Challenges of Treating Postpartum Depression

Postpartum depression (PPD) is the most common obstetric complication, said Marlene Freeman, MD, yet there is a surprising level of debate over how to define it and missed opportunities for screening.

Freeman, an associate professor of psychiatry at Harvard Medical School, spoke at a session called “Solving Clinical Challenges in Postpartum Depression and Mood Disorders” at Psych Congress 2018.

PPD is distinct from postpartum blues, which affect the majority of women after giving birth—60% to 80%—but it is not of the type that rocks the core of someone’s daily functioning, Freeman said. Still, providers want to make sure that it is not going to turn into PPD, which affects 10% to 15% of women.

The Diagnostic and Statistical Manual for Mental Health Disorders, Fifth Edition (DSM-5), has a narrow definition of PPD, and that is a reflection of how different stakeholders think about this issue, she said. The DSM-5 defines PPD as something that happens within 4 weeks of giving birth. But patient advocacy groups have a wider definition, because they want to place the issue in a broader context so that women are encouraged to get help.

However, despite multiple contacts with healthcare providers, PPD is frequently missed, and screening in and of itself is not enough, Freeman said. There is a low rate of follow-up on referrals, and treatment may be suboptimal.

Women with PPD typically have very high levels of pre-existing anxiety and exhibit features of depressive symptoms that are not related to childbirth, including overall impaired functioning.

Freeman emphasized that treating maternal depression improves the health outcomes of children. Left untreated, children are at higher risk for abuse and neglect, impaired attachment, behavioral problems, cognitive impairments, and more.

Having a history of major depressive disorder is a risk factor for PPD (up to 30%), as is a history of bipolar disorder (30% to 50%) and previous PPD or postpartum psychosis (50% to 70%).

Obsessive compulsive disorder (OCD) is another risk factor. In PPD, OCD takes the form of intrusive, upsetting thoughts about hurting the baby or obsessively checking on the baby. These upsetting thoughts may also keep a woman from admitting how she is feeling for fear that her baby will be taken away from her, Freeman said.

There is a difference between postpartum OCD and postpartum psychosis, Freeman noted. In postpartum OCD, a woman will be bothered by the intrusive, upsetting thoughts, and the risk to the infant is low. In postpartum psychosis, however, the woman may not be bothered by the thoughts, and the risk to the infant is high.

Although postpartum psychosis is rare, when Freeman asked how many people in the room had seen a case of it, most people raised their hand.

“It’s a psychiatric emergency,” she said, moving to certain aspects of the disease that no one likes to talk about openly. “One of the hardest things to talk about is the risk of infanticide,” she said. There is about a 4% risk of infanticide, although Freeman said it is unclear where the number comes from.

Breastfeeding Issues in Women With PPD

Freeman emphasized she agreed with the benefits of breastfeeding, but said there are 2 societal pressures that negatively affect women with PPD who are attempting to breastfeed.

“Sometimes we need to say ‘you need to stop breastfeeding,’” so that a woman can get enough rest and consecutive hours of sleep, she said, given the intense physical demands that a nursing newborn places on a mother in the early weeks after birth.

The second is that women are encouraged not to introduce bottles of formula or pumped breast milk so that a baby does not develop nipple confusion. “Nipple confusion doesn’t make the list of the top 10 things we’re worried about,” Freeman said.

“For women who have serious psychiatric disorders, getting consecutive sleep can make all the difference between being well and being seriously unwell,” she said. “Breastfeeding is not the be all and end all,” Freeman said, adding that the role of sleep cannot be overstated.

In addition, she said most studies show low levels of infant exposure to antidepressants in breastmilk, although she did say risks and benefits should be discussed and the lowest effective dose should be used.

She also noted that on November 2, an FDA advisory committee will hear an application from Sage Therapeutics for brexanalone, an infusion treatment for severe PPD. Harvard Medical School was a clinical trial site for the drug.