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REPRODUCTIVE PSYCHIATRY

Postpartum Depression: Prevalence and Considerations in Screening*

Barbara P. Yawn, MD, MSc

Common Clinical Scenario: A 32-year-old mother who delivered uneventfully 1 week ago calls and states she feels depressed at times but is happy and elated at other times. She notes she has a lot of fatigue due to the demands of breastfeeding. Is this just “blues,” or is this more likely to be postpartum depression?

Postpartum depression (PPD) has emerged vividly onto the public stage through both sensational crime reports and celebrity testimonials. Every year, more than 500,000 women (13% of the postpartum population) experience the anxiety, hopelessness, desolation, and fatigue of PPD for the first 3 to 12 months of their children’s lives.1,2 Up to 50% of women with PPD may remain symptomatic at the end of the first postpartum year, and most can accurately recall their symptoms 3 years later.3

The World Health Organization (WHO) identifies mental illness as the greatest disease burden among women of all ages—particularly those in the childbearing years.4 In the United States, most women seek postpartum care for themselves or their babies, offering an excellent opportunity to address depressive symptoms and PPD.5 However, clinicians fail to recognize more than 50% of PPD cases, often making the diagnosis only when women show overt signs.6-11

THE CURRENT PICTURE

Some women and clinicians may confuse PPD with “baby blues,” which occur in more than 80% of mothers. Baby blues begin within hours or days of delivery and are characterized more by major mood swings than consistent depressive symptoms. Baby blues typically disappear by 2 to 4 weeks postpartum.

Patients and their families may not recognize persistent symptoms of PPD, often assuming them to be a normal (if lengthy) part of adjustment to motherhood.2,9,12-14 Women who do recognize the symptoms may be afraid to acknowledge or discuss them, concerned that their lack of interest in the infant, sadness, and inability to cope suggest they are not good mothers.12 Therefore, the patient may not volunteer any information unless specifically questioned about her mood. Few practices routinely ask about a mother’s mood, relying on the woman’s perception of symptoms to initiate identification of PPD—an approach that has been shown to be unsuccessful.6-8,14-16

Perinatal clinicians have significant experience using screening tools to address potentially difficult topics such as maternal smoking, alcohol/drug use, and high-risk sexual behavior. WHO and the US Preventive Services Task Force (USPSTF) consider a condition appropriate for routine/universal screening if it meets 5 criteria. First, it must be common, and PPD affects more than 13% of all women after childbirth.2,6 Second, the condition must have significant recognition issues, and PPD is widely unrecognized.7 Third, an effective, inexpensive screening test that is acceptable to patients must be available, and there are now several such tests validated specifically for PPD.17-19 Fourth, early, effective treatment must exist and improve outcome. While there are several therapies for PPD, screening plus treatment must still be shown to improve outcomes.9 Although in theory early treatment of PPD could reduce its adverse effects on mother, infant, and family, it has yet to be proved.20-22

Currently, few organizations recommend universal PPD screening. This is not due to lack of concern about PPD but rather to a lack of data suggesting that screening can improve outcomes.21,22 Ongoing studies hope to provide this proof. For PPD screening to be added to usual care, the USPSTF and the Intercollegiate Guidelines Network stated that 2 criteria must be met: First, the practice and clinicians must understand that failed screening still requires diagnostic evaluation for PPD. Second, there must be systems in place to ensure comprehensive treatment and follow-up.21,22

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ISSUES IN SCREENING

Definition

Postpartum depression is part of a spectrum of postpartum mood disturbances.9,21,23 Most mental health clinicians divide such disturbances into 3 categories—postpartum “blues,” PPD, and postpartum psychosis—based on the severity, time of onset, type, and duration of symptoms.9,23,24 Postpartum depression represents the middle of this continuum and must be differentiated from baby blues and other minor mood disorders. While baby blues and minor depressive symptoms often clear spontaneously, PPD is a form of major depressive disorder (MDD) as defined by criteria listed in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; see Table).25 MDD is a chronic condition that requires a careful and accurate diagnosis and long-term therapy and monitoring.

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TABLE. Criteria for Diagnosing Postpartum Depressiona,b

However, while the DSM-IV criteria are useful, they are also problematic. For example, the criteria stipulate that PPD exists only if onset occurs within 4 weeks of delivery. Most experts now consider PPD to be any MDD occurring within the first 2 to 6 months postpartum, and some authorities extend this to 1 year post­partum.9,16 Clinicians typically differentiate between baby blues and PPD based on the timing and severity of symptoms, but they do not apply the full DSM-IV criteria for PPD.6,7 It is unclear whether this is due to lack of familiarity with the criteria or a perceived lack of benefit in documenting symptoms according to the criteria.26

Is PPD a separate entity? The rates of PPD and major depression are similar in women ages 20 to 40, suggesting that PPD may not be a distinct condition but merely major depression recognized at a time of biologic, physical, and emotional stress.9,23,27 However, there is a subgroup of women who appear to be particularly vulnerable to the onset/reemergence of depressive illnesses in the postpartum period, suggesting that PPD may be a unique condition in some circumstances.28

Because the treatment for PPD is similar to that used for other MDDs, physicians may believe that the label makes little difference. However, the distinction may be important to patients, insurers, policy makers, researchers, and those developing prevention and screening programs. For example, whereas some women may find upsetting the idea of linking their depression to their baby’s birth, others may feel that relating their depression to a biologic event relieves the “stigma” of mental illness.

Failing to distinguish PPD from other MDDs may allow policy makers to significantly underestimate the cases of depression associated with childbirth, resulting in less attention to this important condition. This could translate into fewer resources aimed at identification and management of PPD, less support for affected families, and less funding for research on prevention and early identification.

To date, studies of neurobiologic etiologies for PPD have been unrewarding.23 For example, the presence of postpartum thyroid antibodies, once considered a risk factor for PPD, now appears to represent a confounding condition associated with postpartum depressive symptoms, but not an etiology of PPD.9,23,29,30 Postpartum estrogen and progesterone fluctuations, the precipitous drop in corticotropin-releasing hormone, and changes in prolactin levels have not been shown to consistently predict or follow PPD.23,29,31,32 Recent studies investigating a broader spectrum of hormones are more promising, but a biochemical test to identify women at risk for PPD does not seem likely in the near future.33

Prevention

Is PPD preventable? If it is, screening could lead to prenatal/early postpartum recognition of risk factors. Risk factors for PPD have been identified and include young age, living without a partner, divorce, multiple life stresses, lower socioeconomic status, and history of affective disorders.2,6,7,9,12,21 However, the presence of these factors can identify only 30% to 40% of the women who will develop significant PPD.2,6,7,9,21 For women who have a history of PPD, the use of prophylactic antidepressant therapy has not been successful in preventing recurrent PPD.34 Nonetheless, women who are depressed during pregnancy have a high likelihood of requiring treatment postdelivery. Furthermore, women receiving therapy for chronic depression preconception can continue to receive both antidepressant medication and cognitive or psychological therapy during pregnancy. In practical terms, though, the only effective intervention for most women with PPD appears to be early recognition and treatment in the postpartum period.

Timely Identification

The onset of PPD during the crucial early developmental stages of an infant’s life mandates early recognition and treatment. The outcome of unabated PPD can be devastating for the patient, her child, and her family.35,36 Untreated PPD can adversely affect parenting and marriage, even resulting in suicide and infanticide.35-39

Children of depressed mothers are more likely to have delayed psychological and cognitive development and are at higher risk of avoidance and distressed behavior.37 The withdrawn, unresponsive, or negative behavior of a depressed mother early in the infant’s life appears to result in fussier infants who vocalize less and make fewer positive facial expressions than infants of mothers who are not depressed.35,37,40 Such abnormal maternal-infant interactions may slow neurologic growth and motor development due to the limited stimuli provided by the depressed mother and the restricted responses allowed to the infant.23,40 Infants younger than 1 year whose mothers have experienced early untreated/unabated PPD display cognitive and behavioral problems such as regressive and neurotic behaviors and insecure attachment to their mothers.38,41 These behavioral difficulties continue through ages 4 to 8 years.36,41 The abnormal parenting patterns and parenting discomfort of women with PPD have been described as a vicious cycle that increases the likelihood of chronic mental health, emotional, and family-function problems.42

The marriages and partnerships of women with PPD are at twice the risk for divorce or dissolution in the first 2 years postpartum, and at increased risk for marital dysfunction for up to 5 years postpartum.39,43 The limited attention given to PPD provides the new father with little basis for understanding his partner’s symptoms. He may respond with confusion, frustration, anger, guilt, anxiety, fear, or feelings of inadequacy—compounding the strain on the parents’ relationship.39 Timely identification of PPD can interrupt these cycles, before damage to mother, child, and family becomes irreparable.

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CONCLUSION

The impact of PPD extends far beyond the immediate postpartum period. Early recognition appears to shorten the course of the condition and decrease the risk of adverse outcomes.18,35,37 While controversy persists regarding the definition, classification, and etiology of PPD, the potential benefits of screening are undeniable, and new data should soon affirm those benefits, providing relief for the woman and her entire family.

Answer to question posed in clinical scenario above: The early onset and wide mood swings suggest this is more likely postpartum blues rather than depression. The fatigue is quite common among new mothers. She should be reassured that this is common and will get better. She should be monitored over the next few weeks. If improvement does not occur, she should undergo further evaluation.

The author reports no actual or potential conflicts of interest in relation to this article.

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Barbara P. Yawn, MD, MSc, is Adjunct Professor, Department of Family and Community Health, University of Minnesota, Minneapolis.

*This article was supported by research grant R01 HS014744-01 from the US Department of Health and Human Services’ Agency for Healthcare Research and Quality.

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