Postpartum Depression Is Not Just Baby Blues

JUNE 17, 2019
Jeannette Y. Wick, MBA, RPh, FASCP
Maternal postpartum depression (PPD), although common, disabling, and sometimes life-threatening, often remains undiagnosed and undertreated. Recent discoveries concerning PPD’s pathophysiology offer tremendous hope to the approximately 400,000 women who develop it annually in the United States.1 Among those women, about 15% will have a disabling, persistent condition, and a small percentage will develop postpartum psychosis.2-4

Subject matter experts indicate that biologic, hormonal, and psychosocial issues are risk factors for postpartum mood disorders (table5-11).12,13 Symptoms can last 1 year or longer, with 25% of women having symptoms at 1 year.4,14 Sadly, many women do not seek prompt treatment, thinking they are just tired or finding other excuses, such as “it’s just postpartum blues.” In addition, tremendous stigma accompanies this condition.



POSTPARTUM BLUES OR PPD?
Postpartum blues—anxiety, fluctuating mood, irritability, and tearfulness—are real and tend to develop around the fourth or fifth day postpartum in about half of women. Generally, these symptoms spontaneously diminish over 2 weeks. Conversely, PPD is persistent and interferes with the mother’s ability to care for herself and others and may not resolve spontaneously. PPD manifests as anhedonia, appetite disturbance, depressed mood, fatigue, insomnia, recurring thoughts of death, suicidal thoughts, and tearfulness. As with other kinds of depression, symptoms occur along a continuum.15 Affected individuals may also have ambivalent feelings, obsess about the baby, or think about hurting her children or herself.16

TREATMENT: MONITOR PATIENT AND PARTNER
Early treatment is crucial and starts with nonpharmacologic strategies in women with mild to moderate depressive symptoms. These include group or individual psychotherapy and psychoeducational support groups. Pharmacists should note that some new mothers are breastfeeding and may be hesitant to take medication. For these women, nonpharmacologic strategies are very important.17-19

When the clinician and patient decide that medication is needed, treatment follows a pattern similar to that used in other kinds of depression (figure4 ). Generally, treatment starts with a selective serotonin reuptake inhibitor (SSRI) or a serotonin/norepinephrine reuptake inhibitor administered at the same doses used for others who have depression. Clinicians can consider other antidepressants if first-line antidepressant medications are ineffective or tolerated poorly.4



In March 2019, the FDA approved the first drug specifically for PPD. Brexanolone is chemically identical to endogenous allopregnanolone, a hormone that falls after childbirth. In PPD, gamma-aminobutyric acid-A receptors become dysregulated. Brexanolone acts as a positive allosteric modulator at those receptors. Clinical trials identified some serious risks, including excessive sedation or sudden loss of consciousness during administration, so brexanolone has a risk evaluation and mitigation strategy: Patients must receive treatment at a certified health care facility under close monitoring; during the 60-hour infusion, patients must have continuous pulse oximetry; and patients may see their children only under direct supervision. Brexanolone’s most common adverse reactions include dry mouth, flushing, loss of consciousness, and sleepiness.20 Postmarketing trials are under way, and obstetricians look forward to the results.4

Pharmacy staff members should note that a form of PPD occurs in fathers. Risk factors appear to be similar to those that mothers experience. A history of depression, financial stressors, and low social support are particularly important in men. When a father and mother both experience depression, they will need increased monitoring and support.21-23

BREASTFEEDING
Most antidepressants can be taken during breastfeeding. Paroxetine and sertraline appear to be least likely to pass into breast milk and are preferred as initial therapy. Clinicians should note that all SSRIs pass into breast milk at levels compatible with breastfeeding, and a healthy full-term infant should not be affected. The benefits of breastfeeding outweigh concerns about SSRI exposure in most cases.24,25 Clinicians and patients can find excellent, evidence-based recommendations about breastfeeding and drugs at LactMed, which is sponsored by the Toxicology Data Network.26

CONCLUSION
With celebrities such as Aarti Sequeira and Chrissy Teigan, going public with their own struggles with PPD, women may be more likely to come forward for help when they have symptoms. Better outcomes will require several things, including appropriate long-term use of medications and therapy, frequent checkin and follow-up from clinicians, and careful reassessment at every opportunity.
 
Jeannette Y. Wick, MBA, RPh, FASCP, is an assistant director of the Office of Pharmacy Professional Development at the University of Connecticut School of Pharmacy in Storrs.

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