Depression related to pregnancy is a common and potentially serious concern. Therefore, it is important to understand the various conditions and when it is important to have a clinical intervention.
Postpartum Blues: Symptoms of mood lability, irritability, interpersonal hypersensitivity and tearfulness are common in the postpartum period and are commonly known as the postpartum “blues”. The incidence is up to 75% and the symptoms typically arise and resolve within 7-14 days after the delivery. The following conditions are of more concern:
Antepartum depression: The prevalence of depression during pregnancy ranges from 10-15% and it may persist into the first postpartum year. Depression during pregnancy is linked to birth complications like pre-eclampsia, low birth weight, premature delivery, and small for gestational age infants.
Postpartum depression: The prevalence of PPD is 10-15%. The postpartum year is one of the highest risk periods for first-onset depression for women with approximately 50% of women experiencing their first episode of depression during that time. In addition 25% of women with a history of Major Depressive Disorder will experience PPD and 50% of women who have had PPD will have a recurrence. The Edinburgh Postnatal Depression Scale and Postpartum Depression Screening Scale are useful screening tools. Women with PPD will typically present with prominent anxiety symptoms that involve distressing and intrusive thoughts about infant safety and feelings of guilt and inadequacy about mothering. Infants of depressed mothers have been found to be less responsive and more irritable than infants of non-depressed mothers. Infants of depressed mothers are also more likely to develop an insecure attachment because of (unintentional) maternal rejection of the baby. If one suspects PPD it is important to rule out medical conditions, like thyroid dysfunction and iron-deficiency anemia.
Postpartum psychosis: Postpartum psychosis is rare and occurs in 1-2 women per 1000. The onset is typically within 2 weeks of delivery. The psychotic symptoms typically accompany affective symptoms of depression and anxiety, rather than represent a psychotic first break. Postpartum psychosis is more common in women who have a history of bipolar disorder. In addition to auditory and visual hallucinations, patients may present with cognitive impairment, confusion, and olfactory and tactile hallucinations. Many mothers are distressed because they experience command hallucinations to harm their infants. If postpartum psychosis is suspected, it is important to seek immediate psychiatric attention and to consider psychiatric hospitalization. Antipsychotic medications are helpful, but it is more appropriate for the treatment to take place in a psychiatric hospital for the safety of mother and baby.
Treatment: Medication can be an important treatment for antepartum depression, if it is moderate-severe and/or not responding to non-medication approaches, like support groups and light therapy. SSRIs are the first line agents, in particular sertraline because of its relatively short half-life and availability of low doses (can be dosed as low as 12.5 mg per day). Paroxetine is pregnancy category D. There is evidence that it increases the risk of birth defects. There is also a possible connection between SSRI use in the 3rd trimester of pregnancy and development of persistent pulmonary hypertension of the newborn. While there are some reports of the risk of limb malformations with the tricyclic antidepressants, like amitriptyline and nortriptyline, these have not been confirmed. There have been reports of newborns experiencing temporary discontinuation symptoms at birth, including jitteriness and irritability when a woman is treated with antidepressants during pregnancy.
Currently, there are no FDA approved medications for PPD, mostly because it is difficult to conduct research. Of the SSRIs, sertraline and paroxetine are the least detectable in breast milk. Several case reports note an association between fluoxetine and citalopram use in lactating women and infant irritability, poor sleep, poor feeding, crying, and restlessness. This might be related to their relatively longer half-life. Other case reports have not noted any adverse effects in infants of mothers taking fluoxetine and citalopram. If one is considering treating PPD with a medication, sertraline is a good first line agent because of its relatively short half-life and ability to dose in smaller doses, as low as 12.5 mg per day. If a woman is already on an antidepressant like fluoxetine with a good response, it is okay to continue with the medication and monitor closely for side effects in the mother and infant.
The important take home point for treating depression related to pregnancy is to first consider a non-medication treatment if that is a viable option. If it is determined medication is needed, it is important to have a careful discussion about the risks and benefits and to try to use the smallest possible dose for the shortest length of time.