Description

• Major depressive disorder (MDD) that recurs or has its onset in the postpartum period
• Postpartum depression (PPD) is similar to nonpregnancy depression (sleep disorders, anhedonia, psychomotor changes, etc.); it most often has its onset within the first 12 weeks postpartum; yet, it can occur in the antepartum period or within 1 year after delivery.
• Different from postpartum “blues” (sadness and emotional lability), which is experienced by 30–70% of women and has an onset and resolution within first 10 days postpartum

Epidemiology

Incidence
9–14% of women experience depression during the postpartum period (1).

Prevalence
>50% of women with PPD enter pregnancy depressed or have an onset during pregnancy (2).

Etiology and Pathophysiology

• May be related to sensitivity in hormonal fluctuations, including estrogen; progesterone; and other gonadal hormones as well as neuroactive steroids; cytokines; hypothalamic–pituitary–adrenal (HPA) axis hormones; altered fatty acid, oxytocin, and arginine vasopressin levels; and genetic and epigenetic factors
• Multifactorial including biologic–genetic predisposition in terms of neurobiologic deficit, destabilizing effects of hormone withdrawal at birth, inflammation, and psychosocial stressors

Risk Factors

• Previous episodes of PPD, history of MDD, or anxiety and depression during pregnancy
• History of premenstrual dysphoria, family history of depression
• Poor pregnancy outcomes (preterm birth, stillbirth, neonatal death, major malformations)
• Substance use, unwanted or unplanned pregnancy, multiple psychosocial stressors, lack of social support, intimate partner violence
• Young maternal age, multiple births; African Americans and Hispanics may have higher rates of PPD.
• Postpartum pain, sleep disturbance, and fatigue
• Recent immigrant status, history of adverse childhood experiences
• Decision to decrease antidepressants during pregnancy

General Prevention

• Universal screening, using validated rating scales, during pregnancy and postpartum year for better detection; evidence suggests that screening pregnant and postpartum women for depression reduces depressive symptoms in women with depression and reduces the prevalence of depression in a given population. Evidence for pregnant women was less robust but is also consistent with the evidence for postpartum women regarding the benefits of screening, the benefits of treatment, and screening instrument accuracy (3)[A].
• Psychotherapy/counseling, particularly using cognitive behavioral therapy (CBT) and interpersonal therapy (IPT) based interventions, has been shown to be effective in small randomized trials in the prevention of PPD in at-risk individuals, but the USPSTF concludes that further research is needed (4)[A].
• The use of SSRIs, specifically sertraline, may be effective in preventing PPD in women at high risk for PPD (4)[A].

Commonly Associated Conditions

• Bipolar mood disorder, depressive disorder not otherwise specified, dysthymic disorder, cyclothymic disorder, MDD
• Postpartum blues