About this course:
This learning module aims to help the nurse understand the risks, diagnostics, and treatments associated with peripartum mood disorders, including postpartum blues, perinatal depression, and postpartum psychosis.
This learning module aims to help the nurse understand the risks, diagnostics, and treatments associated with peripartum mood disorders, including postpartum blues, perinatal depression, and postpartum psychosis.
By completing this educational activity, the learner should be able to:
recognize the risk factors for developing peripartum mood disorders
describe screening tools for peripartum depression
explain the different types of peripartum mood disorders
compare and contrast symptoms of peripartum depression with postpartum psychosis.
summarize standard treatment options for peripartum depression
recommend resources for an individual with peripartum psychiatric illness
Mental health disorders usually present and are diagnosed between 18 and 45 years old, which overlaps with the reproductive years. Pregnancy and the postpartum period can exacerbate an underlying mental health disorder, or the psychological and physical changes that occur during pregnancy and the postpartum period may elicit the onset of a mental health disorder. Peripartum mental health disorders are clinically defined, treatable, and amenable to support, education, and intervention. However, even with increasing awareness of the rates of peripartum mental health disorders and their potential negative consequences on peripartum persons, infants, and families, peripartum mental health is often undiagnosed, under-treated, or not treated at all (Lowdermilk et al., 2016; Postpartum Support International [PSI], 2022).
Mental health disturbances during the peripartum period have gained attention because of the rising incidence and worldwide prevalence and the negative impact on personal, family, and child outcomes. Worldwide, about 10% of pregnant individuals and 13% of individuals who have recently given birth experience a mental health disorder. In developing countries, the prevalence is 15.6% during pregnancy and 19.8% after childbirth. Affected individuals cannot function properly, and if left untreated, peripartum mood disorders are associated with significant maternal and neonatal morbidity. In severe cases, the affected individual may commit suicide or harm the newborn. Suicide among postpartum individuals exceeds the deaths caused by hemorrhage or hypertensive disorders (The American College of Obstetricians and Gynecologists [ACOG], 2018; WHO, 2021).
Peripartum Mood Disorders
The etiology and pathophysiology of peripartum mood disorders are not clearly understood. Varying degrees of biological, social, genetic, and psychological factors may contribute to the development of peripartum psychiatric changes. Some theories attribute these changes to neurotransmitter abnormalities, decreased estrogen levels, hypothalamic-pituitary-adrenal axis dysfunction, thyroid dysfunction, or genetic predisposition. During pregnancy, the placenta acts like an endocrine organ and secretes four hormones: human chorionic gonadotropin (hCG), human chorionic somatomammotropin (hCS), progesterone, and estradiol. The presence of these hormones in varying amounts can contribute to antepartum mood disorders. After childbirth, the levels of estrogen and progesterone in the body drop dramatically. This alteration in hormone levels can lead to chemical changes in the brain that may trigger mood swings. Most new parents cannot get the rest they need to recover fully from giving birth. Sleep deprivation, physical discomfort, and exhaustion can contribute to the symptoms of peripartum mood disorders. However, there is no consistent correlation between levels of estrogen, progesterone, cortisol, or thyroid hormones and postpartum mood disorders (National Institutes of Mental Health [NIMH], n.d.; US Preventive Services Task Force [USPSTF], 2019).
It is estimated that anywhere from 50% to 85% of individuals experience postpartum or baby blues during the first few weeks after delivery. The cause of postpartum blues is not known. Postpartum blues is not considered a mental health disorder. Individuals with
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The term postpartum depression has been updated to include symptoms that appear during pregnancy in addition to the postpartum period. Since 50% of postpartum major depressive episodes begin before delivery, the American Psychiatric Association (APA, 2022) now classifies postpartum depression as major depressive disorder (MDD) with peripartum onset in the DSM-5-TR. In the general population, depression is one of the most common mental health issues. It affects women twice as often as men. A diagnosis of depression also usually occurs during the reproductive years; therefore, it is not surprising that peripartum depression is the most common mental illness and medical complication that affects pregnant and postpartum individuals (ACOG, 2018).
Anyone can develop mental disorders during pregnancy and the first year after delivery, but several clinical, social, and socioeconomic factors can increase an individual's risk (USPSTF, 2019). There are numerous risk factors associated with the development of peripartum depression. Risk factors for developing depression during pregnancy include:
fear of childbirth
maternal anxiety and increased stress
history of depression
lack of support
carrying an unintended pregnancy or a negative attitude toward the fetus
recent victim of domestic violence, including intimate partner violence (physical, verbal, or sexual)
lower socioeconomic status
over 40 years or under 18
gestational diabetes (ACOG, 2018; Lowdermilk et al., 2016; Mughal et al., 2021)
Specific risk factors after delivery include:
depression or anxiety during pregnancy
living in an urban area
stressful life events occurring shortly after delivery
traumatic birth experience
lack of support
preterm birth or low birth weight
baby being admitted to the neonatal intensive care unit (NICU)
breastfeeding complications or not initiating breastfeeding
postpartum symptoms increased in patients who did not intend to breastfeed but initiated breastfeeding after delivery
failure to breastfeed when intended increased the risk of postpartum depressive symptoms
parents who never established breastfeeding experienced postpartum depressive symptoms 2.5 times more than breastfeeding parents (ACOG, 2018; Lowdermilk et al., 2016; Mughal et al., 2021; Pope & Mazmanian, 2016)
According to the APA (2022) guidelines, peripartum depression is defined as a major depressive episode that occurs during pregnancy or within 4 weeks of delivery (Mughal et al., 2021; USPSTF, 2019). The ACOG (2018) states that peripartum depression can occur up to 12 months after delivery. To diagnose an individual with peripartum depression, symptoms must include a depressed mood for at least 2 weeks plus five or more of the following:
significant weight loss of more than 5%
depressed mood most of the day, almost every day
insomnia or hypersomnia nearly every day
psychomotor agitation or retardation observable by others
fatigue or loss of energy
feelings of worthlessness or excessive or inappropriate guilt
decreased ability to think or concentrate
recurrent thoughts of death or suicide (Lowdermilk et al., 2016; Narlesky et al., 2020; USPSTF, 2019)
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, 2018; 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 has nine questions. 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 is 90%. Other screening tools are available; however, they each consist of more than 20 questions and thus take longer to complete (ACOG, 2018; PSI, 2022; Viguera, 2020).
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 (PSI, 2022). 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 (PSI, 2022)
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 (PSI, 2022; Viguera, 2020). 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, 2020)
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 (PSI, 2022; Viguera, 2020).
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 (PSI, 2022).
The USPSTF (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 condition
being pregnant as a teenager or a single parent
experiencing stressful life circumstances
being a victim of intimate partner violence (USPSTF, 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 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, 2019).
Education about postpartum 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, n.d.).
Treatment of peripartum depression is multifaceted and includes pharmacological and nonpharmacological interventions. The first-line treatments include psychotherapy and antidepressants. CBT and IPT are effective in treating 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 concerned about taking medications while pregnant or breastfeeding. A combination of psychotherapy and an antidepressant is recommended for individuals with moderate to severe symptoms. Selective serotonin reuptake inhibitors (SSRIs) are the preferred first-line antidepressants as they are anxiolytic, non-sedating, and well-tolerated. Fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine (Luvox), and venlafaxine (Effexor) have shown efficacy in the treatment of peripartum depression. If treatment with an SSRI is ineffective, the patient may be switched to a serotonin-norepinephrine reuptake inhibitor (SNRI) or mirtazapine (Remeron). Once an effective drug and dose are established, treatment should continue for 6 to 12 months to prevent reoccurrence (Lowdermilk et al., 2016; Mughal et al., 2021).
The risks associated with medication administration during pregnancy and lactation are individual and should be discussed openly with the patient and weighed against the risks of untreated mental health concerns. SSRIs are generally considered safe, although they do cross into the placenta and may reach the fetus. Most were previously categorized by the FDA as pregnancy category C (risk cannot be ruled out) with the exception of paroxetine (Paxil) which was category D. There may be an association between SSRI use during the third trimester and breathing problems in the newborn. Some benzodiazepines, mood stabilizers, and antipsychotics are linked with birth defects and should be avoided in pregnant patients (NIMH, 2022).
The use of psychotropic medications during lactation should be addressed. 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 can be restricted to times when the drug concentration is lowest, either just before or after taking the medication (Laskey, 2021; Lowdermilk et al., 2016).
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 procedure is non-invasive and 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 (Mughal et al., 2021).
Patients with severe postpartum depression may not respond to psychotherapy and pharmacotherapy. If symptoms are not resolved after four medication regimen changes, electroconvulsive therapy (ECT) is recommended. This is especially useful in patients with postpartum psychosis and thoughts of suicide or infanticide. For patients who continue to experience symptoms despite treatment with ECT, intravenous brexanolone (Zulresso) is the treatment of choice. Brexanolone (Zulresso) was approved by the FDA in 2019 and is the first medication approved specifically for patients with postpartum depression. However, due to limited clinical data and restricted medication availability, it is only used once all other treatment options have failed (Mughal et al., 2021).
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., 2016).
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., 2016).
Nurses must be aware of the resources available to new or expecting parents for support. 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 741741 (National Alliance on Mental Illness [NAMI], 2022)
National Suicide Prevention Lifeline: 800-273-TALK (8255) or the three-digit dialing code 988 that is active across the US as of July 16, 2022 (Substance Abuse and Mental Health Services Administration [SAMHSA], 2022)
Postpartum Support International helpline: call or text 800-944-4PPD (4773) or text in Spanish to 971-203-773 (PSI, n.d.)
Maternal Mental Health Hotline: 833-9-HELP4MOMS (833-943-5746); this is not an emergency response line, and emergent situations need to be directed to the National Suicide Prevention Lifeline (Health and Human Services (HHS), 2022)
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 parent 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 new parent support group
be flexible with daily activities
sleep as much as possible; commit to sleeping when the baby sleeps (Lowdermilk et al., 2016).
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, 2019).
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 mothers 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 postpartum 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).
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