Postpartum Depression: Risk Factors and Treatment OptionsPublished on Psychiatric Times(http://www.psychiatrictimes.com)

Postpartum Depression: Risk Factors and Treatment OptionsOctober 01, 2004 | Depression [1], Major Depressive Disorder [2], Addiction [3]By Riyi Shi, MD, PhD [4] and Lori L. Altshuler, MD [5]

The postpartum period represents a time of increased vulnerability for women, though postpartumdisorders are often under-recognized and undertreated.

Lifetime prevalence rates of major depressive disorder (MDD) in women are estimated to be as highas 21% (Kessler et al., 1993; Weissman et al., 1993). The postpartum period in particular representsa time of increased vulnerability for women (Cox et al., 1993; O'Hara et al., 1990), thoughpostpartum disorders are often under-recognized and undertreated. Pregnant women generallyreceive little education about the possibility of depression after delivery, and because symptoms ofdepression can overlap with common postpartum symptoms, they may go unrecognized. Womenmay also feel ashamed of having negative emotions at a time when they "should be joyful" and thusnot seek professional help.

The DSM-IV defines postpartum depression as a major depressive episode with an onset in the firstfour weeks following childbirth. Although epidemiologic studies vary in the time frame used to definethe postpartum period, ranging from four weeks to six months after delivery, the period of increasedrisk seems to occur relatively close to delivery. A study by Cox et al. (1993) of 232 postpartumwomen found that rates of depression were threefold higher in the five weeks after giving birth, butcomparable at six months postpartum, when compared to a similarly matched control group ofwomen who had not had a baby within the last 12 months. Wisner et al. (2004a) found that in 51nondepressed women with a history of postpartum depression, 21 women developed a recurrentpostpartum episode when followed for the year after childbirth. Five (24%) of these womenexperienced depression in the first postpartum month.Postpartum depression should be distinguished from postpartum blues (commonly known as thebaby blues), a relatively common condition that can affect 50% to 80% of women and ischaracterized by emotional lability, irritability, anxiety and sleep disturbance that usually resolveswithin two postnatal weeks. Treatment for postpartum blues includes reassurance and validation ofthe woman's experience, as well as assistance in caring for herself, the home and the baby.However, follow-up of women with postpartum blues is important, as up to 20% go on to developpostpartum depression (Stowe, 1996).Postpartum depression is the most common psychiatric disorder that occurs in the puerperium, andit affects approximately 10% to 15% of women. Women without a history of major depression have a10% risk of developing postpartum depression, though the risk of depressive symptomatology maybe higher (O'Hara et al., 1990). With a history of major depression, the risk for postpartumdepression rises to 25%, and with a history of a prior postpartum depression, the risk of recurrencerises further to 50% (Garvey et al., 1983; O'Hara, 1995). In addition to prior history of depression orpostpartum depression, other risk factors for developing a postpartum depression include thefollowing (Beck, 1996; Gotlib et al., 1991; Marks et al., 1992; O'Hara, 1986; Zelkowitz and Milet,1996):

depressive symptoms during pregnancyfamily history of depressionmarital difficultiesambivalence about the pregnancylimited social support and stressful life events.

Symptoms of postpartum depression are consistent with those of major depression that occurs atany other time in a woman's life, though women suffering from postpartum depression often havemarked anxiety (Hendrick et al., 2000) and a tendency to ruminate or even obsess over the healthand well-being of the baby. Other features associated with postpartum depression include lowerincidence of suicidality (Pitt, 1968) and more difficult social adjustment (O'Hara et al., 1990), whencompared to MDD. Although symptoms of postpartum depression can be quite distressing, they are

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Postpartum Depression: Risk Factors and Treatment OptionsPublished on Psychiatric Times(http://www.psychiatrictimes.com)

often missed due to preoccupation with the baby or because the symptoms are attributed to thenatural stress of caring for a newborn. Since sleep disturbances, appetite and weight changes, andfatigue are common to the postpartum period, the Edinburgh Postnatal Depression Scale (EPDS)(Cox et al., 1987), which focuses on nonsomatic symptoms, is a useful screening instrument forpostpartum depression. A thorough evaluation is also important, as failure to address evensubsyndromal symptoms can result in progression to a major depressive episode and/or causeimpairment in psychosocial functioning and interactions with the infant.Hormonal FactorsDramatic hormonal changes occur during pregnancy and shortly after childbirth, and a number ofstudies have investigated the contribution of reproductive events to the occurrence of postpartummood disorders. Estrogens, progesterone, β-endorphin, human chorionic gonadotropin, prolactin andcortisol levels rise during pregnancy, reaching maximum levels near term and declining sharply afterbirth. To date, studies of these biologic factors have not identified a specific etiologic link betweenreproductive changes and postpartum mood disorders (Hendrick et al., 1998). Nevertheless, womenwho develop postpartum depression may be especially sensitive to these reproductive changes.Oxytocin, which rises sharply at delivery to stimulate uterine muscle contraction and promote therelease of breast milk, has not been studied in relationship to postpartum depression.Abnormalities in postpartum thyroid function have also been postulated as contributing topostpartum mood disturbance. Rates of postpartum hypothyroidism are relatively high in the first sixmonths after childbirth, with the rate of thyroiditis reaching 9%, compared to 3% to 4% in thegeneral population (Goldman, 1986). While thyroid dysfunction does not seem to account for mostcases of postpartum depression, it may play a role for a subgroup of women. In a prospective studyof 303 pregnant euthyroid women, postpartum thyroid dysfunction developed in 21 women (7%)(Pop et al., 1991). Of these 21 women, 38% had postpartum depression that resolved with treatmentof the thyroid abnormality. Thus, thyroid dysfunction should be considered in the evaluation of awoman who presents with postpartum depression.Untreated DepressionUntreated postpartum depression may impact maternal functioning, mother-infant bonding andfamily functioning. Mothers who are depressed are at risk for compromised emotional responsivity totheir babies, though maternal behavior varies and maternal depression may not have a singulareffect on the infant (Weinberg and Tronick, 1998). Some mothers with depression are disengagedand withdrawn when interacting with their infants, while others can be intrusive, displaying angerand interference. Other mothers are able to mobilize themselves sufficiently to interact positivelywith their infants (Cohn and Tronick, 1989; Weinberg and Tronick, 1998). Maternal behavior may beinfluenced by variables such as severity of depression and infant temperament. Nevertheless,maternal depression has been associated with adverse effects on infant attachment and behavior(Murray, 1992; Stein et al., 1991) as well as cognitive development (Cogill et al., 1986).In a review of the literature, Grace et al. (2003) found that the adverse effects of postpartumdepression tend to be greater when the depressive episode is severe and prolonged and when itoccurs in the context of adversity. They also found that chronic or recurrent maternal depression ismore likely to be related to subsequent effects on the child. These findings underscore theimportance of early recognition and treatment of postpartum depression.Treatment OptionsThe treatment of postpartum depression is multifactorial and includes reassurance, suggestions forincreased help around the home, psychoeducation, and, in some cases, psychotherapy and/orpharmacologic treatment (Altshuler et al., 2001). Individual psychotherapy can be an essential partof treatment, especially for women with difficulties adjusting to motherhood and/or fears about newresponsibilities. Including a woman's partner in at least one or two meetings can be useful forproviding information as well as support. For mothers who find themselves feeling isolated, grouppsychotherapy may also be helpful.Psychotherapy treatment studies of postpartum depression have demonstrated the efficacy ofinterpersonal psychotherapy (IPT). A prospective study by O'Hara et al. (2000) of 120 postpartumwomen with major depression randomly assigned to 12 weeks of IPT versus a waiting list conditioncontrol group found that subjects receiving IPT had significantly greater reduction in depressivesymptoms and improvement in social adjustment. Thus, IPT may present an alternative form oftreatment to pharmacotherapy, especially for women who are nursing.Pharmacologic treatment studies for postpartum depression are limited and include one double-blindstudy demonstrating efficacy of fluoxetine (Prozac) or cognitive-behavioral therapy for major orminor depression (Appleby et al., 1997); one open study each for sertraline (Zoloft), venlafaxine(Effexor) and fluvoxamine (Luvox) (Cohen et al., 2001; Stowe et al., 1995; Suri et al., 2001); and onedouble-blind, placebo-controlled preventive study for sertraline (Wisner et al., 2004b). Approximately60% of mothers initiate nursing, and most antidepressants are excreted into breast milk. The

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Postpartum Depression: Risk Factors and Treatment OptionsPublished on Psychiatric Times(http://www.psychiatrictimes.com)

majority of reports have not described adverse behavioral effects in nursing infants exposed toantidepressants. In a recent analysis of the available data, Weissman et al. (2004) identified 57studies of maternal plasma, breast milk and/or infant plasma antidepressant levels from nursingmother-infant pairs. They concluded that sertraline, paroxetine (Paxil) and nortriptyline (Aventyl,Pamelor) may be the preferred choices for nursing women. However, the total number of casesreported for any given medication is small, and concern for infant safety must beconsidered.ConclusionThe few months after childbirth represent a time when women may be vulnerable to experiencingpostpartum depression. Women should be followed during this period, especially if they have ahistory of depression or depressive symptoms during pregnancy. Treatment should be multifactorial,including consideration of psychosocial as well as pharmacologic options. Adequate recognition andtreatment of postpartum depression is essential to the health and well-being of the mother, theinfant and the family. References: References 1. Altshuler LL, Cohen LS, Moline ML et al. (2001), The Expert Consensus Guideline Series.Treatment of depression in women. Postgrad Med (Spec No):1-107. 2. Appleby L, Warner R, Whitton A, Faragher B (1997), A controlled study of fluoxetine andcognitive-behavioural counselling in the treatment of postnatal depression. BMJ 314(7085):932-936[see comments]. 3. Beck CT (1996), A meta-analysis of predictors of postpartum depression. Nurs Res45(5):297-303. 4. Cohen LS, Viguera AC, Bouffard SM et al. (2001), Venlafaxine in the treatment of postpartumdepression. J Clin Psychiatry 62(8):592-596. 5. Cogill SR, Caplan HL, Alexandra H et al. (1986), Impact of maternal postnatal depression oncognitive development of young children. Br Med J (Clin Res Ed) 292(6529):1165-1167. 6. Cohn JF, Tronick EZ (1989), Specificity of infants' response to mothers' affective behavior. J AmAcad Child Adolesc Psychiatry 28(2):242-248. 7. Cox JL, Holden JM, Sagovsky R (1987), Detection of postnatal depression. Development of the10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 150:782-786 [see comments]. 8. Cox JL, Murray D, Chapman G (1993), A controlled study of the onset, duration and prevalence ofpostnatal depression. Br J Psychiatry 163:27-31. 9. Garvey MJ, Tuason VB, Lumry AE, Hoffmann NG (1983), Occurrence of depression in thepostpartum state. J Affect Disord 5(2):97-101. 10. Goldman JM (1986), Postpartum thyroid dysfunction. Arch Intern Med 146(7):1296-1299. 11. Gotlib IH, Whiffen VE, Wallace PM, Mount JH (1991), Prospective investigation of postpartumdepression: factors involved in onset and recovery. J Abnorm Psychol 100(2):122-132. 12. Grace SL, Evindar A, Stewart DE (2003), The effect of postpartum depression on child cognitivedevelopment and behavior: a review and critical analysis of the literature. Arch Women Ment Health6(4):263-274. 13. Hendrick V, Altshuler L, Strouse T, Grosser S (2000), Postpartum and nonpostpartumdepression: differences in presentation and response to pharmacologic treatment. Depress Anxiety11(2):66-72. 14. Hendrick V, Altshuler LL, Suri R (1998), Hormonal changes in the postpartum and implicationsfor postpartum depression. Psychosomatics 39(2):93-101. 15. Kessler RC, McGonagle KA, Swartz M et al. (1993), Sex and depression in the NationalComorbidity Survey. I: Lifetime prevalence, chronicity and recurrence. J Affect Disord 29(2-3):85-96. 16. Marks MN, Wieck A, Checkley SA, Kumar R (1992), Contribution of psychological and socialfactors to psychotic and non-psychotic relapse after childbirth in women with previous histories ofaffective disorder. J Affect Disord 24(4):253-263. 17. Murray L (1992), The impact of postnatal depression on infant development. J Child PsycholPsychiatry 33(3):543-561. 18. O'Hara MW (1986), Social support, life events, and depression during pregnancy and thepuerperium. Arch Gen Psychiatry 43(6):569-573. 19. O'Hara MW (1995), Postpartum Depression: Causes and Consequences (Series inPsychopathology). New York: Springer-Verlag. 20. O'Hara MW, Stuart S, Gorman LL, Wenzel A (2000), Efficacy of interpersonal psychotherapy forpostpartum depression. Arch Gen Psychiatry 57(11):1039-1045.

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Postpartum Depression: Risk Factors and Treatment OptionsPublished on Psychiatric Times(http://www.psychiatrictimes.com)

21. O'Hara MW, Zekoski EM, Philipps LH, Wright EJ (1990), Controlled prospective study ofpostpartum mood disorders: comparison of childbearing and nonchildbearing women. J AbnormPsychol 99(1):3-15. 22. Pitt B (1968), "Atypical" depression following childbirth. Br J Psychiatry 114(516):1325-1335. 23. Pop VJ, de Rooy HA, Vader HL et al. (1991), Postpartum thyroid dysfunction and depression inan unselected population. [Published erratum N Engl J Med 325(5):371.] N Engl J Med324(25):1815-1816. 24. Stein A, Gath DH, Bucher J et al. (1991), The relationship between post-natal depression andmother-child interaction. Br J Psychiatry 158:46-52. 25. Stowe ZN (1996), Selected topics pertaining to postpartum psychiatric disorders. Currents inAffective Illness 15(5):5-12. 26. Stowe ZN, Casarella J, Landry J, Nemeroff CB (1995), Sertraline in the treatment of women withpostpartum major depression. Depression 3:49-55. 27. Suri R, Burt VK, Altshuler LL et al. (2001), Fluvoxamine for postpartum depression. Am JPsychiatry 158(10):1739-1740 [letter]. 28. Weinberg MK, Tronick EZ (1998), The impact of maternal psychiatric illness on infantdevelopment. J Clin Psychiatry 59(suppl 2):53-61. 29. Weissman AM, Levy BT, Hartz AJ et al. (2004), Pooled analysis of antidepressant levels inlactating mothers, breast milk, and nursing infants. Am J Psychiatry 161(6):1066-1078. 30. Weissman MM, Bland R, Joyce PR et al. (1993), Sex differences in rates of depression:cross-national perspectives. J Affect Disord 29(2-3):77-84. 31. Wisner KL, Perel JM, Peindl KS, Hanusa BH (2004a), Timing of depression recurrence in the firstyear after birth. J Affect Disord 78(3):249-252. 32. Wisner KL, Perel JM, Peindl KS et al. (2004b), Prevention of postpartum depression: a pilotrandomized clinical trial. Am J Psychiatry 161(7):1290-1292. 33. Zelkowitz P, Milet T (1996), Postpartum psychiatric disorders: their relationship to psychologicaladjustment and marital satisfaction in the spouses. J Abnorm Psychol 105(2):281-285. Source URL: http://www.psychiatrictimes.com/articles/postpartum-depression-risk-factors-and-treatment-options

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