[Transcript edited for clarity]

Learning Objectives

After the webinar, clinicians should:

1. Identify risk factors for postpartum depression

2. Understand to reliably diagnose postpartum depression

3. Employ safe treatment approaches for postpartum depression, including for women who are breastfeeding

4. Summarize some of the current research findings in psychiatric treatment

Welcome to the Carlat Psychiatry webinar. My name is Dr. Victoria Hendrick. I will be talking about the treatment of depression during breastfeeding. I'm a clinical professor at the department of psychiatry at Olive View UCLA Medical Center and the Editor-in-Chief of The Carlat Hospital Psychiatry Report. I have no conflicts to disclose. 

The learning objectives for today are that we will identify risk factors for postpartum depression, understand and reliably diagnose postpartum depression, employ safe treatment approaches for postpartum depression, including for women who are breastfeeding, and summarize some of the current and latest research findings in the field

Postpartum psychiatric disorders

To begin with, what are the postpartum psychiatric disorders? There's postpartum blues or the baby blues, which are very common in the postpartum, especially in the first few days -- the first week after the baby's born. These are not symptoms that we typically worry about. Women describe these symptoms as being like bad PMS.

They feel moody, weepy, but they're not clinically depressed. And we know these symptoms are short lasting and will resolve spontaneously. Where we do worry is postpartum depression, which is a clinical depression that begins at the earliest about two weeks postpartum. It doesn't usually start right away.

And that can be quite disabling for new moms and make it really hard for them to care for their infants. And I'll also talk a bit about postpartum psychosis, which is much more rare. You could spend your entire career not seeing this, but if you do come across this, this illness, it's very important to know what to do.

I'll talk about that in a bit. Let's begin with postpartum depression. The risk factors are primarily a history of depression. Also: stressful life events are another risk, as well as conflict with a baby's father and financial stressors. What's the prevalence? For women with a past history of depression, about one in four will have postpartum depression.

If they specifically had postpartum depression after a previous birth, then they are even higher risk. About one in two of those new moms face a risk of postpartum depression. If they're depressed during pregnancy, about one third of those new moms will experience postpartum depression. But for women with no history of depression, their risk of postpartum depression is actually pretty low at 2-5%.

Globally, rates of postpartum depression vary widely. I'm showing you here a meta-analysis of nearly 300 studies from women from around the world. The pooled prevalence of postpartum depression was about 18% varying from 3% in Singapore to 38% in Chile. The rate in the US, according to this study was 13%, which, which is pretty close to what other studies of postpartum depression in the United States have found. Nations with significantly higher rates of income, inequality, higher rates of maternal infant mortality, or women of childbearing age working more than 40 hours a week all have higher rates of postpartum depression among their new moms.

The American Academy of Pediatrics, the American College of Obstetrics and Gynecology, and the American Psychiatric Association all recommend screening for depression in pregnant and postpartum women. One of the simplest and most reliable tools is the Edinborough Postnatal Depression scale. It's been validated across a variety of cultures and languages, and it has the advantage of being very brief, just 10 questions. And it's been found to be twice as effective as clinician interviews in detecting depression. It is a very handy tool to have; you can find it online. It's a free tool. It's good to print it and have it to share with patients. I keep copies in my office. 

What are distinguishing features of postpartum depression? I did some research on this topic. Women with postpartum depression don't present lethargic with no energy. That is not how they present. Instead, they're anxious, they're wringing their hands. They're obsessing. In fact, it's very interesting that obsessive compulsive disorder has been linked with elevated oxytocin levels. And we also see a lot of obsessing in postpartum depressed women. What do we know about OCD?

People who have symptoms of OCD wash their hands; they check on things. And it makes sense, when you think about it, oxytocin is the hormone of childcare. Basically, it spikes in late pregnancy and the postpartum and it's associated with grooming behaviors, checking behavior in new mammal mothers. 

Whether you're a human mom or a bear mom, you're checking your offspring, you're grooming and cleaning them. And when you think about the obsessive thoughts in the postpartum, it's these new moms having a lot of preoccupation with the child. Safety and cleanliness that can get to the point of being quite distressing, where new moms won't want anybody else to care for their child, or look after their child. They want to take care of everything because they're so obsessed with cleanliness and caring for the child. So I reassure new moms that in some ways, this obsessive quality is pretty normative. They shouldn't feel there is anything wrong with them when they feel that intense preoccupation for their babies.

But when it gets to an extreme, then it can be really distressing, make it hard for them to sleep and relax. And then you get to a point where these patients might need treatment. 

What other distinguishing features will you see with postpartum depression compared to depression at other times in women's lives? Thankfully, these women tend to be less likely to think of suicide or to behave in suicidal ways. In fact, the rate of suicidality for new mothers is about half of that in compared to women at other times in their lives. 

One of the most important things we can do for women who present with postpartum depression is reassure them about how common their condition is. As I mentioned earlier, about 13% of women with new babies in the United States will experience postpartum depression. This is a very common condition. So we counsel these, these women, their condition is common. The treatments are effective. They will get better.

In fact, I did a study on this particular topic and 96% of women got better within the three months of treatment in my study. And then the last point we want to emphasize to these new moms is they are no less of a mother for experiencing depression. They're going to get over this. It's a common condition and it doesn't mean they're a bad mom.

Treatments

Treatments fall into these four categories. Antidepressants, counseling, transcranial magnetic stimulation. And the newest treatment is a form of hormone therapy, which I'll talk about. 

Antidepressants

All antidepressants are about equally effective. Choose based on a patient's past treatment history, family history, the side effect profile, whether she might want to breastfeed, and insurance and cost. 

What about psychotherapy? 

There are two forms of psychotherapy that have been specifically studied for new moms. Interpersonal psychotherapy is brief—12 to 16 weeks—and specifically focuses on interpersonal problems and conflicts and helps women develop more adaptive communication patterns and establish realistic expectations from their social support. The other form of therapy that's been very widely studied is cognitive therapy. It's also brief 12 to 16 weeks, and it looks at negative thought patterns. Patients can then learn to challenge automatic thoughts or ways in which they might be catastrophizing or thinking in black and white. They are basically negative thought patterns that to some extent or another, we all tend to fall into. CBT can be very helpful for women in overcoming their depressive symptoms. 

TMS

Then there's transcranial magnetic stimulation (TMS), which I like as an option because it involves no medication exposure to the breastfeeding baby. If you're seeing a pregnant woman, there's no medication exposure to the fetus. It's a nonpharmacologic, noninvasive treatment involving a coil that is placed over, over the head. It's approved for the treatment of depression and migraines. It's been studied a little bit in pregnant women and there have been no adverse pregnancy or fetal outcomes. TMS seems like a promising treatment option for pregnant and breastfeeding women. The downside is it's pricey and it also is a time commitment, five days a week, four to six weeks. The sessions themselves are brief—about 30 minutes—so patients can come before they go to work in the morning or at the end of the day. But it is five days a week for four to six weeks. So, it is quite a commitment. Insurance may very well cover it, but if it doesn't, then it is it might be out of reach for a lot of patients. 

Allopregnanolone: Zulressa (brexanolone)

And then the newest treatment is allopregnanolone, a metabolite of progesterone. It's just been FDA approved as Zulressa. It's the first FDA-approved treatment for postpartum depression. It's a formulation of allopregnanolone, a metabolite of progesterone. It works on GABA receptors. The tricky thing is it's administered as a continuous IV dose for 60 hours, so obviously it has to be done in a hospital. It's only available through a REMS program. REMS stands for risk evaluation and mitigation strategy. Doctors and hospitals have to be enrolled in REMS before the medication can be administered, but it does look like it's very helpful. 

A study of 375 women with postpartum depression found significant reductions in the Hamilton Depression Rating score at 60 hours compared to placebo. The onset was rapid, and the treatment effect seemed to be lasting. It looks very promising except for the fact that it's pretty cumbersome to have a patient have a continuous IV infusion of this medication for 60 hours. Plus, it's also very expensive. 

But some good news is there's a sister formulation called Zuranolone. It's oral. It appears similar in efficacy to brexanolone. It produces less sedation -- brexanolone can be quite sedating. Zuranolone is not yet approved for use, but it's anticipated that it will be. Hopefully we'll soon have an alternative option to offer our patients. 

Prophylactic treatment

Now, what about prophylactic treatment? If you know someone is at high risk of experiencing postpartum depression, should we start them on antidepressants ahead of time? Surprisingly, this has not been well studied, but the research we have suggests that yes, it makes sense to initiate prophylactic treatment. Don't wait for your patient to fall into a postpartum depression. Just treat her ahead of time. 

A study looked at women who had had an episode of postpartum depression and they were recruited before they gave birth. You would expect that about half would go on to have a postpartum depression, based on the statistics I showed you earlier, right? What did this study find? Of subjects who took antidepressants, only one (7%) suffered a recurrences was a recurrence of depression in the postpartum, but among the subjects who just took placebo, who did not protect themselves with antidepressants, four (50%) had a recurrence, just as we would expect. This study implies that yes, we should protect our patients before they fall into their depression. As soon as they give birth, have them bring their antidepressant to the hospital with them so they can start the medication.

Postpartum psychosis

I want to say some things about postpartum psychosis. This is quite a remarkable illness. Once you see a case of this, you basically never forget it. Symptoms develop rapidly. You might have a patient who gave birth on Sunday. You talked to her on that Monday or Tuesday, and she's doing well. And then by Wednesday she is frankly psychotic. The symptoms can be very abrupt in the onset. Most cases, the vast majority, happen in the first four weeks postpartum. If your patient has made it to the fifth week without symptoms, she's probably out of the woods. 

Women with bipolar disorder are the group at greatest risk. About half will have a postpartum psychotic mania or a psychotic depression. And then the other half will have postpartum depression. But among the patients that have a postpartum psychotic mania or psychotic depression, those are the cases that we consider as having postpartum psychosis. 

What's the role of sleep deprivation? We know that fathers with bipolar disorder also seem to be at risk of relapse after the baby is born. Often there's a family history of bipolar disorder in patients who have brand new postpartum psychosis and have never been themselves diagnosed with bipolar disorder. 

One of the things that's concerning about postpartum psychosis is that delusions often involve the infant. As an example, I’ll tell you about a patient that I saw. She had a healthy baby girl. The mother and the baby seemed fine. But a few days after the delivery, the mother began to insist her baby daughter was dead and she would not take care of her child. Luckily there were other family members who took over the care, but that's an example of a psychotic delusion that can put that baby in harm’s way.

In terms of the diagnostic category of postpartum psychosis, it's not a separate disease entity in DSM-5. In fact, it's used instead as a as a specifier: mood disorder, manic or mixed or major depressive episode with psychotic features, and you would add the specifier “with postpartum onset.” It can also be applied to psychotic disorder not otherwise specified or brief psychotic disorder.

Prevention. Similar to our thinking about preventing postpartum depression, should we provide prophylaxis against postpartum psychosis? It has not been well studied, but there is some data on this, and it does look like we should be providing prophylactic treatment to our patients if we think they're at high risk of a postpartum psychotic episode. So in this study of women with bipolar disorder, who we know would be at risk of postpartum psychosis, women who took medications during pregnancy were compared with women who did not. A total of 19% of women who remained on meds experienced postpartum psychosis versus 40% of women who did not remain on meds. 

The precise timing of when to initiate prophylaxis remains unclear. My approach is to initiate prophylaxis at the latest in the third trimester as women approach their delivery date. If they have not already been on medications during pregnancy, I don't wait until the baby is born. I begin in the third trimester and back to what I was saying earlier about why we really need to worry about postpartum psychosis is the concern about the baby's safety. 

We hear about postpartum psychotic episodes in tragic news stories of women harming their children. This is an example from a few years ago of a woman who tossed her newborn son from her fourth story window saying an evil spirit had taken over the child; and another tragic case is this one where a woman with psychotic postpartum depression was also in the news. It's always very tragic to hear about these cases.

And it's a reason it's so important for us as clinicians to do everything we can to protect our patients and to educate our colleagues in OB-GYN so they know to ask their patients if they have a history of mental illnesses, so they can be referred for prophylactic treatment before they deliver.

This was an interesting study I came across a couple of years ago saying that postpartum psychosis gives us clues to mental illness. What is it about this time in women's lives that puts them at such risk of severe psychopathology? Is it the precipitous fall of hormones? Is it something immunological or having to do with inflammation? We know that pregnancy is a time of immunological quiescence. And as soon as the mom delivers, there's an immunological rebound. You see autoimmune illnesses often getting worse in the postpartum because of this reason. 

And then what about circadian rhythm disturbances? Since we know sleep patterns are almost universally affected after childbirth, maybe the circadian rhythm disruption is part of the reason that we see a higher rate of psychosis in the postpartum period. 

Breastfeeding

There are many safe choices of antidepressants and breastfeeding. I spent many years researching this topic and I feel very comfortable with many of the antidepressants that we have available, like sertraline, paroxetine, citalopram, fluoxetine. The main thing that I found was that pharmacokinetic parameters determine how much exposure the baby gets through breast milk.

So you want a medication that's highly protein bound, because then it won't traverse through the milk and into the baby as much, and with a short half-life, because it'll clear out of the baby and the mom a lot quicker. The medications that were most likely to show up in the breast milk and in the baby were fluoxetine because of its long half-life and venlafaxine because of its low protein binding. Nevertheless, even babies exposed to these medications were fine, but all things being equal, I prefer to go with medications that are not going to show up in the baby's bloodstream at all. Highly protein bound medications like paroxetine and sertraline had the lowest likelihood; in fact, I never saw them showing up in the baby's blood work. I would choose those medications instead, but if your patient has done very well on fluoxetine or venlafaxine, I would just keep her on those. You don't want to start on a new medication that might or might not work.

One thing that I think deserves more attention is what's the impact of depression in the mother or the father on the child's outcomes. There's been some research which is very compelling, that parents with depressive symptoms show more negative behaviors toward their children.

They criticize them more. They spank them more. They neglect them more. And these negative behaviors are associated with children having more externalizing behaviors like acting out, aggression, of impulsivity. The children don't do as well in cognitive and language development, they're at greater risk of being overweight, and they do worse in school performance all the way through the end of high school.

Even exposure to parental or pre-postpartum depression in the first year of life can have this long lasting effect. And remission of parental depression is associated with a reduction in these negative behaviors in the children. I emphasize to parents that the treatment benefits not just them but also the child that they're going home to parent.

Sometimes I've had new moms who are ambivalent about getting treatment for depression, but when I present it that it's not just for their own benefit, it's also for the child's benefit, they tend to come totally on board with getting help. And I feel fathers have been neglected in this area. Fathers, as we know, are often as involved as much in taking care of their babies. It's not just the mom that's the primary caregiver anymore. So we really need to be paying attention to new fathers. I wish there were more research on how fathers are doing, but there's some research and it's growing and we have found that the rate of depression and fathers is high. It's not quite as high as the rate in new mothers, but it is enough that we should be screening new fathers whenever possible.

I like to have new moms coming in with their partners for evaluation. Higher rates of paternal depression make it harder for the mother, if she's depressed, to get over her depression. We want to treat both parents. So I want to emphasize, don't forget the dads. 

This is where I will wrap up. I want to give you some hotlines that I think are helpful to know. This new National Maternal Mental Health Hotline just started this year, on Mother's Day in May 2022. It's a free hotline for pregnant women and new mothers in English and Spanish with interpreter services in 60 languages.

And then the other hotline has been around for quite some time, Postpartum Support International. It was started by a new mom in Santa Barbara many years ago, I think in the 1980s. And she had experienced postpartum depression and found no help at the time. She began this organization that's now become international and they provide support groups, provider directories, peer counseling, resources for adoptive and birth mothers, resources for fathers and families. Often women who've experienced postpartum depression and then overcome it and are eager to give back to the community of new moms by becoming peer counselors for Postpartum Support International. So I'm going to stop there and thank you for listening.

Note: In August 2023, the FDA approved zuranolone (Zurzuvae) for the treatment of postpartum depression.

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The Carlat CME Institute is accredited by the ACCME to provide continuing medical education for physicians. Carlat CME Institute maintains responsibility for this program and its content. Carlat CME Institute designates this enduring material educational activity for a maximum of one-half (.5) AMA PRA Category 1 Credits^TM. Physicians or psychologists should claim credit commensurate only with the extent of their participation in the activity.