17.
Bobo WV, Yawn BP. Concise review for physicians and other clinicians: postpartum depression. Mayo Clin Proc. 2014 Jun;89(6):835-44.
Molyneaux E, Howard LM, McGeown HR, Karia AM, Trevillion K. Antidepressant treatment for postnatal depression. Cochrane Database Syst Rev. 2014 Sep 11;9:CD002018.
Yonkers KA, Blackwell KA, Glover J, Forray A. Antidepressant use in pregnant and postpartum women. Annu Rev Clin Psychol. 2014;10:369-92.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital