Postpartum Mood and Anxiety Disorders

Postpartum depression is defined as a major depressive episode meeting all the criteria for a major depressive episode that has an onset in late pregnancy or within 4 weeks of delivery.^[1] There is some debate within the scientific community about the defined onset of postpartum depression. However, if a woman experiences a major depressive episode while caring for a newborn, whether that is immediately after birth or within the first year, clinicians are encouraged to consider what “postpartum” means to each individual patient. Debilitating anxiety is often the chief complaint for women who have postpartum depression; however, clinicians should be aware that women can have postpartum anxiety disorders without meeting criteria for a major depressive episode. To best manage psychiatric conditions in the postpartum, it is essential that clinicians are able to differentiate postpartum depression from other mood and anxiety disorders.

Differentiating Postpartum Depression from Other Mood and Anxiety Disorders

Postpartum depression is not specifically included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, as its own category; instead, it falls into the general category of postpartum mood and anxiety disorders that includes postpartum blues, postpartum psychosis, postpartum episode of bipolar disorder, and postpartum anxiety disorders. It is particularly important that clinicians caring for women in the postpartum are able to distinguish between postpartum depression and postpartum blues. Postpartum blues is considered a normal, transient experience in the postpartum period that tends to subside after the first 2 weeks of delivery.^[2] It is common for many women to be more emotional and experience some sadness or tearfulness, but not to the extent that it affects overall function. It is important to watch for escalation of symptoms to distinguish the normal experience of postpartum blues with the beginning of a postpartum depressive episode.

It is also important for clinicians to be aware that postpartum obsessions are common as part of depression and sometimes occur alone as part of an obsessive compulsive disorder (OCD) spectrum disorder in the postpartum. These obsessions are incredibly distressing and prominent for many women and are more common in the postpartum period than in the general population. For example, many women will have intrusive, distressing thoughts about something terrible happening to the baby or with the baby’s health, or even thoughts about hurting the baby.^[3] A woman may have disturbing images or thoughts about harming the baby even though she has no intent and there is low risk for harm for the baby. Clinicians should recognize that the intense shame that occur as a result of these thoughts may prevent her from telling someone. A holistic assessment of the mother and education that these thoughts are common and treatable will facilitate early intervention.

A woman who is experiencing postpartum psychosis, in contrast, and who is having thoughts about harming the baby poses a high risk to the newborn. Postpartum psychosis has a completely different presentation than postpartum OCD and can be differentiated as ego-syntonic versus ego-dystonic.^[4] An ego-dystonic presentation occurs when the mother experiencing postpartum OCD recognizes their thoughts as inconsistent with their values and beliefs. Conversely, an ego-syntonic presentation occurs in psychosis when the mother is convicted that their thoughts are appropriate for the situation. Postpartum psychosis manifests as a delusional scheme and can be very alarming. For example, religious delusions may be present, where a woman might harm the baby, thinking that she is saving the baby’s soul. In this situation, urgent action is required and hospitalization is recommended to protect the woman from harming either herself or the baby.

Risk for Postpartum Depression and Hormonal Implications

There is a lot of misrepresentation about the role of hormones in postpartum depression. It is important for clinicians to be aware that postpartum depression is a multifaceted condition and that no one hormone has been implicated as a cause of postpartum depression.^[5] There is as much heterogeneity with postpartum depression as there is for major depressive disorder. It is possible that there may be a small subset of women who have never had depression before who are sensitive to the hormonal changes that occur in the postpartum and become depressed. In terms of hormonal abnormalities, thyroid disorder is very common among women in general, but occurs frequently in the postpartum. However, thyroid abnormalities and postpartum depression are not interchangeable. If abnormal thyroid function tests are present, clinicians should treat the thyroid dysfunction and postpartum depression concurrently.

A comprehensive assessment and awareness of risk factors is essential for the early and accurate management of postpartum depression.

Predictors of Postpartum Depression

There are a number of predictors of postpartum depression. The women who are at the highest risk and who need to be monitored the most closely are those who have had past histories of postpartum depression or major depressive disorder or who have depression and anxiety during the pregnancy. Other predictors of postpartum depression include low self-esteem, difficult infant temperament, and marital dissatisfaction. Weaker predictors include unwanted or unplanned pregnancy, lower socioeconomic status, and being single.^[6]

Initial evaluation of a prior history of depression and ongoing assessment of perinatal depressive symptoms is critical. Clinicians should be aware, however, that women may not accurately report feelings of depression during pregnancy to avoid taking another medication and are often reluctant to seek psychotherapy. However, if depression is not addressed in the perinatal period, it will significantly worsen in the acute postpartum period. An effective approach is to set a goal for accomplishing remission before delivery. This will provide the mother with the skills necessary to navigate the inevitable emotional and physical demands that accompany the postpartum period.

Postpartum depression is often missed, as it is often confused with what is normal or expected. Therefore, screening for postpartum depression is easy, and it can be given to women to fill out in the waiting room while waiting for an appointment. The most common screening tool is the Edinburgh Postnatal Depression Scale (EPDS).^[7] This is a 10-item, self-rated scale that is freely available online and has been validated in several languages. Monitoring for symptoms of postpartum depression is a function of the interprofessional healthcare team. Holistic screening for maternal and child well-being should be conducted in postnatal appointments for both the mother and baby. Multiple touchpoints and follow-up appointments provide excellent opportunities to address symptoms often and early.

Effects of Postpartum Depression on Maternal and Child Well-being

There is an abundance of literature related to the profound negative effects of maternal depression on child development. Effects of maternal depression on the child include insecure attachment, behavioral problems, increased risk for abuse and neglect, and higher rates of childhood psychiatric disorders.^[8] Longitudinal research has shown that exposure to maternal depression in the early postpartum month may have an enduring effect on a child’s psychological adjustment.^[9] Therefore, the prioritization of maternal mental health, in turn, can have a positive impact on the entire family unit.

As it relates to postpartum depression and breast-feeding, most clinicians are focused on the potential negative effect of the medications used to treat depression on breast-feeding; however, there are other important factors to consider as it relates to maternal well-being. The societal pressure on new mothers to breast-feed, combined with the challenges after birth, are stressful for all mothers. A very complex bidirectional relationship between psychiatric problems in the postpartum and difficulty with breast-feeding exists. Many women feel terrible and carry an immense amount of guilt when challenges with breast-feeding arise.^[10] For women at risk for postpartum depression, a referral to a lactation consultant may help to manage the stress and anxiety associated with breast-feeding. Lactation consultants are certified healthcare professionals--often nurses--who specialize in providing support around breast-feeding issues.

All members of the healthcare team should recognize that women are in a very vulnerable state in the postpartum period and reassure mothers for whom breast-feeding is not an option that their ability to parent their child will not be defined by whether they breast-feed or not. In consultation with the lactation consultant or other clinician, a combination of breast-feeding and formula might be recommended. Clinicians must recognize that the world will not stop spinning if a baby is fed formula, because women often actually really need that message, especially now.

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