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PSYCHOPHARMACOLOGY
Mama Bare: Depression During Pregnancy and the Postpartum Period
May 16, 2018   

Pregnancy and the birth of a child are often viewed as joyous, miraculous events. However, a significant portion of women suffer with depression during pregnancy and in the postpartum period. Unfortunately, stigma and fear of potential medication dangers commonly prevent women from openly discussing their depressive symptoms with their friends, family, and clinicians. Yet women with depression during the perinatal period (extending from pregnancy through 1 year after childbirth) are not alone. In fact, as many as 70% of women report symptoms of depression during pregnancy and approximately 16% fulfill diagnostic criteria for a major depressive disorder during this time. After childbirth, many women suffer with the "Baby Blues," a condition characterized by sleep deprivation, anxiety, irritability, and depression that typically resolve within 2 weeks. More alarmingly, as many as 30% of new mothers experience a clinically significant major depressive episode during the postpartum period. If left untreated (or improperly treated), postpartum mood disorders can have dire consequences to both the mother and the newborn. Aside from the effects on infant-maternal bonding and child neurodevelopment, suicide or infanticide can be the consequences of overlooking mood disorders during the postpartum period. The American College of Obstetricians and Gynecologists (ACOG) advises that women be screened at least once during the perinatal period for mood and anxiety symptoms, and that new mothers be screened at least once for postpartum depression and anxiety using a validated instrument.

During pregnancy, many patients and clinicians have concerns over the risks of initiating or continuing psychotropic medications for depression: what short- and long-term harm might various psychotropic medications have on the developing fetus? Although there are indeed some established associated risks from taking certain psychotropic medications during pregnancy, there are also risks associated with untreated depression during pregnancy (Figure). Pharmacological treatment vs. non-treatment for mood disorders during pregnancy is an important and personal decision—one that must be well-informed and carefully considered by both the mother and the clinician. However, no decision can be made unless we encourage expectant mothers to openly discuss their symptoms of depression—away from stigma or judgment.

Figure. Risk of Untreated Depression vs. Use of Antidepressants During Pregnancy

Following childbirth, the most common complication is postpartum depression. And the leading cause of death to new mothers is…suicide. Likely this alarming statistic is due to undiagnosed, undiscussed, and/or maltreated postpartum depression. For many women, their symptoms of depression are held as a deep dark secret that goes against the societal view that a new baby brings only overwhelming joy. This stigma is outdated and downright dangerous. Postpartum depression must be recognized and appropriately treated according to the symptom presentation and needs of the patient. The latest research indicates that postpartum depression is often associated with mixed features of (sub)syndromal (hypo)mania, a condition for which the appropriate treatment may not be the traditional antidepressants that are used to treat unipolar postpartum depression. According to recent expert guidelines, a family history of bipolar spectrum disorder or symptoms of hypomania during a depressive episode (such as we commonly see in postpartum depression) preclude the use of antidepressant monotherapy and instead suggest the use of a mood stabilizer or atypical antipsychotic with mood-stabilizing properties.

Perhaps the first step in the accurate diagnosis and implementation of an effective treatment strategy for women suffering with depression during pregnancy and the postpartum period is a societal shift that not only allows, but encourages, women to openly discuss their symptoms of depression and (hypo)mania during the peripartum period. After all, such patients are far from alone.

References

Becker M, Weinberger T, Chandy A et al. Depression during pregnancy and postpartum. Curr Psychiatry Rep 2016;18(32):1-9.

Celik SB, Bucaktepe GE, Uludag A et al. Screening mixed depression and bipolarity in the postpartum period at a primary health care center. Comprehenc Psychiatry 2016;71:57-62.

Howard MM, Mehta ND, Powrie R. Peripartum depression: early recognition improves outcomes. Cleve Clin J Med 2017;84(5):388-96.

Langan RC, Goodbred AJ. Identification and management of peripartum depression. Am Fam Physician 2016;93(10):852-8.

McAllister-Williams RH, Baldwin DS, Cantwell R et al. British Association for Psychopharmacology consensus guidance on the use of psychotropic medication preconception, in pregnancy, and postpartum 2017. J Psychopharmacol 2017;31(5):519-52.

Meltzer-Brody S, Jones I. Optimizing the treatment of mood disorders in the perinatal period. Dialogues Clin Neurosci 2015;17:207-18.

Payne JL. Psychopharmacology in pregnancy and breastfeeding. Psychiatr Clin N Am 2017;40:217-38.

Presidential Task Force on Redefining the Postpartum Visit. Committee on Obstetric Practice. ACOG committee opinion: optimizing postpartum care. Obstetrics Gynecol 2018;131(5):e140-50.

Sharma V, Doobay M, Baczynski C. Bipolar postpartum depression: an update and recommendations. J Affect Disord 2017;219:105-11.

Sharma V, Sommerdyk C. Are antidepressants effective in the treatment of postpartum depression? A systematic review. Prim Care Companion CNS Disord 2013;15(6):PCC.13r01529.

Thomson M, Sharma V. Therapeutics of postpartum depression. Exp Rev Neurotherapeutics 2017;17(5):495-507.



Additional Resources:

Between a Rock-a-bye and a Hard Place: Mood Disorders During the Peripartum Period
This Month in Psychopharmacology: Pregnancy/Postpartum
2018 NEI Congress, November 7–11
Agenda and registration information