Postpartum Depression: Recognizing the Signs

JUNE 12, 2015
Kathleen Kenny, PharmD, RPh
Serious depression necessitating hospitalization is more prevalent in women after giving birth.
Although the overall prevalence of depression appears to be similar among women of childbearing years—both postpartum and age-matched nonpostpartum women—serious depression necessitating hospitalization is more prevalent in women after the birth of a child.1 The infant–mother bond can be disrupted by ongoing postpartum depression (PPD) resulting in impairment of the child’s cognitive, emotional, behavioral, and interpersonal developments.1,2 Therefore, early diagnosis and treatment are imperative. Women suspected of having PPD should be referred to their primary health care provider.

The most common form of affective disorder in new mothers is the postpartum blues, also known as the baby blues, with an estimated incidence of 30% to 75%1 and episodes that can last from a few days to a few weeks. Mild symptoms include mood swings, anxiety, sadness, irritability, tearfulness, and disturbances in concentration, appetite, and sleep.1,3

PPD may initially appear to be the baby blues, but its symptoms are more intense and last longer, and ultimately interfere with the mother’s ability to care for her child.3 Incidents of PPD range from 3% to 25% among women within the first year after giving birth4 and typically occur about 1 to 3 months postpartum— but can occur up to 1 year later.5 In addition to a more severe form of the symptoms of the baby blues, symptoms of PPD include fatigue, loss of interest in the joys of life, withdrawal from friends and family, feelings of guilt or shame, difficulty bonding with baby, and thoughts of harming oneself or the baby.3

Causes
While there is no single cause of PPD, physical, emotional, and/or lifestyle changes may play a role.3,6,7 The changes to a woman’s body during and after pregnancy are extreme: the extra hormones that build up during pregnancy, such as estrogen and progesterone, as well as thyroid hormones, quickly return to normal in the first 48 to 72 hours after giving birth.8 The body’s blood volume, blood pressure, immune system, and metabolism also change.3

Emotional factors also contribute to PPD. Sleep deprivation and feeling overwhelmed may result in the inability to make decisions and handle small challenges.9 Anxiety is also common, as some women doubt their ability to be good caregivers, struggle with their sense of identity, and feel unattractive.3 Lifestyle changes, such as lack of support from family and friends, difficulty breast-feeding, financial problems, and demanding children, can all have a negative effect on a new mother’s mental stability.3,5 Women may also have to redefine their relationships with their partners, loved ones, and work colleagues to provide immediate and constant care for their infants.2

Risk Factors
All postpartum women are at risk for developing PPD. Some women, however, have a higher risk than others, including those who have a history of depression, live alone or with marital conflict, lack social support, suffer from financial and substance abuse problems, or have an unplanned or unwanted pregnancy.1,3,6,8 The younger a woman is, the more likely she is to develop PPD. If a woman has had problems with a previous pregnancy or birth or has other children, the risk of developing PPD also increases.6,8 At least one-third of women who have previously suffered from PPD have a recurrence of symptoms following later births.9

Prevention
If PPD is the result of chemical or physical changes in the body, not much can be done to prevent its occurrence, although hormone treatment is under investigation. If the depression is a result of emotional or lifestyle factors, however, women can take a few preventive steps.3,7,10

Getting enough sleep and rest are especially difficult during this time and may require some changes to the daily schedule. Healthy lifestyle choices may also make a difference. Eating healthy foods that provide essential vitamins and minerals can increase energy and feelings of well-being. Including physical activity in the daily routine can increase the energy level and improve outlook. Avoiding smoking, caffeine, alcohol, and recreational drugs may help, as they can increase feelings of fatigue and depression or interfere with sleep.

Talking to friends and family and making new friends can alleviate feelings of isolation, so too much time alone should be avoided. Joining play groups and talking to the other mothers about how it feels to be a new mom can go a long way in keeping spirits up.

Taking some time alone with or without a partner can also help keep a sense of individuality and partnership. Even running errands alone can give new moms a break.

Focusing on thinking positively, especially when circumstances look bad, is important. Taking action to make circumstances better can be empowering, but personal limits should be acknowledged. Sometimes things will not change. When that happens, a person can only control his or her reaction to the circumstances.

Treatment
If PPD is left untreated, it can last for months, even years, and the long-term complications can be severe. Treatment includes psychotherapy or pharmacotherapy, or a combination of the two. Because of controversy regarding the safety of using antidepressants while breast-feeding, many women choose a nonpharmacologic form of treatment to avoid exposing their child to psychotropic medications through breast milk.9 Psychotherapy comes in many forms based on individual needs. One-on-one therapy, group therapy, couples therapy, and family therapy have all been shown to help treat PPD. Sometimes, however, if depression is persistent or severe, pharmacotherapy may be necessary.9

While there is a lack of data concerning PPD pharmacotherapy, firstline therapy should include selective serotonin reuptake inhibitors or tricyclic antidepressants (Online Table).9,11 All antidepressants are excreted in breast milk in much the same way as they pass through the blood–brain barrier. The initial daily dose should be given for 2 weeks before an increase is contemplated. The dosage should be slowly titrated to the lowest effective dose. Improvement should be seen within 6 to 8 weeks.9

Table: Tricyclic Antidepressants and Selective Serotonin Reuptake Inhibitors9
Drug/Class Initial Daily Dose (mg) Usual Daily Dose(mg) Adverse Effects
Amitriptyline/TCA 25-75 100-200 Constipation, sedation, weight gain, orthostatic hypotension, blurred vision, dry mouth
Desipramine/TCA 25-75 150-200 Same as amitriptyline
Imipramine/TCA 25-75 150-200 Same as amitriptyline
Nortriptyline/TCA 25 75-100 Same as amitriptyline
Clomipramine/TCA 50 150-200 Same as amitriptyline
Doxepin 75 75-150 Same as amitriptyline
Trimipramine 75 75-150 Same as amitriptyline
Fluoxetine a/SSRI 20 20-40 Headache, nausea, diarrhea, anxiety, sedation, insomnia, tremor
Sertraline/SSRI 50 50-150 Same as fluoxetine
Fluvoxamine/SSRI 50 100-300 Same as fluoxetine
Paroxetine/SSRI 20 20-40 Same as fluoxetine
Escitalopram 10 10-20 Same as fluoxetine
Citalopram 20 20-40 Same as fluoxetine
aNot recommended while breast feeding due to long half-life.9
SSRI = selective serotonin reuptake inhibitor; TCA = tricyclic antidepressant.

Conclusion
Pharmacists are in a unique position for recognizing women suffering from PPD. Before giving birth, pregnant patients pick up prenatal vitamins and other medications at pharmacies. If they look harried, unkempt, or depressed after giving birth, it may be more than just lack of sleep. Women suspected of having PPD should be referred to their primary health care provider immediately.


Dr. Kenny earned her doctorate from the University of Colorado Health Sciences Center. She has 20-plus years’ experience as a community pharmacist and is a clinical medical writer based out of Colorado Springs, Colorado. She is also the Colorado Educational Director for the Rocky Mountain Chapter of the American Medical Writers Association.

References
  1. Robertson E, Grace S, Wallington T, Stewart DE. Antenatal risk factors for postpartum depression: a synthesis of recent literature. Gen Hosp Psychiatry. 2004;26(4):289-295.
  2. O’Hara MW, Stuart S, Gorman LL, Wenzel A. Efficacy of interpersonal psychotherapy for postpartum depression. Arch Gen Psychiatry. 2000;57(11):1039-1045.
  3. Postpartum depression. Mayo Clinic website. www.mayoclinic.org/diseases-conditions/postpartum-depression/basics/definition/con-20029130. Accessed March 27, 2015.
  4. Takahashi Y, Tamakoshi K. Factors associated with early postpartum maternity blues and depression tendency among Japanese mothers with full-term healthy infants. Nagoya J Med Sci. 2014;76(1):129-138.
  5. Postpartum depression. The American College of Obstetricians and Gynecologists website. www.acog.org/Patients/FAQs/Postpartum-Depression. Published December 2013. Accessed March 27, 2015.
  6. Depression during and after pregnancy fact sheet.WomensHealth.gov website. www.womenshealth.gov/publications/our-publications/fact-sheet/depression-pregnancy.html. Updated July 16, 2012. Accessed Marth 27, 2015.
  7. Postpartum depression. American Psychological Association website. www.apa.org/pi/women/programs/depression/postpartum.aspx. Accessed March 27, 2015.
  8. Postpartum depression health center. WebMD website. www.webmd.com/depression/postpartum-depression/default.htm. Accessed March 27, 2015.
  9. Epperson CN. Postpartum major depression: detection and treatment. Am Fam Physician. 1999;59(8):2247-2254.
  10. Postpartum depression. Medline Plus website. www.nlm.nih.gov/medlineplus/ency/article/007215.htm. Updated September 2, 2014. Accessed March 27, 2015.
  11. Kim DR, Epperson CN, Weiss AR, Wisner KL. Pharmacotherapy of postpartum depression: an update. Expert Opin Pharmacother. 2014;15(9):1223-1234. doi: 10.1517/14656566.2014.911842.


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