Peripartum depression: Early recognition improves outcomes

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Peripartum depression: Early recognition improves outcomes
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Margaret M. Howard, PhD
Niharika D. Mehta, MD
Raymond Powrie, MD

Contrary to common belief, pregnancy does not confer protection against depression.1,2 In fact, pregnant women are just as likely as nonpregnant women to become or remain depressed, and up to 12.7% of pregnant women meet criteria for depression.1

In the postpartum period, women are particularly vulnerable to a major depressive episode, whether a first episode or a recurrence. The estimated prevalence of a depressive episode in the first 3 postpartum  months is 19.2%,2 making postpartum depression the most common complication of childbearing.2 At the same time, peripartum depression remains largely underrecognized and undertreated.3

As evidence mounts regarding the deleterious impact of untreated mental illness on the mother, the developing fetus, and the infant, early detection and intervention for peripartum depression are paramount.3

DEPRESSION DURING PREGNANCY: SIGNIFICANT CONSEQUENCES

Although the rates of depression in pregnant and nonpregnant women are similar, depression in pregnancy carries additional significant consequences. Further, many depressed pregnant women believe their depression will lift once their baby is born, though it is well documented that depression during pregnancy is the strongest predictor of postpartum depression and that if left untreated it can be devastating for mother, infant, and family.4

Compared with nondepressed pregnant women, depressed pregnant women have poorer overall health status,5 are more likely to engage in behaviors that pose risk to the developing fetus such as smoking,5 alcohol consumption, and substance use,6 and have poor nutrition and inadequate weight gain.7,8

Pregnant women who are depressed and are also experiencing domestic violence are especially at risk for poor prenatal care as they tend to miss more prenatal appointments.9 Evidence also suggests that depressed pregnant women are less attached to the fetus and more likely to have elective terminations.10,11

Depression in pregnancy is associated with higher rates of adverse pregnancy outcomes such as preterm birth, low birth weight, operative delivery, and longer predelivery hospital stay.3,12 Depression and anxiety during pregnancy have been associated with prenatal hypertension,13 gestational diabetes,14 preeclampsia,15 and HELLP syndrome (ie, hemolysis, elevated liver enzymes, and low platelet count).15 Depression and anxiety during pregnancy are associated with subsequent poorer infant attachment16,17 and an overall unfavorable impact on infant and child development.18

Risk factors for depression during pregnancy include past episodes of depression, current anxiety, poor social support, unintended pregnancy, life stress, being single, domestic violence, and being on Medicaid.19

Undoubtedly the most devastating consequence of severe depression during pregnancy is suicide. Rates of suicide are lower in peripartum women,20 but when suicide does occur, pregnant women tend to use more violent means than nonpregnant women. Pregnant adolescents represent a particularly high-risk group.21

POSTPARTUM DEPRESSION

Postpartum depression is the most common complication of childbearing. Although the precise pathogenesis is undetermined, there is converging evidence of a subset of women particularly sensitive to dramatic fluctuations in levels of estradiol and progesterone that occur during childbirth.22,23 There is also evidence that dysregulation of the hypothalamic-pituitary-adrenal axis contributes to the development of postpartum depression in certain women.24 Further, women who have depression or anxiety during pregnancy are much more likely to experience postpartum depression than those who are not symptomatic during pregnancy.4 A history of peripartum depression or other lifetime depressive episodes, poverty, conflict with a primary partner, poor social support, stressful life events, and low self-esteem are strongly associated with postpartum depression.25

When unrecognized and untreated, postpartum depression can have profound and persistent effects on the mother and the developing infant.18,26 Mothers with postpartum depression are much more likely than mothers without depression to have impaired bonding,27 to be less responsive to their infant’s needs,17 and to be more likely to miss well-baby checkups.28

Postpartum depression’s effects on maternal-infant interactions can include maternal withdrawal, disengagement, intrusion, and hostility and can lead to long-term effects on child development, including poor cognitive functioning, emotional maladjustment, and behavioral inhibition.29,30 Infants and children of mothers with untreated postpartum depression have been shown to exhibit a higher incidence of colic, excessive crying, sleep problems, and irritability.31,32 Women with postpartum depression may be less likely to initiate or maintain breastfeeding, and depressive symptoms have been noted to precede the discontinuation of breastfeeding.33–35

Risk factors for postpartum depression

Characteristics to look for in the prenatal care of pregnant women include the following:

  • Depression during pregnancy
  • History of postpartum or other depressive episode
  • Poverty
  • Conflict with primary partner
  • Poor social support
  • Low self-esteem
  • Single status.

 

 

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.

Source: Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a brief depression severity measure. J Gen In-tern Med 2001; 16:606–616. No permission required to reproduce, translate, display, or distribute.
FIGURE 1. Patient Health Questionnaire–9. A score 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.

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.

 

 

CLINICAL MANAGEMENT

Many women prefer nondrug therapy

The gold standard treatment for moderate to severe major depressive disorder is psychotherapy plus pharmacotherapy. Yet many peripartum women voice concerns about exposure to pharmacologic treatment, and studies have shown that many women prefer nonpharmacologic intervention.47

Evidence-based psychotherapies that have demonstrated efficacy in peripartum women include cognitive behavioral therapy48 and interpersonal psychotherapy when administered by a psychotherapist trained in these treatments. Pregnant and breastfeeding women often express preference for psychotherapy and complementary and alternative treatments as a means of avoiding fetal and infant exposure to antidepressants.47

For mild to moderate depression, complementary therapies such as exercise, yoga, bright light therapy, and acupuncture have shown efficacy and can be used alone or adjunctively.49 Because a poor marital relationship is consistently associated with peripartum depression,25 primary care physicians who routinely address social support and screen for family conflict are well positioned to detect this significant correlate and to recommend marital or family therapy as a primary or adjunctive treatment.

When to consider drug therapy

The decision to recommend drug therapy must be individualized and based on the severity of symptoms, functional impairment, number and frequency of depressive episodes, history of response to medications, and the preferences of the patient, with the recognition that no decision is risk-free and that antidepressants enter the amniotic fluid, so fetal exposure is unavoidable.

Table 2 lists common antidepressants. The antidepressants most commonly prescribed, especially in the primary care setting, are selective serotonin reuptake inhibitors (SSRIs), which are favored because of their effectiveness, low side-effect profile, and lack of overdose toxicity.

Serotonin syndrome is no more likely to occur in pregnant than in nonpregnant women. Close monitoring for this condition is warranted only when patients are taking very  high doses of SSRIs or SSRIs in combination with other serotonergic agonists.

Prescribing antidepressants for pregnant or breastfeeding women requires thoughtful consideration of the patient’s preferences, as well as weighing the risks and benefits of fetal and infant exposure to maternal depression vs exposure to medications. Additional considerations include monotherapy, avoiding medication changes, choosing drugs that have been effective in the past, and avoiding drugs with known drug-drug interactions or teratogenic effects.50

There is increasing consensus that the short- and long-term consequences of undertreatment or nontreatment of maternal depression outweigh the risk of fetal exposure to SSRIs.3,51,52 Cohen et al53 have recommended that if a woman is on an antidepressant and learns she is pregnant, she should not discontinue it because of the likelihood of relapse; they found a 68% relapse rate in women who discontinued their antidepressant in the first trimester of pregnancy.53

In a comprehensive review of studies published between 1996 and 2012 that examined antidepressant use during pregnancy, Byatt et al54 found little or no evidence of increased teratogenic risk with antidepressants with the exception of paroxetine, which is associated with a small but significant increased risk of cardiac malformation during first-trimester exposure.54

These conclusions were underscored in a large cohort study in the United Kingdom.55 In addition, a joint task force of the American Psychiatric Association and ACOG reviewed studies looking at the association between depression, antidepressants, and birth outcomes including miscarriage, preterm birth, cardiac abnormalities (resulting from first trimester exposure), persistent pulmonary hypertension (related to second- and third-trimester exposure), and neonatal adaptation syndrome (associated with third-trimester exposure).8 They concluded that the available data neither support nor refute a link between the use of antidepressants and several of the above outcomes. No increase in risk of congenital malformations (including cardiac abnormalities) was found. An increased risk of persistent pulmonary hypertension was noted, although the absolute risk of this disorder remained low, at 3 to 6 per 1,000 infants exposed to SSRIs in utero.8,56

Neonatal adaptation syndrome

Neonatal adaptation syndrome is characterized by jitteriness, irritability, decreased muscle tone, and feeding difficulty in the neonate. It can occur in 15% to 30% of infants exposed to SSRIs antenatally.57,58 These symptoms, however, are transient and typically resolve within 7 to 10 days after birth. A more recent study suggested that neurobehavioral symptoms for some infants extend beyond 2 weeks and that concomitant exposure to benzodiazepines results in even higher rates of this syndrome.59 There is no evidence that tapering or discontinuing antidepressants near term is necessary, safe, or effective in preventing transient neonatal complications. However, this approach would increase the risk of relapse for the mother.

Autism spectrum disorders

The possible association between antidepressants and autism spectrum disorders in pregnancy has captured much attention in recent years. One study based on healthcare claims60 and one registry-based study61 associated in utero exposure to antidepressants with autism liability in children. However, a large-scale Danish registry-based study did not replicate this association.62 In addition, 2 recent cohort studies, identifying children with autism spectrum disorder or attention-deficit hyperactivity disorder from electronic health records, found that neither disorder was significantly associated with prenatal antidepressant exposure in crude or adjusted models. However, both studies found a significant association with the use of antidepressants before pregnancy, indicating that the risk of autism observed with prenatal antidepressant exposure is likely confounded by the severity of maternal illness.63,64

Concerns about drug therapy during breastfeeding

For infants of breastfeeding women, exposure to antidepressants through breast milk is minimal. Amounts in breast milk depend on the timing of the antidepressant dose, timing of feeding, and genetically influenced metabolic activity in mother and infant. The current literature supports antidepressant use for breastfeeding mothers of healthy full-term infants.65

The 2 most widely studied antidepressants in breastfed infants are paroxetine and sertraline. It has been shown that very little can be detected in the infant’s serum, with relative infant doses ranging from 0.4% to 2.8%.65 While clinicians are cautioned against prescribing paroxetine for pregnant women, the drug remains a suitable alternative for breastfeeding women.

If an antidepressant is started postpartum, the recommendation is to start with a low dose and then slowly titrate upward while monitoring the infant for adverse effects.65,66 Possible adverse effects in breastfeeding infants include irritability, sedation, poor weight gain, and a change in feeding patterns.67 Adverse events are most likely to occur in newborns up to 8 weeks of age, and infants born prematurely or with medical problems may be particularly at risk.65,68

Helping patients weigh risks and benefits of drug therapy

Women may hear about the risks of medications to the fetus and during breastfeeding and so may be reluctant to seek or accept intervention. Often, the information is not from a reliable, scientifically based source. Primary care physicians are well positioned to guide peripartum women in risk-benefit analysis of proper treatment of their depression vs no treatment or undertreatment. In addition, establishing referral sources—ideally with a peripartum mental health specialist—is advisable. Online resources that clinicians can refer patients to for help in managing peripartum depression include the following:

INCREASED AWARENESS IS KEY

Primary care physicians must remain alert to the high prevalence of depression in women of childbearing age and embrace routine screening for depression. (See the sidebar, “The primary care management of peripartum depression.”) Since half of pregnancies are unintended, awareness of the risks of undetected and untreated peripartum depression to the mother, developing fetus, and infant is essential. Untreated antepartum depression has been linked to poor pregnancy outcomes, nutritional deficits, and substance abuse. Untreated postpartum depression negatively affects mother-infant attachment, infant, and child development and maternal self care.

Not treating depression is hazardous

Drug treatment during pregnancy and breastfeeding poses challenges for the patient and physician due to the inevitability of fetal and infant exposure, but lack of treatment can be hazardous.

To date, the evidence on the use of antidepressants in pregnant and lactating women is reassuring. Specialized peripartum psychiatric partial hospital programs69 and inpatient programs70 exist for women who need a higher level of care. There is also substantial evidence that psychotherapy, especially cognitive behavioral therapy and interpersonal therapy, is highly effective, and emerging data on complementary and alternative treatments are promising. Coordinated care between primary care and behavioral healthcare providers with expertise in treating peripartum depression is most likely to yield optimal outcomes.

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Author and Disclosure Information

Margaret M. Howard, PhD
Departments of Psychiatry and Human Behavior and Medicine, Warren Alpert Medical School of Brown University; Professor (Clinical), Women and Infants Hospital of Rhode Island, Providence

Niharika D. Mehta, MD
Department of Medicine, Warren Alpert Medical School of Brown University; Assistant Professor, Women and Infants Hospital of Rhode Island, Providence

Raymond Powrie, MD
Departments of Medicine and Obstetrics and Gynecology, Warren Alpert Medical School of Brown University; Professor, Women and Infants Hospital of Rhode Island, Providence

Address: Margaret M. Howard, PhD, Division of Women’s Behavioral Health, Women and Infants Hospital, 101 Dudley Street, Providence, RI 02905; [email protected]

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Cleveland Clinic Journal of Medicine - 84(5)
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Cleveland Clinic Journal of Medicine
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Drug Therapy
Mental Health
Neurology
Women's Health
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388-396
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depression, postpartum, peripartum, major depressive disorder, pregnancy, Patient Health Questionnaire-9, PHQ-9, selective serotonin reuptake inhibitors, SSRIs, antidepressants, Margaret Howard, Niharika Mehta, Raymond Powrie
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Author(s)
Margaret M. Howard, PhD
Niharika D. Mehta, MD
Raymond Powrie, MD
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Niharika D. Mehta, MD
Raymond Powrie, MD
Author and Disclosure Information

Margaret M. Howard, PhD
Departments of Psychiatry and Human Behavior and Medicine, Warren Alpert Medical School of Brown University; Professor (Clinical), Women and Infants Hospital of Rhode Island, Providence

Niharika D. Mehta, MD
Department of Medicine, Warren Alpert Medical School of Brown University; Assistant Professor, Women and Infants Hospital of Rhode Island, Providence

Raymond Powrie, MD
Departments of Medicine and Obstetrics and Gynecology, Warren Alpert Medical School of Brown University; Professor, Women and Infants Hospital of Rhode Island, Providence

Address: Margaret M. Howard, PhD, Division of Women’s Behavioral Health, Women and Infants Hospital, 101 Dudley Street, Providence, RI 02905; [email protected]

Author and Disclosure Information

Margaret M. Howard, PhD
Departments of Psychiatry and Human Behavior and Medicine, Warren Alpert Medical School of Brown University; Professor (Clinical), Women and Infants Hospital of Rhode Island, Providence

Niharika D. Mehta, MD
Department of Medicine, Warren Alpert Medical School of Brown University; Assistant Professor, Women and Infants Hospital of Rhode Island, Providence

Raymond Powrie, MD
Departments of Medicine and Obstetrics and Gynecology, Warren Alpert Medical School of Brown University; Professor, Women and Infants Hospital of Rhode Island, Providence

Address: Margaret M. Howard, PhD, Division of Women’s Behavioral Health, Women and Infants Hospital, 101 Dudley Street, Providence, RI 02905; [email protected]

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Related Articles
Recognizing and managing depression in women throughout the stages of life

Contrary to common belief, pregnancy does not confer protection against depression.1,2 In fact, pregnant women are just as likely as nonpregnant women to become or remain depressed, and up to 12.7% of pregnant women meet criteria for depression.1

In the postpartum period, women are particularly vulnerable to a major depressive episode, whether a first episode or a recurrence. The estimated prevalence of a depressive episode in the first 3 postpartum  months is 19.2%,2 making postpartum depression the most common complication of childbearing.2 At the same time, peripartum depression remains largely underrecognized and undertreated.3

As evidence mounts regarding the deleterious impact of untreated mental illness on the mother, the developing fetus, and the infant, early detection and intervention for peripartum depression are paramount.3

DEPRESSION DURING PREGNANCY: SIGNIFICANT CONSEQUENCES

Although the rates of depression in pregnant and nonpregnant women are similar, depression in pregnancy carries additional significant consequences. Further, many depressed pregnant women believe their depression will lift once their baby is born, though it is well documented that depression during pregnancy is the strongest predictor of postpartum depression and that if left untreated it can be devastating for mother, infant, and family.4

Compared with nondepressed pregnant women, depressed pregnant women have poorer overall health status,5 are more likely to engage in behaviors that pose risk to the developing fetus such as smoking,5 alcohol consumption, and substance use,6 and have poor nutrition and inadequate weight gain.7,8

Pregnant women who are depressed and are also experiencing domestic violence are especially at risk for poor prenatal care as they tend to miss more prenatal appointments.9 Evidence also suggests that depressed pregnant women are less attached to the fetus and more likely to have elective terminations.10,11

Depression in pregnancy is associated with higher rates of adverse pregnancy outcomes such as preterm birth, low birth weight, operative delivery, and longer predelivery hospital stay.3,12 Depression and anxiety during pregnancy have been associated with prenatal hypertension,13 gestational diabetes,14 preeclampsia,15 and HELLP syndrome (ie, hemolysis, elevated liver enzymes, and low platelet count).15 Depression and anxiety during pregnancy are associated with subsequent poorer infant attachment16,17 and an overall unfavorable impact on infant and child development.18

Risk factors for depression during pregnancy include past episodes of depression, current anxiety, poor social support, unintended pregnancy, life stress, being single, domestic violence, and being on Medicaid.19

Undoubtedly the most devastating consequence of severe depression during pregnancy is suicide. Rates of suicide are lower in peripartum women,20 but when suicide does occur, pregnant women tend to use more violent means than nonpregnant women. Pregnant adolescents represent a particularly high-risk group.21

POSTPARTUM DEPRESSION

Postpartum depression is the most common complication of childbearing. Although the precise pathogenesis is undetermined, there is converging evidence of a subset of women particularly sensitive to dramatic fluctuations in levels of estradiol and progesterone that occur during childbirth.22,23 There is also evidence that dysregulation of the hypothalamic-pituitary-adrenal axis contributes to the development of postpartum depression in certain women.24 Further, women who have depression or anxiety during pregnancy are much more likely to experience postpartum depression than those who are not symptomatic during pregnancy.4 A history of peripartum depression or other lifetime depressive episodes, poverty, conflict with a primary partner, poor social support, stressful life events, and low self-esteem are strongly associated with postpartum depression.25

When unrecognized and untreated, postpartum depression can have profound and persistent effects on the mother and the developing infant.18,26 Mothers with postpartum depression are much more likely than mothers without depression to have impaired bonding,27 to be less responsive to their infant’s needs,17 and to be more likely to miss well-baby checkups.28

Postpartum depression’s effects on maternal-infant interactions can include maternal withdrawal, disengagement, intrusion, and hostility and can lead to long-term effects on child development, including poor cognitive functioning, emotional maladjustment, and behavioral inhibition.29,30 Infants and children of mothers with untreated postpartum depression have been shown to exhibit a higher incidence of colic, excessive crying, sleep problems, and irritability.31,32 Women with postpartum depression may be less likely to initiate or maintain breastfeeding, and depressive symptoms have been noted to precede the discontinuation of breastfeeding.33–35

Risk factors for postpartum depression

Characteristics to look for in the prenatal care of pregnant women include the following:

  • Depression during pregnancy
  • History of postpartum or other depressive episode
  • Poverty
  • Conflict with primary partner
  • Poor social support
  • Low self-esteem
  • Single status.

 

 

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.

Source: Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a brief depression severity measure. J Gen In-tern Med 2001; 16:606–616. No permission required to reproduce, translate, display, or distribute.
FIGURE 1. Patient Health Questionnaire–9. A score 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.

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.

 

 

CLINICAL MANAGEMENT

Many women prefer nondrug therapy

The gold standard treatment for moderate to severe major depressive disorder is psychotherapy plus pharmacotherapy. Yet many peripartum women voice concerns about exposure to pharmacologic treatment, and studies have shown that many women prefer nonpharmacologic intervention.47

Evidence-based psychotherapies that have demonstrated efficacy in peripartum women include cognitive behavioral therapy48 and interpersonal psychotherapy when administered by a psychotherapist trained in these treatments. Pregnant and breastfeeding women often express preference for psychotherapy and complementary and alternative treatments as a means of avoiding fetal and infant exposure to antidepressants.47

For mild to moderate depression, complementary therapies such as exercise, yoga, bright light therapy, and acupuncture have shown efficacy and can be used alone or adjunctively.49 Because a poor marital relationship is consistently associated with peripartum depression,25 primary care physicians who routinely address social support and screen for family conflict are well positioned to detect this significant correlate and to recommend marital or family therapy as a primary or adjunctive treatment.

When to consider drug therapy

The decision to recommend drug therapy must be individualized and based on the severity of symptoms, functional impairment, number and frequency of depressive episodes, history of response to medications, and the preferences of the patient, with the recognition that no decision is risk-free and that antidepressants enter the amniotic fluid, so fetal exposure is unavoidable.

Table 2 lists common antidepressants. The antidepressants most commonly prescribed, especially in the primary care setting, are selective serotonin reuptake inhibitors (SSRIs), which are favored because of their effectiveness, low side-effect profile, and lack of overdose toxicity.

Serotonin syndrome is no more likely to occur in pregnant than in nonpregnant women. Close monitoring for this condition is warranted only when patients are taking very  high doses of SSRIs or SSRIs in combination with other serotonergic agonists.

Prescribing antidepressants for pregnant or breastfeeding women requires thoughtful consideration of the patient’s preferences, as well as weighing the risks and benefits of fetal and infant exposure to maternal depression vs exposure to medications. Additional considerations include monotherapy, avoiding medication changes, choosing drugs that have been effective in the past, and avoiding drugs with known drug-drug interactions or teratogenic effects.50

There is increasing consensus that the short- and long-term consequences of undertreatment or nontreatment of maternal depression outweigh the risk of fetal exposure to SSRIs.3,51,52 Cohen et al53 have recommended that if a woman is on an antidepressant and learns she is pregnant, she should not discontinue it because of the likelihood of relapse; they found a 68% relapse rate in women who discontinued their antidepressant in the first trimester of pregnancy.53

In a comprehensive review of studies published between 1996 and 2012 that examined antidepressant use during pregnancy, Byatt et al54 found little or no evidence of increased teratogenic risk with antidepressants with the exception of paroxetine, which is associated with a small but significant increased risk of cardiac malformation during first-trimester exposure.54

These conclusions were underscored in a large cohort study in the United Kingdom.55 In addition, a joint task force of the American Psychiatric Association and ACOG reviewed studies looking at the association between depression, antidepressants, and birth outcomes including miscarriage, preterm birth, cardiac abnormalities (resulting from first trimester exposure), persistent pulmonary hypertension (related to second- and third-trimester exposure), and neonatal adaptation syndrome (associated with third-trimester exposure).8 They concluded that the available data neither support nor refute a link between the use of antidepressants and several of the above outcomes. No increase in risk of congenital malformations (including cardiac abnormalities) was found. An increased risk of persistent pulmonary hypertension was noted, although the absolute risk of this disorder remained low, at 3 to 6 per 1,000 infants exposed to SSRIs in utero.8,56

Neonatal adaptation syndrome

Neonatal adaptation syndrome is characterized by jitteriness, irritability, decreased muscle tone, and feeding difficulty in the neonate. It can occur in 15% to 30% of infants exposed to SSRIs antenatally.57,58 These symptoms, however, are transient and typically resolve within 7 to 10 days after birth. A more recent study suggested that neurobehavioral symptoms for some infants extend beyond 2 weeks and that concomitant exposure to benzodiazepines results in even higher rates of this syndrome.59 There is no evidence that tapering or discontinuing antidepressants near term is necessary, safe, or effective in preventing transient neonatal complications. However, this approach would increase the risk of relapse for the mother.

Autism spectrum disorders

The possible association between antidepressants and autism spectrum disorders in pregnancy has captured much attention in recent years. One study based on healthcare claims60 and one registry-based study61 associated in utero exposure to antidepressants with autism liability in children. However, a large-scale Danish registry-based study did not replicate this association.62 In addition, 2 recent cohort studies, identifying children with autism spectrum disorder or attention-deficit hyperactivity disorder from electronic health records, found that neither disorder was significantly associated with prenatal antidepressant exposure in crude or adjusted models. However, both studies found a significant association with the use of antidepressants before pregnancy, indicating that the risk of autism observed with prenatal antidepressant exposure is likely confounded by the severity of maternal illness.63,64

Concerns about drug therapy during breastfeeding

For infants of breastfeeding women, exposure to antidepressants through breast milk is minimal. Amounts in breast milk depend on the timing of the antidepressant dose, timing of feeding, and genetically influenced metabolic activity in mother and infant. The current literature supports antidepressant use for breastfeeding mothers of healthy full-term infants.65

The 2 most widely studied antidepressants in breastfed infants are paroxetine and sertraline. It has been shown that very little can be detected in the infant’s serum, with relative infant doses ranging from 0.4% to 2.8%.65 While clinicians are cautioned against prescribing paroxetine for pregnant women, the drug remains a suitable alternative for breastfeeding women.

If an antidepressant is started postpartum, the recommendation is to start with a low dose and then slowly titrate upward while monitoring the infant for adverse effects.65,66 Possible adverse effects in breastfeeding infants include irritability, sedation, poor weight gain, and a change in feeding patterns.67 Adverse events are most likely to occur in newborns up to 8 weeks of age, and infants born prematurely or with medical problems may be particularly at risk.65,68

Helping patients weigh risks and benefits of drug therapy

Women may hear about the risks of medications to the fetus and during breastfeeding and so may be reluctant to seek or accept intervention. Often, the information is not from a reliable, scientifically based source. Primary care physicians are well positioned to guide peripartum women in risk-benefit analysis of proper treatment of their depression vs no treatment or undertreatment. In addition, establishing referral sources—ideally with a peripartum mental health specialist—is advisable. Online resources that clinicians can refer patients to for help in managing peripartum depression include the following:

INCREASED AWARENESS IS KEY

Primary care physicians must remain alert to the high prevalence of depression in women of childbearing age and embrace routine screening for depression. (See the sidebar, “The primary care management of peripartum depression.”) Since half of pregnancies are unintended, awareness of the risks of undetected and untreated peripartum depression to the mother, developing fetus, and infant is essential. Untreated antepartum depression has been linked to poor pregnancy outcomes, nutritional deficits, and substance abuse. Untreated postpartum depression negatively affects mother-infant attachment, infant, and child development and maternal self care.

Not treating depression is hazardous

Drug treatment during pregnancy and breastfeeding poses challenges for the patient and physician due to the inevitability of fetal and infant exposure, but lack of treatment can be hazardous.

To date, the evidence on the use of antidepressants in pregnant and lactating women is reassuring. Specialized peripartum psychiatric partial hospital programs69 and inpatient programs70 exist for women who need a higher level of care. There is also substantial evidence that psychotherapy, especially cognitive behavioral therapy and interpersonal therapy, is highly effective, and emerging data on complementary and alternative treatments are promising. Coordinated care between primary care and behavioral healthcare providers with expertise in treating peripartum depression is most likely to yield optimal outcomes.

Contrary to common belief, pregnancy does not confer protection against depression.1,2 In fact, pregnant women are just as likely as nonpregnant women to become or remain depressed, and up to 12.7% of pregnant women meet criteria for depression.1

In the postpartum period, women are particularly vulnerable to a major depressive episode, whether a first episode or a recurrence. The estimated prevalence of a depressive episode in the first 3 postpartum  months is 19.2%,2 making postpartum depression the most common complication of childbearing.2 At the same time, peripartum depression remains largely underrecognized and undertreated.3

As evidence mounts regarding the deleterious impact of untreated mental illness on the mother, the developing fetus, and the infant, early detection and intervention for peripartum depression are paramount.3

DEPRESSION DURING PREGNANCY: SIGNIFICANT CONSEQUENCES

Although the rates of depression in pregnant and nonpregnant women are similar, depression in pregnancy carries additional significant consequences. Further, many depressed pregnant women believe their depression will lift once their baby is born, though it is well documented that depression during pregnancy is the strongest predictor of postpartum depression and that if left untreated it can be devastating for mother, infant, and family.4

Compared with nondepressed pregnant women, depressed pregnant women have poorer overall health status,5 are more likely to engage in behaviors that pose risk to the developing fetus such as smoking,5 alcohol consumption, and substance use,6 and have poor nutrition and inadequate weight gain.7,8

Pregnant women who are depressed and are also experiencing domestic violence are especially at risk for poor prenatal care as they tend to miss more prenatal appointments.9 Evidence also suggests that depressed pregnant women are less attached to the fetus and more likely to have elective terminations.10,11

Depression in pregnancy is associated with higher rates of adverse pregnancy outcomes such as preterm birth, low birth weight, operative delivery, and longer predelivery hospital stay.3,12 Depression and anxiety during pregnancy have been associated with prenatal hypertension,13 gestational diabetes,14 preeclampsia,15 and HELLP syndrome (ie, hemolysis, elevated liver enzymes, and low platelet count).15 Depression and anxiety during pregnancy are associated with subsequent poorer infant attachment16,17 and an overall unfavorable impact on infant and child development.18

Risk factors for depression during pregnancy include past episodes of depression, current anxiety, poor social support, unintended pregnancy, life stress, being single, domestic violence, and being on Medicaid.19

Undoubtedly the most devastating consequence of severe depression during pregnancy is suicide. Rates of suicide are lower in peripartum women,20 but when suicide does occur, pregnant women tend to use more violent means than nonpregnant women. Pregnant adolescents represent a particularly high-risk group.21

POSTPARTUM DEPRESSION

Postpartum depression is the most common complication of childbearing. Although the precise pathogenesis is undetermined, there is converging evidence of a subset of women particularly sensitive to dramatic fluctuations in levels of estradiol and progesterone that occur during childbirth.22,23 There is also evidence that dysregulation of the hypothalamic-pituitary-adrenal axis contributes to the development of postpartum depression in certain women.24 Further, women who have depression or anxiety during pregnancy are much more likely to experience postpartum depression than those who are not symptomatic during pregnancy.4 A history of peripartum depression or other lifetime depressive episodes, poverty, conflict with a primary partner, poor social support, stressful life events, and low self-esteem are strongly associated with postpartum depression.25

When unrecognized and untreated, postpartum depression can have profound and persistent effects on the mother and the developing infant.18,26 Mothers with postpartum depression are much more likely than mothers without depression to have impaired bonding,27 to be less responsive to their infant’s needs,17 and to be more likely to miss well-baby checkups.28

Postpartum depression’s effects on maternal-infant interactions can include maternal withdrawal, disengagement, intrusion, and hostility and can lead to long-term effects on child development, including poor cognitive functioning, emotional maladjustment, and behavioral inhibition.29,30 Infants and children of mothers with untreated postpartum depression have been shown to exhibit a higher incidence of colic, excessive crying, sleep problems, and irritability.31,32 Women with postpartum depression may be less likely to initiate or maintain breastfeeding, and depressive symptoms have been noted to precede the discontinuation of breastfeeding.33–35

Risk factors for postpartum depression

Characteristics to look for in the prenatal care of pregnant women include the following:

  • Depression during pregnancy
  • History of postpartum or other depressive episode
  • Poverty
  • Conflict with primary partner
  • Poor social support
  • Low self-esteem
  • Single status.

 

 

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.

Source: Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a brief depression severity measure. J Gen In-tern Med 2001; 16:606–616. No permission required to reproduce, translate, display, or distribute.
FIGURE 1. Patient Health Questionnaire–9. A score 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.

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.

 

 

CLINICAL MANAGEMENT

Many women prefer nondrug therapy

The gold standard treatment for moderate to severe major depressive disorder is psychotherapy plus pharmacotherapy. Yet many peripartum women voice concerns about exposure to pharmacologic treatment, and studies have shown that many women prefer nonpharmacologic intervention.47

Evidence-based psychotherapies that have demonstrated efficacy in peripartum women include cognitive behavioral therapy48 and interpersonal psychotherapy when administered by a psychotherapist trained in these treatments. Pregnant and breastfeeding women often express preference for psychotherapy and complementary and alternative treatments as a means of avoiding fetal and infant exposure to antidepressants.47

For mild to moderate depression, complementary therapies such as exercise, yoga, bright light therapy, and acupuncture have shown efficacy and can be used alone or adjunctively.49 Because a poor marital relationship is consistently associated with peripartum depression,25 primary care physicians who routinely address social support and screen for family conflict are well positioned to detect this significant correlate and to recommend marital or family therapy as a primary or adjunctive treatment.

When to consider drug therapy

The decision to recommend drug therapy must be individualized and based on the severity of symptoms, functional impairment, number and frequency of depressive episodes, history of response to medications, and the preferences of the patient, with the recognition that no decision is risk-free and that antidepressants enter the amniotic fluid, so fetal exposure is unavoidable.

Table 2 lists common antidepressants. The antidepressants most commonly prescribed, especially in the primary care setting, are selective serotonin reuptake inhibitors (SSRIs), which are favored because of their effectiveness, low side-effect profile, and lack of overdose toxicity.

Serotonin syndrome is no more likely to occur in pregnant than in nonpregnant women. Close monitoring for this condition is warranted only when patients are taking very  high doses of SSRIs or SSRIs in combination with other serotonergic agonists.

Prescribing antidepressants for pregnant or breastfeeding women requires thoughtful consideration of the patient’s preferences, as well as weighing the risks and benefits of fetal and infant exposure to maternal depression vs exposure to medications. Additional considerations include monotherapy, avoiding medication changes, choosing drugs that have been effective in the past, and avoiding drugs with known drug-drug interactions or teratogenic effects.50

There is increasing consensus that the short- and long-term consequences of undertreatment or nontreatment of maternal depression outweigh the risk of fetal exposure to SSRIs.3,51,52 Cohen et al53 have recommended that if a woman is on an antidepressant and learns she is pregnant, she should not discontinue it because of the likelihood of relapse; they found a 68% relapse rate in women who discontinued their antidepressant in the first trimester of pregnancy.53

In a comprehensive review of studies published between 1996 and 2012 that examined antidepressant use during pregnancy, Byatt et al54 found little or no evidence of increased teratogenic risk with antidepressants with the exception of paroxetine, which is associated with a small but significant increased risk of cardiac malformation during first-trimester exposure.54

These conclusions were underscored in a large cohort study in the United Kingdom.55 In addition, a joint task force of the American Psychiatric Association and ACOG reviewed studies looking at the association between depression, antidepressants, and birth outcomes including miscarriage, preterm birth, cardiac abnormalities (resulting from first trimester exposure), persistent pulmonary hypertension (related to second- and third-trimester exposure), and neonatal adaptation syndrome (associated with third-trimester exposure).8 They concluded that the available data neither support nor refute a link between the use of antidepressants and several of the above outcomes. No increase in risk of congenital malformations (including cardiac abnormalities) was found. An increased risk of persistent pulmonary hypertension was noted, although the absolute risk of this disorder remained low, at 3 to 6 per 1,000 infants exposed to SSRIs in utero.8,56

Neonatal adaptation syndrome

Neonatal adaptation syndrome is characterized by jitteriness, irritability, decreased muscle tone, and feeding difficulty in the neonate. It can occur in 15% to 30% of infants exposed to SSRIs antenatally.57,58 These symptoms, however, are transient and typically resolve within 7 to 10 days after birth. A more recent study suggested that neurobehavioral symptoms for some infants extend beyond 2 weeks and that concomitant exposure to benzodiazepines results in even higher rates of this syndrome.59 There is no evidence that tapering or discontinuing antidepressants near term is necessary, safe, or effective in preventing transient neonatal complications. However, this approach would increase the risk of relapse for the mother.

Autism spectrum disorders

The possible association between antidepressants and autism spectrum disorders in pregnancy has captured much attention in recent years. One study based on healthcare claims60 and one registry-based study61 associated in utero exposure to antidepressants with autism liability in children. However, a large-scale Danish registry-based study did not replicate this association.62 In addition, 2 recent cohort studies, identifying children with autism spectrum disorder or attention-deficit hyperactivity disorder from electronic health records, found that neither disorder was significantly associated with prenatal antidepressant exposure in crude or adjusted models. However, both studies found a significant association with the use of antidepressants before pregnancy, indicating that the risk of autism observed with prenatal antidepressant exposure is likely confounded by the severity of maternal illness.63,64

Concerns about drug therapy during breastfeeding

For infants of breastfeeding women, exposure to antidepressants through breast milk is minimal. Amounts in breast milk depend on the timing of the antidepressant dose, timing of feeding, and genetically influenced metabolic activity in mother and infant. The current literature supports antidepressant use for breastfeeding mothers of healthy full-term infants.65

The 2 most widely studied antidepressants in breastfed infants are paroxetine and sertraline. It has been shown that very little can be detected in the infant’s serum, with relative infant doses ranging from 0.4% to 2.8%.65 While clinicians are cautioned against prescribing paroxetine for pregnant women, the drug remains a suitable alternative for breastfeeding women.

If an antidepressant is started postpartum, the recommendation is to start with a low dose and then slowly titrate upward while monitoring the infant for adverse effects.65,66 Possible adverse effects in breastfeeding infants include irritability, sedation, poor weight gain, and a change in feeding patterns.67 Adverse events are most likely to occur in newborns up to 8 weeks of age, and infants born prematurely or with medical problems may be particularly at risk.65,68

Helping patients weigh risks and benefits of drug therapy

Women may hear about the risks of medications to the fetus and during breastfeeding and so may be reluctant to seek or accept intervention. Often, the information is not from a reliable, scientifically based source. Primary care physicians are well positioned to guide peripartum women in risk-benefit analysis of proper treatment of their depression vs no treatment or undertreatment. In addition, establishing referral sources—ideally with a peripartum mental health specialist—is advisable. Online resources that clinicians can refer patients to for help in managing peripartum depression include the following:

INCREASED AWARENESS IS KEY

Primary care physicians must remain alert to the high prevalence of depression in women of childbearing age and embrace routine screening for depression. (See the sidebar, “The primary care management of peripartum depression.”) Since half of pregnancies are unintended, awareness of the risks of undetected and untreated peripartum depression to the mother, developing fetus, and infant is essential. Untreated antepartum depression has been linked to poor pregnancy outcomes, nutritional deficits, and substance abuse. Untreated postpartum depression negatively affects mother-infant attachment, infant, and child development and maternal self care.

Not treating depression is hazardous

Drug treatment during pregnancy and breastfeeding poses challenges for the patient and physician due to the inevitability of fetal and infant exposure, but lack of treatment can be hazardous.

To date, the evidence on the use of antidepressants in pregnant and lactating women is reassuring. Specialized peripartum psychiatric partial hospital programs69 and inpatient programs70 exist for women who need a higher level of care. There is also substantial evidence that psychotherapy, especially cognitive behavioral therapy and interpersonal therapy, is highly effective, and emerging data on complementary and alternative treatments are promising. Coordinated care between primary care and behavioral healthcare providers with expertise in treating peripartum depression is most likely to yield optimal outcomes.

References
  1. World Health Organization (WHO). A message from the Director General. www.who.int/whr/2001/dg_message/en/index.html. Accessed March 6, 2017.
  2. Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G, Swinson T. Perinatal depression: a systematic review of prevalence and incidence. Obset Gynecol 2005; 106:1071–1083.
  3. Davalos DB, Yadon CA, Tregellas HC. Untreated prenatal maternal depression and the potential risks to offspring: a review. Arch Women’s Mental Health 2012; 15:1–14.
  4. Chaudron LH, Klein MH, Remington P, Palta M, Allen C, Essex MJ. Predictors, prodromes and incidence of postpartum depression. J Psychosom Obstet Gynaecol 2001; 22:103–112.
  5. Orr ST, Blazer DG, Orr CA. Maternal prenatal depressive symptoms, nicotine addiction, and smoking-related knowledge, attitudes, beliefs, and behaviors. Matern Child Health J 2012; 16:973–978.
  6. Flynn HA, Chermack ST. Prenatal alcohol use: the role of lifetime problems with alcohol,drugs, depression, and violence. J Stud Alcohol Drugs 2008; 69:500–509.
  7. Bodnar LM, Wisner KL, Moses-Kolko E, Sit DK, Hanusa BH. Prepregnancy body mass index, gestational weight gain, and the likelihood of major depressive disorder during pregnancy. J Clin Psychiatry 2009; 70:1290–1296.
  8. Yonkers KA, Wisner KL, Stewart DE, et al. The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Obstet Gynecol 2009; 114:703–713.
  9. Han A, Stewart DE. Maternal and fetal outcomes of intimate partner violence associated with pregnancy in the Latin American and Caribbean region. Int J Gynecol Obstet 2014; 124:6–11.
  10. McFarland J, Salisbury AL, Battler CL, Hawes K, Halloran K, Lester BM. Major depressive disorder during pregnancy and emotional attachment to the fetus. Arch Womens Ment Health 2011; 14:425–434.
  11. Suri R, Althuler LA, Mintz J. Depression and the decision to abort. Am J Psychiatry 2004; 161:1502.
  12. Kim DR, Sockol LE, Sammel MD, Kelly C, Moseley M, Epperson CN. Elevated risk of adverse obstetric outcomes in pregnant women with depression. Arch Women’s Ment Health 2013; 16:475–482.
  13. Mautner E, Greimel E, Trutnovsky G, Daghofer F, Egger JW, Lang U. Quality of life outcomes in pregnancy and postpartum complicated by hypertensive disorders, gestational diabetes, and preterm birth. J Psychosom Obstet Gynaecol 2009; 30:231–237.
  14. Katon JG, Russo J, Gavin AR, Melville JL, Katon WJ. Diabetes and depression in pregnancy: is there an association? J Women’s Health (Larchmt) 2011; 20:983–989.
  15. Delahaije DH, Dirksen CD, Peeters LL, Smits LJ. Anxiety and depression following preeclampsia or HELLP syndrome: a systematic review. Acta Obstet Gynecol Scand 2013; 92:746–761.
  16. O’Higgins M, Roberts IS, Glover V, Taylor A. Mother-child bonding at 1 year; associations with symptoms of postnatal depression and bonding in the first few weeks. Arch Women’s Ment Health 2013; 16:381–389.
  17. Field T, Healy BT, Goldstein S, Guthertz M. Behavior-state matching and synchrony in mother-infant interactions of nondepressed versus depressed dyads. Dev Psychol 1990; 26:7–14.
  18. Kingston D, Tough S, Whitfield H. Prenatal and postpartum maternal psychological distress and infant development: a systematic review. Child Psychiatry Hum Dev 2012; 43:683–714.
  19. 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; 202:5–14.
  20. Lindahl V, Pearson JL, Colpe L. Prevalence of suicidality during pregnancy and the postpartum. Arch Women’s Ment Health 2005; 8:77–87.
  21. Appleby L. Suicide after pregnancy and the first postnatal year. BMJ 1991; 302:137–140.
  22. Bloch M, Schmidt PJ, Danaceau M, Murphy J, Nieman L, Rubinow DR. Effects of gonadal steroids in women with a history of postpartum depression. Am J Psychiatry 2000; 157:924–930.
  23. Workman JL, Barha CK, Galea LAM. Endocrine substrates of cognitive and affective changes during pregnancy and postpartum. Behav Neurosci 2012; 126:54–72.
  24. Meltzer-Brody S. New insights into perinatal depression: pathogenesis and treatment during pregnancy and postpartum. Dialogues Clin Neurosci 2011; 13:89–100.
  25. O’Hara MW, McCabe JE. Postpartum depression: current status and future directions. Annu Rev Clin Psychol 2013; 9:379–407.
  26. Goodman SH, Rouse MH, Connell AM, Broth MR, Hall CM, Heyward D. Maternal depression and child psychopathology: a meta-analytic review. Clin Child Fam Psychol Rev 2011; 14:1–27
  27. Muzik M, Bocknek EL, Broderick A, et al. Mother-infant bonding impairment across the first 6 months postpartum: the primacy of psychopathology in women with childhood abuse and neglect histories. Arch Women’s Ment Health 2013; 16:29–38.
  28. Farr SL, Dietz PM, Rizzo JH, et al. Health care utilisation in the first year of life among infants of mothers with perinatal depression or anxiety. Paediatr Perinat Epidemiol 2013; 27:81–88.
  29. Grace SL, Evindar A, Stewart DE. The effect of postpartum depression on child cognitive development and behavior: a review and critical analysis of the literature. Arch Women’s Ment Health 2003; 6:263–274.
  30. Murray L, Cooper PJ. Postpartum depression and child development. Psychol Med 1997; 27:253–260.
  31. Orhon FS, Ulukol B, Soykan A. Postpartum mood disorders and maternal perceptions of infant patterns in well-child follow-up visits. Acta Paediatr 2007; 96:1777–1783.
  32. Dennis CL, Ross L. Relationships among infant sleep patterns, maternal fatigue, and development of depressive symptomatology. Birth 2005; 32:187–193.
  33. Ip S, Chung M, Raman G, et al. Breastfeeding and maternal and infant health outcomes in developed countries. Evid Rep Technol Assess (Full Rep) 2007; 153:1–186.
  34. Dennis CL, McQueen K. Does maternal postpartum depressive symptomatology influence infant feeding outcomes? Acta Paediatr 2007; 96:590–594.
  35. Hatton DC, Harrison-Hohner J, Coste S, Dorato V, Curet LB, McCarron DA. Symptoms of postpartum depression and breastfeeding. J Hum Lact 2005; 21:444–449.
  36. Klein MH, Essex MJ. Pregnant or depressed? The effect of overlap between symptoms of depression and somatic complaints of pregnancy on rates of major depression in the second trimester. Depression 1994; 2:308–314.
  37. Seyfried LS, Marcus SM. Postpartum mood disorders. Int Rev Psychiatry 2003; 15:231–242.
  38. Buttner MM, O’Hara MW, Watson D. The structure of women’s mood in the early postpartum. Assessment 2012; 19:247–256.
  39. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA; American Psychiatric Association Publishing: 2013.
  40. Wisner KL, Peindl KS, Gigliotti T, Hanusa BH. Obsessions and compulsions in women with postpartum depression. J Clin Psychiatry 1999: 60:176-180.
  41. Di Florio A, Smith S, Jones I. Postpartum psychosis. The Obstetrician & Gynecologist 2013; 15:145–150.
  42. O’Connor E, Rossom RC, Henniger M, Groom HC, Burda BU. Primary care screening for and treatment of depression in pregnant and postpartum women: evidence report and systematic review for the US Preventive Services Task Force. JAMA 2016; 315:388–406.
  43. Committee on Obstetric Practice. The American College of Obstetricians and Gynecologists Committee Opinion no. 630. Screening for perinatal depression. Obstet Gynecol 2015; 125:1268–1271.
  44. 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; 126:1032–1039.
  45. 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.
  46. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001; 16:606–616.
  47. Battle CL, Salisbury AL, Schofield CA, Ortiz-Hernandez S. Perinatal antidepressant use: understanding women’s preferences and concerns. J Psychiatr Pract 2013; 19:443–453.
  48. Stuart S, Koleva H. Psychological treatments for perinatal depression. Best Pract Res Clin Obstet Gynaecol 2014; 28:61–70.
  49. Deligiannidis KM, Freeman MP. Complementary and alternative medicine therapies for perinatal depression. Best Pract Res Clin Obstet Gynaecol 2014; 28:85–95.
  50. 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; 111:1001–1020.
  51. Ornoy A, Koren G. Selective serotonin reuptake inhibitors in human pregnancy: on the way to resolving the controversy. Semin Fetal Neonatal Med 2014; 19:188–194.
  52. Salisbury AL, Wisner KL, Pearlstein T, Battle CL, Stroud L, Lester BM. Newborn neurobehavioral patterns are differentially related to prenatal maternal major depressive disorder and serotonin reuptake inhibitor treatment. Depress Anxiety 2011; 28:1008–1019.
  53. Cohen LS, Altshuler LL, Harlow BL, et al. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA 2006; 295:499–507.
  54. Byatt N, Deligiannidis KM, Freeman MP. Antidepressant use in pregnancy: a critical review focused on risks and controversies. Acta Psychiatr Scand 2013; 127:94–114.
  55. Ban L, Gibson JE, West J, et al. Maternal depression, antidepressant prescriptions, and congenital anomaly risk in offspring: a population-based cohort study. BJOG 2014; 121:1471–1481.
  56. Kallen B, Olausson P. Maternal use of selective serotonin re-uptake inhibitors and persistent pulmonary hypertension of the newborn. Pharmacoepidemiol Drug Saf 2008; 17:801–806.
  57. Chambers CD, Johnson KA, Dick LM, Felix RJ, Jones KL. Birth outcomes in pregnant women taking fluoxetine. N Engl J Med 1996; 335:1010–1015.
  58. Costei AM, Kozer E, Ho T, Ito S, Koren G. Perinatal outcome following third trimester exposure to paroxetine. Arch Pediatr Adolesc Med 2002; 156:1129–1132.
  59. Salisbury AL, O’Grady KE, Battle CL, et al. The roles of maternal depression, serotonin reuptake inhibitor treatment, and concomitant benzodiazepine use on infant neurobehavioral functioning over the first postnatal month. Am J Psychiatry 2016; 173:147–157.
  60. Croen LA, Grether JK, Yoshida CK, Odouli R, Hendrick V. Antidepressant use during pregnancy and childhood autism spectrum disorders. Arch Gen Psychiatry 2011; 68:1104–1112.
  61. Rai D, Lee BK, Dalman C, Golding J, Lewis G, Magnusson C. Parental depression, maternal antidepressant use during pregnancy, and risk of autism spectrum disorders: population based case-control study. BMJ 2013; 346:f2059.
  62. Sorensen MJ, Gronborg TK, Christensen J, et al. Antidepressant exposure in pregnancy and risk of autism spectrum disorders. Clin Epidemiol 2013; 5:449–459.
  63. 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; 20:727–734.
  64. Castro VM, Kong SW, Clements CC, et al. Absence of evidence for increase in risk for autism or attention-deficit hyperactivity disorder following antidepressant exposure during pregnancy: a replication study. Transl Psychiatry 2016; 6:e708.
  65. Hale TW, Rowe HE. Medications and Mothers’ Milk. 16th ed. Amarillo, TX: Hale Publishing, L.P; 2014.
  66. Abreu AC, Stuart S. Pharmacologic and hormonal treatments for postpartum depression. Psychiatr Ann 2005; 35:568–576.
  67. Sit DK, Wisner KL. Decision making for postpartum depression treatment. Psychiatr Ann 2005; 35:577–584.
  68. Wisner KL, Parry BL, Piontek CM. Clinical practice. Postpartum depression. N Engl J Med 2002; 347:194–199.
  69. Howard M, Battle CL, Pearlstein T, Rosene-Montella K. A psychiatric mother-baby day hospital for pregnant and postpartum women. Arch Women’s Ment Health 2006; 9:213–218.
  70. Meltzer-Brody S, Brandon AR, Pearson B, et al. Evaluating the clinical effectiveness of a specialized perinatal psychiatry inpatient unit. Arch Women’s Ment Health 2014; 17:107–113.
References
  1. World Health Organization (WHO). A message from the Director General. www.who.int/whr/2001/dg_message/en/index.html. Accessed March 6, 2017.
  2. Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G, Swinson T. Perinatal depression: a systematic review of prevalence and incidence. Obset Gynecol 2005; 106:1071–1083.
  3. Davalos DB, Yadon CA, Tregellas HC. Untreated prenatal maternal depression and the potential risks to offspring: a review. Arch Women’s Mental Health 2012; 15:1–14.
  4. Chaudron LH, Klein MH, Remington P, Palta M, Allen C, Essex MJ. Predictors, prodromes and incidence of postpartum depression. J Psychosom Obstet Gynaecol 2001; 22:103–112.
  5. Orr ST, Blazer DG, Orr CA. Maternal prenatal depressive symptoms, nicotine addiction, and smoking-related knowledge, attitudes, beliefs, and behaviors. Matern Child Health J 2012; 16:973–978.
  6. Flynn HA, Chermack ST. Prenatal alcohol use: the role of lifetime problems with alcohol,drugs, depression, and violence. J Stud Alcohol Drugs 2008; 69:500–509.
  7. Bodnar LM, Wisner KL, Moses-Kolko E, Sit DK, Hanusa BH. Prepregnancy body mass index, gestational weight gain, and the likelihood of major depressive disorder during pregnancy. J Clin Psychiatry 2009; 70:1290–1296.
  8. Yonkers KA, Wisner KL, Stewart DE, et al. The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Obstet Gynecol 2009; 114:703–713.
  9. Han A, Stewart DE. Maternal and fetal outcomes of intimate partner violence associated with pregnancy in the Latin American and Caribbean region. Int J Gynecol Obstet 2014; 124:6–11.
  10. McFarland J, Salisbury AL, Battler CL, Hawes K, Halloran K, Lester BM. Major depressive disorder during pregnancy and emotional attachment to the fetus. Arch Womens Ment Health 2011; 14:425–434.
  11. Suri R, Althuler LA, Mintz J. Depression and the decision to abort. Am J Psychiatry 2004; 161:1502.
  12. Kim DR, Sockol LE, Sammel MD, Kelly C, Moseley M, Epperson CN. Elevated risk of adverse obstetric outcomes in pregnant women with depression. Arch Women’s Ment Health 2013; 16:475–482.
  13. Mautner E, Greimel E, Trutnovsky G, Daghofer F, Egger JW, Lang U. Quality of life outcomes in pregnancy and postpartum complicated by hypertensive disorders, gestational diabetes, and preterm birth. J Psychosom Obstet Gynaecol 2009; 30:231–237.
  14. Katon JG, Russo J, Gavin AR, Melville JL, Katon WJ. Diabetes and depression in pregnancy: is there an association? J Women’s Health (Larchmt) 2011; 20:983–989.
  15. Delahaije DH, Dirksen CD, Peeters LL, Smits LJ. Anxiety and depression following preeclampsia or HELLP syndrome: a systematic review. Acta Obstet Gynecol Scand 2013; 92:746–761.
  16. O’Higgins M, Roberts IS, Glover V, Taylor A. Mother-child bonding at 1 year; associations with symptoms of postnatal depression and bonding in the first few weeks. Arch Women’s Ment Health 2013; 16:381–389.
  17. Field T, Healy BT, Goldstein S, Guthertz M. Behavior-state matching and synchrony in mother-infant interactions of nondepressed versus depressed dyads. Dev Psychol 1990; 26:7–14.
  18. Kingston D, Tough S, Whitfield H. Prenatal and postpartum maternal psychological distress and infant development: a systematic review. Child Psychiatry Hum Dev 2012; 43:683–714.
  19. 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; 202:5–14.
  20. Lindahl V, Pearson JL, Colpe L. Prevalence of suicidality during pregnancy and the postpartum. Arch Women’s Ment Health 2005; 8:77–87.
  21. Appleby L. Suicide after pregnancy and the first postnatal year. BMJ 1991; 302:137–140.
  22. Bloch M, Schmidt PJ, Danaceau M, Murphy J, Nieman L, Rubinow DR. Effects of gonadal steroids in women with a history of postpartum depression. Am J Psychiatry 2000; 157:924–930.
  23. Workman JL, Barha CK, Galea LAM. Endocrine substrates of cognitive and affective changes during pregnancy and postpartum. Behav Neurosci 2012; 126:54–72.
  24. Meltzer-Brody S. New insights into perinatal depression: pathogenesis and treatment during pregnancy and postpartum. Dialogues Clin Neurosci 2011; 13:89–100.
  25. O’Hara MW, McCabe JE. Postpartum depression: current status and future directions. Annu Rev Clin Psychol 2013; 9:379–407.
  26. Goodman SH, Rouse MH, Connell AM, Broth MR, Hall CM, Heyward D. Maternal depression and child psychopathology: a meta-analytic review. Clin Child Fam Psychol Rev 2011; 14:1–27
  27. Muzik M, Bocknek EL, Broderick A, et al. Mother-infant bonding impairment across the first 6 months postpartum: the primacy of psychopathology in women with childhood abuse and neglect histories. Arch Women’s Ment Health 2013; 16:29–38.
  28. Farr SL, Dietz PM, Rizzo JH, et al. Health care utilisation in the first year of life among infants of mothers with perinatal depression or anxiety. Paediatr Perinat Epidemiol 2013; 27:81–88.
  29. Grace SL, Evindar A, Stewart DE. The effect of postpartum depression on child cognitive development and behavior: a review and critical analysis of the literature. Arch Women’s Ment Health 2003; 6:263–274.
  30. Murray L, Cooper PJ. Postpartum depression and child development. Psychol Med 1997; 27:253–260.
  31. Orhon FS, Ulukol B, Soykan A. Postpartum mood disorders and maternal perceptions of infant patterns in well-child follow-up visits. Acta Paediatr 2007; 96:1777–1783.
  32. Dennis CL, Ross L. Relationships among infant sleep patterns, maternal fatigue, and development of depressive symptomatology. Birth 2005; 32:187–193.
  33. Ip S, Chung M, Raman G, et al. Breastfeeding and maternal and infant health outcomes in developed countries. Evid Rep Technol Assess (Full Rep) 2007; 153:1–186.
  34. Dennis CL, McQueen K. Does maternal postpartum depressive symptomatology influence infant feeding outcomes? Acta Paediatr 2007; 96:590–594.
  35. Hatton DC, Harrison-Hohner J, Coste S, Dorato V, Curet LB, McCarron DA. Symptoms of postpartum depression and breastfeeding. J Hum Lact 2005; 21:444–449.
  36. Klein MH, Essex MJ. Pregnant or depressed? The effect of overlap between symptoms of depression and somatic complaints of pregnancy on rates of major depression in the second trimester. Depression 1994; 2:308–314.
  37. Seyfried LS, Marcus SM. Postpartum mood disorders. Int Rev Psychiatry 2003; 15:231–242.
  38. Buttner MM, O’Hara MW, Watson D. The structure of women’s mood in the early postpartum. Assessment 2012; 19:247–256.
  39. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA; American Psychiatric Association Publishing: 2013.
  40. Wisner KL, Peindl KS, Gigliotti T, Hanusa BH. Obsessions and compulsions in women with postpartum depression. J Clin Psychiatry 1999: 60:176-180.
  41. Di Florio A, Smith S, Jones I. Postpartum psychosis. The Obstetrician & Gynecologist 2013; 15:145–150.
  42. O’Connor E, Rossom RC, Henniger M, Groom HC, Burda BU. Primary care screening for and treatment of depression in pregnant and postpartum women: evidence report and systematic review for the US Preventive Services Task Force. JAMA 2016; 315:388–406.
  43. Committee on Obstetric Practice. The American College of Obstetricians and Gynecologists Committee Opinion no. 630. Screening for perinatal depression. Obstet Gynecol 2015; 125:1268–1271.
  44. 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; 126:1032–1039.
  45. 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.
  46. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001; 16:606–616.
  47. Battle CL, Salisbury AL, Schofield CA, Ortiz-Hernandez S. Perinatal antidepressant use: understanding women’s preferences and concerns. J Psychiatr Pract 2013; 19:443–453.
  48. Stuart S, Koleva H. Psychological treatments for perinatal depression. Best Pract Res Clin Obstet Gynaecol 2014; 28:61–70.
  49. Deligiannidis KM, Freeman MP. Complementary and alternative medicine therapies for perinatal depression. Best Pract Res Clin Obstet Gynaecol 2014; 28:85–95.
  50. 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; 111:1001–1020.
  51. Ornoy A, Koren G. Selective serotonin reuptake inhibitors in human pregnancy: on the way to resolving the controversy. Semin Fetal Neonatal Med 2014; 19:188–194.
  52. Salisbury AL, Wisner KL, Pearlstein T, Battle CL, Stroud L, Lester BM. Newborn neurobehavioral patterns are differentially related to prenatal maternal major depressive disorder and serotonin reuptake inhibitor treatment. Depress Anxiety 2011; 28:1008–1019.
  53. Cohen LS, Altshuler LL, Harlow BL, et al. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA 2006; 295:499–507.
  54. Byatt N, Deligiannidis KM, Freeman MP. Antidepressant use in pregnancy: a critical review focused on risks and controversies. Acta Psychiatr Scand 2013; 127:94–114.
  55. Ban L, Gibson JE, West J, et al. Maternal depression, antidepressant prescriptions, and congenital anomaly risk in offspring: a population-based cohort study. BJOG 2014; 121:1471–1481.
  56. Kallen B, Olausson P. Maternal use of selective serotonin re-uptake inhibitors and persistent pulmonary hypertension of the newborn. Pharmacoepidemiol Drug Saf 2008; 17:801–806.
  57. Chambers CD, Johnson KA, Dick LM, Felix RJ, Jones KL. Birth outcomes in pregnant women taking fluoxetine. N Engl J Med 1996; 335:1010–1015.
  58. Costei AM, Kozer E, Ho T, Ito S, Koren G. Perinatal outcome following third trimester exposure to paroxetine. Arch Pediatr Adolesc Med 2002; 156:1129–1132.
  59. Salisbury AL, O’Grady KE, Battle CL, et al. The roles of maternal depression, serotonin reuptake inhibitor treatment, and concomitant benzodiazepine use on infant neurobehavioral functioning over the first postnatal month. Am J Psychiatry 2016; 173:147–157.
  60. Croen LA, Grether JK, Yoshida CK, Odouli R, Hendrick V. Antidepressant use during pregnancy and childhood autism spectrum disorders. Arch Gen Psychiatry 2011; 68:1104–1112.
  61. Rai D, Lee BK, Dalman C, Golding J, Lewis G, Magnusson C. Parental depression, maternal antidepressant use during pregnancy, and risk of autism spectrum disorders: population based case-control study. BMJ 2013; 346:f2059.
  62. Sorensen MJ, Gronborg TK, Christensen J, et al. Antidepressant exposure in pregnancy and risk of autism spectrum disorders. Clin Epidemiol 2013; 5:449–459.
  63. 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; 20:727–734.
  64. Castro VM, Kong SW, Clements CC, et al. Absence of evidence for increase in risk for autism or attention-deficit hyperactivity disorder following antidepressant exposure during pregnancy: a replication study. Transl Psychiatry 2016; 6:e708.
  65. Hale TW, Rowe HE. Medications and Mothers’ Milk. 16th ed. Amarillo, TX: Hale Publishing, L.P; 2014.
  66. Abreu AC, Stuart S. Pharmacologic and hormonal treatments for postpartum depression. Psychiatr Ann 2005; 35:568–576.
  67. Sit DK, Wisner KL. Decision making for postpartum depression treatment. Psychiatr Ann 2005; 35:577–584.
  68. Wisner KL, Parry BL, Piontek CM. Clinical practice. Postpartum depression. N Engl J Med 2002; 347:194–199.
  69. Howard M, Battle CL, Pearlstein T, Rosene-Montella K. A psychiatric mother-baby day hospital for pregnant and postpartum women. Arch Women’s Ment Health 2006; 9:213–218.
  70. Meltzer-Brody S, Brandon AR, Pearson B, et al. Evaluating the clinical effectiveness of a specialized perinatal psychiatry inpatient unit. Arch Women’s Ment Health 2014; 17:107–113.
Issue
Cleveland Clinic Journal of Medicine - 84(5)
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Cleveland Clinic Journal of Medicine - 84(5)
Page Number
388-396
Page Number
388-396
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Cleveland Clinic Journal of Medicine
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Peripartum depression: Early recognition improves outcomes
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Peripartum depression: Early recognition improves outcomes
Legacy Keywords
depression, postpartum, peripartum, major depressive disorder, pregnancy, Patient Health Questionnaire-9, PHQ-9, selective serotonin reuptake inhibitors, SSRIs, antidepressants, Margaret Howard, Niharika Mehta, Raymond Powrie
Legacy Keywords
depression, postpartum, peripartum, major depressive disorder, pregnancy, Patient Health Questionnaire-9, PHQ-9, selective serotonin reuptake inhibitors, SSRIs, antidepressants, Margaret Howard, Niharika Mehta, Raymond Powrie
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  • 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.
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