Postpartum Depression – Postpartum Psychosis

This is a major depression occurring shortly before or more likely within four weeks after a pregnancy. The incidence is approximately 10% of pregnancies. Postpartum depression may last up to a year (20%) left untreated.

This is not to be confused with “the baby blues” which peak at 2 to 5 days after delivery consisting of weeping, sadness, mood changes, irritability and anxiety. They do not interfere with care of the newborn and resolve spontaneously by two weeks.

Regarding the diagnosis of major depression at least five of the following symptoms occurring for more than two weeks make the diagnosis: sadness, hopelessness, loss of self-esteem, guilt, insomnia, over or under eating, inability it concentrate, loss of pleasure from hobbies, avoidance of social intercourse, low energy, anxiety, fearing the coming day and suicidal ideation.

A stand-alone diagnosis not related to postpartum depression is postpartum psychosis. Like other types of schizophrenia this diagnosis includes hallucination, delusions, bizarre behavior and disorganized speech. Although this psychosis is considered a variant of bipolar disorder most feel it is a severe manic state that has led to psychosis also called schizoaffective disorder. The incidence is 1 to 2 cases per 1000 births. It requires hospitalization because of the chance of suicide and infanticide.

It is felt that the greatest risk factor for postpartum depression is having a prior history major depression. There is a seven-fold higher chance of postpartum depression if antenatal depression is not treated. I find the terms used in the discussion of postpartum depression confusing. Does prenatal depression mean that the women have had a history of major depression in the past i.e. unrelated to any pregnancies. I interpret the statistic on antenatal depression means a history of occurring during a pregnancy. The confusion is the interchangeable use of the terms perinatal, postnatal, antiinatal and postpartum.

I think this is important because the drugs of choice for postpartum depression are SSRIs such as Zoloft or Celexa have been passed the proof of time as safe for the fetus. The newer agents have not. Also, SSRIs are safe for breast feeding as only 10% get into breast milk. As for major depression during early or midway in pregnancy SSRIs are okay but in severe cases the newer agents such as atypical anit-psychotics are not. Some feel that in these cases ECT is preferred.

Children of parents with post partum depression have higher rates of emotional problems, behavioral problems, defiance disorder and hyperactivity.

The other risk factors are social, lack of a support person or group, marital difficulties, current or history of violence or abuse, major life events, decreased income, unintended or unwanted pregnancy.

The major cause of this form of depression is felt to be hormonal. Sudden drop in estrogen and progesterone after pregnancy being the most likely. Low thyroid, testosterone and cortisol are also felt to play a role. A thyroid level and a thyroid stimulating hormone should be measured to rule out Hashimoto’s thyroiditis which is correlated with depression.

Much confusion still remains when describing whether cases of postpartum depression which in most cases develop about two to four weeks AFTER giving birth are associated with a past history of a diagnosis of major depression unrelated to pregnancy. I was asked to see an 18 year old young lady by an obstetrician who developed typical symptoms of postpartum depression during her second pregnancy that began one month after delivery. Her child was then three months old and she was referred to me as I was dealing with high risk pregnancies at the time as a nephrologist. In her first pregnancy she had developed major depression which resolved spontaneously. Is the episode during the first pregnancy a prenatal depression or unrelated major depression episode. I would tend to agree with the latter. I would consider that depression a preexisting episode whether during that pregnancy or at any time prior to this pregnancy. It would not be the same as when it is said that a prior history of major depression disorder predisposes to postpartum depression. It does not treat the treatment as both episodes in the second and the one. The distinction affects the statistics of incidence of postpartum depression and the statistic that women with a prior history of postpartum depression have a seven-fold higher chance of postpartum depression in subsequent pregnancies and that 10% of all pregnancies develop postpartum depression.

During a conference with the Ob-Gyn department they stated that in the first pregnancy she had developed postpartum depression AGAIN in the first pregnancy. I had to disagree and got a lot of flak for it.