Postpartum depression is a form of major depressive disorder that occurs after childbirth, characterized by feelings of extreme sadness, anxiety, and exhaustion. Postpartum depression (PPD) typically develops within the first six weeks following childbirth and affects approximately 6.5% to 20% of women.

For some women – more than 10 percent of mothers – postpartum depression (PPD) is a serious condition that can persist for a year or more after childbirth. It can interfere with a mother’s ability to care for and bond with her baby, potentially harming the child’s development and safety. In rare and severe cases, new mothers may harm themselves and/or their babies due to the overwhelming symptoms of PPD.

Risk Factors

Psychological Factors

• History of depression and anxiety
• Premenstrual syndrome (PMS)
• Negative feelings towards the baby or its gender
• History of sexual abuse

Obstetric Factors

• Complicated pregnancies, including emergency cesarean sections and hospitalizations
• Meconium passage, umbilical cord prolapse
• Preterm birth or low birth weight
• Low hemoglobin levels

Social Factors

• Lack of social support
• Domestic violence (sexual, physical, and verbal abuse)
• Smoking during pregnancy

Lifestyle Factors

• Poor eating habits and disrupted sleep cycles
• Lack of physical activity and exercise
• Vitamin B6 deficiency affecting serotonin levels
• Decreased sleep associated with higher risk of PPD
• Exercise reduces depressive symptoms, boosts self-esteem, and improves mental health through increased endorphins and opioids.

Clinical Features

Symptoms must include either a depressed mood or anhedonia (loss of interest) and can significantly impair daily functioning. The nine key symptoms, which must represent a change from previous behavior and be present almost every day, include:

1. Depressed mood for most of the day
2. Loss of interest or pleasure in activities
3. Insomnia or hypersomnia
4. Psychomotor retardation or agitation
5. Feelings of worthlessness or excessive guilt
6. Fatigue or loss of energy
7. Suicidal ideation or attempts, and recurrent thoughts of death
8. Impaired concentration or indecisiveness
9. Significant change in weight or appetite (5% change over one month)

Diagnosis

Postpartum depression is a clinical diagnosis. Postpartum depression (PPD) is diagnosed when at least five depressive symptoms are present for a minimum of two weeks. According to the DSM-5, PPD is a major depressive episode with peripartum onset, occurring during pregnancy or within four weeks of delivery, and is not categorized as a separate disorder.

ICD-10 Criteria

In the ICD-10, postpartum onset is defined as occurring within six weeks after delivery. A depressive episode is characterized by:

• Depressed mood with decreased activity and energy
• Reduced capacity for enjoyment, interest, and concentration
• Extreme fatigue with minimal effort, sleep disturbances, and decreased appetite
• Feelings of guilt or worthlessness, along with reduced self-esteem and self-confidence
• Somatic symptoms such as anhedonia, early morning agitation, weight loss, loss of libido, decreased appetite, and marked psychomotor retardation, which are consistent daily and unresponsive to circumstances.

Postpartum Depression in the Other Parent

Paternal postpartum depression (PPPD) is a condition that affects fathers in the period following the birth of their child. While maternal postpartum depression is more widely recognized, PPPD is an important issue that can have significant implications for the father’s mental health, the child’s development, and the family dynamic.

Treatment for Postpartum Depression

First-Line Treatment

• Psychotherapy and antidepressant medications.
• Preferred for women with mild to moderate peripartum depression, especially if nursing or hesitant about medications.
• Combination of therapy and antidepressants recommended for moderate to severe depression.

Medication Choices

• SSRIs are the first choice.
• Consider SNRIs or mirtazapine if SSRIs are ineffective.
• Continue treatment for 6 to 12 months to prevent relapse.

Lactating Women

• Discuss benefits of breastfeeding, risks of antidepressant use during lactation, and risks of untreated depression.
• TMS is a suitable alternative for those concerned about medication exposure.
• Sertraline is well-supported for use in preventing and treating postpartum depression.

Cognitive-Behavioral Therapy (CBT)

• Effective as monotherapy after 12 weeks, showing significant improvement.
• Demonstrated rapid initial gains compared to sertraline alone and combination therapy.
• Delayed treatment can prolong the duration of depression.

Transcranial Magnetic Stimulation (TMS)

• Non-invasive procedure using magnetic waves to stimulate nerve cells.
• Administered five times a week for 4 to 6 weeks.
• Effective for patients not responding to antidepressants and psychotherapy.
• Generally safe, with possible side effects including headaches, lightheadedness, scalp discomfort, and facial muscle twitching.

Electroconvulsive Therapy (ECT)

• Recommended for severe postpartum depression unresponsive to psychotherapy and pharmacotherapy.
• Particularly useful for psychotic depression, suicidal or infanticidal intent, or refusal to eat.
• Considered safer for lactating mothers with fewer adverse effects.

Intravenous Brexanolone

• FDA-approved in March 2019 for postpartum depression.
• Recommended for severe cases unresponsive to antidepressants or ECT.
• Administered as a continuous 60-hour IV infusion at certified healthcare facilities.
• Requires enrollment in the Risk Evaluation and Mitigation Strategy Program.
• Clinical trials show rapid beneficial response, with further studies needed for long-term safety and efficacy.