Peripartum Mood Disorders Nursing CE Course

stfeeding was associated with a general reduction in the risk of developing depression by about 14%

caregivers who did not participate in breastfeeding experienced depressive symptoms 2.5 times more frequently than breastfeeding caregivers (ACOG, 2023; Carlson et al., 2025; Lowdermilk et al., 2023; Xia et al., 2022)

Symptoms

According to the APA (2022) guidelines, peripartum depression is defined as a major depressive episode that occurs during pregnancy or in the 4 weeks following delivery; the specifier with peripartum onset is used (Carlson et al., 2025; USPSTF et al., 2019). To diagnose an individual with peripartum depression, symptoms must persist for at least 2 weeks. Symptoms must include either a depressed mood or anhedonia plus four or more of the following:

• substantial and unintentional decrease or increase in weight (more than 5%)
• the inability to sleep at night or stay awake during the day
• psychomotor excitement or delay observable by others
• feeling lethargic, weary, or exhausted
• feelings of insignificance, extreme or unwarranted guilt
• reduced mental clarity, focus, or decision-making
• a preoccupation with death or suicide (APA, 2022; Lowdermilk et al., 2023; Narlesky et al., 2020; USPSTF et al., 2019)

Screening

Peripartum depression often goes undiagnosed and untreated due to the overlap of symptoms with those of a normal pregnancy and postpartum period. Individuals also underreport or downplay symptoms and concerns for many reasons, including fear of stigma, lack of knowledge of which symptoms are abnormal during pregnancy, and feelings of shame or guilt. Due to the underreporting of symptoms, it is essential for healthcare professionals (HCPs) to directly ask pregnant or postpartum patients about their mood and how they are coping with the physical and emotional changes they are experiencing (ACOG, 2023; Garthus-Niegel et al., 2022).

It is recommended that every pregnant or postpartum patient is screened for peripartum mood disorders. Validated tools used for screening are the Edinburgh Postnatal Depression Screen (EPDS) or Patient Health Questionnaire (PHQ-9). The EPDS screens for anxiety and depressive symptoms and suicidal thoughts over the previous seven days. The PHQ-9 does not address anxiety but does screen for the presence of depressive symptoms and suicidal ideation for the last two weeks. Both tests are self-administered, available in various languages, and easy to complete. The EPDS has only 10 questions, and the PHQ-9 only nine. Each tool takes less than 5 minutes for the patient to complete and can be done in the waiting room. The sensitivity of the EPDS is 59%-100%, and the specificity is 49%-100%. The sensitivity of the PHQ-9 is 75% and the specificity 90%. Other screening tools are available; however, they each consist of more than 20 questions and thus take longer to complete (ACOG, 2023; Viguera, 2025b).

The 10 questions included in the EPDS are multiple choice, with four answer options. Each answer is assigned a score of 0 to 3. The score is totaled, with the highest possible score being 30 (ACOG, 2023). Scoring and indications for treatment are as follows:

• ≤ 8: depression is not likely
• 9-11: depression is possible, and the patient should be rescreened in 2-4 weeks with a referral to their primary care provider (PCP) for follow-up
• 12-13: there is a relatively high possibility of the patient experiencing depression and warrants follow-up with their PCP or a referral to a mental health specialist

The PHQ-9 follows the same format as the EPDS; however, the questions focus more on physical effects such as sleep, energy, and appetite, which can be normal findings for the peripartum period. As with the EPDS, each question of the PHQ-9 is scored 0 to 3 depending on the patient’s response (ACOG, 2023; Viguera, 2025b). Score ranges and indications are as follows:

• 0 to 4: normal or minimal depression
• 5 to 9: mild depression
• 10 to 14: moderate depression
• 15 to 19: moderately severe depression
• ≥20: severe depression (Viguera, 2025b)

The last question on the EPDS and PHQ-9 asks the patient if they have thought about harming themselves. Any score above zero on that question requires immediate intervention (Viguera, 2025b).

These tools should be used at prenatal, postnatal, primary care, and pediatric visits. HCPs should screen patients at the first prenatal visit, at least once during the second and third trimesters, and the 6-week postpartum visit. Screening should also be completed at 6 and 12 months postpartum in the obstetric or primary care settings. Pediatricians or family practice providers should screen the postpartum parent at the child’s 3-, 9-, and 12-month routine visits (ACOG, 2023).

Prevention

The USPSTF et al. (2019) recommends that “clinicians provide or refer pregnant and postpartum persons who are at increased risk of peripartum depression to counseling interventions” (p. 581). The task force recommends counseling for individuals with one or more of the following risk factors:

• current signs and symptoms of depression
• history of depression or other mental health conditions
• being pregnant as an adolescent or a single caregiver
• experiencing stressful life circumstances
• having experienced intimate partner violence (USPSTF et al., 2019)

Studies on counseling interventions to prevent peripartum depression focus on cognitive behavioral therapy (CBT) and interpersonal therapy (IPT). With CBT, positive changes in mood and behavior are achieved by addressing and managing negative thoughts, beliefs, and attitudes and by increasing positive events and activities. Standard techniques include patient education, goal setting, interventions to identify and modify maladaptive thought patterns, and behavioral activation. IPT treats interpersonal issues thought to contribute to psychological disorders. Standard techniques include exploratory questions, role-playing, decision analysis, and communication analysis. IPT can result in a reduction in depressive symptoms and an improvement in social adjustment. There is no data on the ideal time recommendation for offering or referral to counseling interventions. In studies, most patients started counseling during the second trimester of pregnancy. The number of counseling sessions reviewed for this recommendation ranged from 4 to 20, spread over 4 to 70 weeks. Most counseling consisted of group and individual sessions involving in-person visits. An example of an IPT approach is the Reach Out, Stand Strong, Essentials for New Mothers (ROSE) program. When participating in this program, the individual attends 4 to 5 prenatal group sessions and one individual postpartum session. Topics addressed in the sessions include baby blues, peripartum depression, stress management, and how to develop a support system. The group sessions involve role-playing activities, with feedback from the other group members (USPSTF et al., 2019).

Treatment

Education about peripartum mental illness and emotional support for the partner and family members is essential. Respite care services may be recommended to minimize the individual’s sleep disruption. In cases of postpartum psychosis, separation from the infant might be necessary to prevent harm. The individual needs reassurance and emotional support to boost her self-esteem and confidence. Supportive care is often ineffective in reducing symptoms, and most patients require more aggressive treatment (NIMH, 2023).

Treatment of peripartum depression is multifaceted and includes pharmacological and nonpharmacological interventions. The first-line treatments include psychotherapy or antidepressants. CBT and IPT are effective in treating antenatal and peripartum depression, addressing the individual’s fears and concerns, and monitoring for changes in symptoms. Psychotherapy alone is the first-line treatment for individuals with mild to moderate symptoms (5 or 6 reported symptoms of depression without suicidality) concerned about taking medications while pregnant or breastfeeding. A combination of psychotherapy and an antidepressant is recommended for individuals with moderate to severe symptoms (7 to 9 symptoms or the presence of suicidality) of depression during pregnancy. Selective serotonin reuptake inhibitors (SSRIs) are the preferred first-line antidepressants for mild to moderate symptoms as they are anxiolytic, nonsedating, and well tolerated. Fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine (Luvox), and venlafaxine (Effexor) have shown efficacy in the treatment of peripartum depression. Use of paroxetine (Paxil) during pregnancy may be associated with a small risk of congenital cardiac defects. There may also be a slightly increased risk of preterm birth and postpartum hemorrhage with SSRI use during the third trimester. Monotherapy and maintaining a lower dose may help limit exposure to the fetus, although dosing may need to be increased throughout pregnancy. Once an effective drug and dose are established, treatment should continue for 6 to 12 months to prevent reoccurrence. Adjunctive treatments, such as exercise, yoga, acupuncture, massage therapy, and bright light therapy, may also be beneficial, along with increased intake of folic acid and omega-3 fatty acids (Carlson et al., 2025; Grigoriadis, 2023, 2024; Stewart & Vigod, 2025; Viguera, 2025a).

If treatment with an SSRI is ineffective, the patient may be switched to a serotonin-norepinephrine reuptake inhibitor (SNRI), such as duloxetine (Cymbalta) or venlafaxine (Effexor), or mirtazapine (Remeron) or bupropion (Wellbutrin). The risks of SNRI use are similar to SSRI use, with potential increased risk of hypertension, hemorrhage, and preterm birth. Bupropion (Wellbutrin) may be associated with a very small risk of cardiac defects and pregnancy loss. Mirtazapine (Remeron) appears safe but may be associated with poor neonatal adaptation syndrome. Tricyclic antidepressants (TCAs) do not appear to cause significant congenital malformations, although clomipramine (Anaframil) may cause a slight increase in this risk. TCAs may also increase the risk of preeclampsia, postpartum hemorrhage, and transient neonatal withdrawal symptoms (Carlson et al., 2025; Stewart & Vigod, 2024).

In 2023, the first FDA-approved medication, zuranolone (Zurzuvae),specifically for postpartum depression was introduced into the market. Zuranolone (Zurzuvae) is classified as an antidepressant, specifically a gamma-aminobutyric acid (GABA) A receptor positive modulator. Dosing for this medication is unlike most other psychotropic medications, as it is dosed 50 mg once daily in the evening for 14 days, and then the medication is discontinued. Zuranolone possesses a US Boxed Warning stating it can cause driving impairment due to central nervous system (CNS) depressant effects (somnolence, drowsiness). The clinician must advise patients not to drive or engage in other potentially hazardous activities until at least 12 hours after zuranolone (Zurzuvae) administration for the 14-day treatment course (Deligiannidis et al., 2021). Notably, this medication can be coadministered with one of the SSRIs mentioned previously (Sharma et al., 2024). Zuranolone (Zurzuvae) is present in breast milk but in minimal amounts; however, it should not be used during pregnancy as it may cause fetal harm based on available data from animal studies (Deligiannidis et al., 2024).

The amount of medication an infant is exposed to depends on the maternal dosage, timing and frequency of dosing, rate of maternal drug metabolism, and metabolism of the ingested drug in the infant. In premature infants or infants with compromised hepatic metabolism, breastfeeding should be deferred if the person takes psychotropic medications. Breastfeeding at times when the drug concentration is lowest, either just before or after taking the medication, may be effective but is generally not recommended (Laskey, 2021; Lowdermilk et al., 2023). In general, the benefits of breastfeeding outweigh the risks, and patients on pharmacotherapy for mental health disorders can be encouraged to continue breastfeeding. In most cases, an individual who is successfully treated with pharmacotherapy during pregnancy should not change medication solely for breastfeeding, as the greatest fetal exposure occurs during pregnancy rather than for the breastfeeding infant. Medications with shorter half-lives and greater protein-binding may reduce exposure of the infant, and polypharmacy is typically discouraged when breastfeeding. Paroxetine (Paxil) and sertraline (Zoloft) may result in lower medication levels in breast milk, but most SSRIs, SNRIs, and TCAs are considered safe. It is less clear if atypical antidepressants or monoamine oxidase inhibitors are compatible with breastfeeding. Serum concentrations of antidepressants do not need to be monitored in infants, but infant behavior, feeding, sleep, and level of alertness should be observed (Kimmel, 2024).

Due to the potential risk of utilizing antidepressants while pregnant or breastfeeding and the long-term effects of not treating the illness, alternate treatments may be needed. One alternative treatment is repetitive transcranial magnetic stimulation (TMS). This noninvasive procedure stimulates nerve cells using magnetic waves. TMS must be done five times weekly for 4 to 6 weeks to be effective. TMS can also be used in patients not responding to treatment with antidepressants and psychotherapy. Side effects include headaches, lightheadedness, scalp discomfort, and facial muscle twitching (Carlson et al., 2025).

For patients with severe depression following birth who have not previously been on an effective antidepressant and need to be started on an antidepressant for the first time, the first-line option is zuranolone (Zurzuvae). An alternative is brexanolone (Zulresso), an intravenous neuroactive steroid similar in mechanism to zuranolone (Zurzuvae). It must be administered in an inpatient facility and often causes dry mouth and sedation, similar to zuranolone (Zurzuvae). Typically, patients should cease breastfeeding during administration and for four days following this. The primary advantage of this medication is its rapid therapeutic effect. SSRIs are considered second line for severe depression. For those that may not respond to psychotherapy and pharmacotherapy, electroconvulsive therapy (ECT) is recommended as a third-line treatment option for severe peripartum depression. This is especially useful in patients with postpartum psychosis and thoughts of suicide or infanticide (Rundgren et al., 2018; Viguera, 2024).

Postpartum Psychosis

Postpartum psychosis is the most severe of the peripartum mood disorders. This rare condition affects only 0.1% to 0.2% of postpartum individuals. Symptoms of postpartum psychosis include auditory and visual hallucinations, paranoid or grandiose delusions, delirium or disorientation, impulsivity, poor judgment, abnormally elevated mood or energy levels, and depression. Impulsivity and poor judgment occur in 5% of individuals experiencing postpartum psychosis, increasing the risk of suicide or infanticide. Delusions are present in 50% of cases, and hallucinations occur in 25% of cases. Auditory hallucinations instructing the individual to kill the baby are rare but can occur in severe cases. The affected individual may also believe that the child is possessed by the devil or an evil spirit or has special powers. Symptoms can appear as early as the first 48 to 72 hours after delivery, and most people develop symptoms within the first 2 weeks. Some individuals may become detached from the baby and stop providing care. In contrast, others may believe something is wrong with the baby and accuse family members or hospital staff of hurting or poisoning the baby. Symptoms start mild and progressively become more severe. Initially reported symptoms often include fatigue, insomnia, restlessness, emotional lability, and periods of crying. The postpartum individual may also report an inability to stand, walk, or move. Symptoms eventually progress to the individual experiencing suspiciousness, confusion, irrational thoughts, and incoherence. The individual may become obsessed with the baby’s health and well-being (Lowdermilk et al., 2023).

Postpartum psychosis is commonly associated with a diagnosis of bipolar disorder or manic-depressive disorder. In individuals diagnosed with bipolar disorder before pregnancy, the relapse rate is 32% to 62% during the postpartum stage. Postpartum psychosis has a good prognosis if symptoms are detected early and treated aggressively. Postpartum psychosis is considered a psychiatric emergency due to the risks to the patient and their baby; therefore, admission to an inpatient psychiatric facility is required. Treatment includes the use of typical and atypical antipsychotics and mood stabilizers. Unfortunately, these medications can pose a risk to the baby if the affected individual is breastfeeding. Therefore, educating the patient on the risks to the baby versus the benefits of treating the mental illness is essential. Antidepressants should be used cautiously in these patients as their use can trigger rapid cycling through manic and depressive states. Once an individual experiences postpartum psychosis, the recurrence rate in subsequent pregnancies is 30% to 50% (APA, 2022; Lowdermilk et al., 2023).

Nursing Implications

Nurses must be aware of the resources available to new or expecting caregivers for support. Postpartum Support International (PSI) offers weekly online support meetings. Emergency hotlines are available 24 hours a day. Examples of hotlines include:

• National Alliance on Mental Illness: 800-950-NAMI (6264) or text NAMI to 62640 (National Alliance on Mental Illness [NAMI], 2023)
• National Suicide Prevention Lifeline: Three-digit dialing code 988 that has been active across the United States since 2022 (Substance Abuse and Mental Health Services Administration, 2023)
• Postpartum Support International helpline: call or text 800-944-4PPD (4773) or text in Spanish to 971-203-773 (PSI, n.d.)
• National Maternal Mental Health Hotline: 1-833-TLC-MAMA (833-852-6262); this is not an emergency response line, and emergent situations need to be directed to the National Suicide Prevention Lifeline (Health Resources and Services Administration, n.d.)

Family and friends may be the first to notice a problem. Education about the signs and symptoms of peripartum depression is critical. Nurses can also educate the new caregiver(s) and family about things they can do to help:

• refrain from alcohol and drug use
• exercise regularly; at least 30 minutes per day
• eat a well-balanced diet
• keep in touch with a support system
• leave the house for 30 minutes a day, even if just a walk outside
• take time for self-care and relax for at least 15 minutes per day
• ask for and accept help when needed
• engage in stress-reducing activities such as meditation or reading
• join a support group for new caregivers
• be flexible with daily activities
• sleep as much as possible; commit to sleeping when the baby sleeps (Lowdermilk et al., 2023)

Future Research

Further research is needed to address gaps in several areas. There is a lack of high-quality evidence on how to best identify high-risk patients who could potentially benefit from preventive interventions. Larger-scale trials are needed for depression prevention interventions, such as physical activity, infant sleep education, in-hospital peripartum education, and peer counseling. Symptoms help predict future peripartum depression, but more research is needed on incorporating peripartum risk factors into screening tools. Larger-scale trials of CBT and IPT are required to demonstrate whether these strategies are scalable and applicable to individuals at lower risk. Data on the benefits and harms of antidepressant medications to prevent peripartum depression are lacking. Dietary supplements, such as selenium and vitamin D, have shown potential, but more research is needed (USPSTF et al., 2019). Single-dose esketamine (Spravato) after childbirth was found to decrease major depressive episodes at 42 days postpartum. Primary mood symptoms were both transient and did not require additional pharmacologic intervention (Wang et al., 2024). Additionally, biological markers that predict risk of postpartum depression were discovered by Osborne et al. (2022), who found that extracellular RNA communication levels during pregnancy and the postpartum period were “extensively altered” in women who developed peripartum depression.

Placentophagy, also known as placentophagia, involves ingesting all or a portion of the placenta. Although numerous mammals do this, it is a growing trend in Western human societies; however, no empirical evidence supports the benefits or risks. A convenience sample that questioned individuals about their beliefs and experience with ingesting the placenta found that they mainly perceived positive effects, such as mood stabilization, increased milk production, and decreased bleeding and recovery time. A better understanding of the placenta’s properties is needed, including how the placenta affects mood and lactation. One study assimilated data from more than 7,000 female parents who engaged in placentophagy within a larger study, including the medical records of more than 23,000 individuals who planned a community birth. The vast majority ingested the placenta in encapsulated form, and 73% reported they were attempting to avoid depressive symptoms. The study found no reported adverse neonatal outcomes (Benyshek et al., 2018; Botelle & Willott, 2020). Farr and colleagues (2018) published an expert review in the American Journal of Obstetrics and Gynecology recommending that HCPs not encourage the practice; they found a lack of scientific evidence regarding any clinical benefit. They found a lack of placental nutrients or hormones retained in sufficient quantities after the tissue is steamed and dehydrated for encapsulation. A case of recurrent group B Streptococcus sepsis in an infant was also linked to contaminated placenta capsules, as the encapsulation process did not sufficiently eradicate all infectious pathogens. This case prompted a warning issued by the CDC (Farr et al., 2018).

References

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