Post-Partum Depression
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Post-partum disorder is a depressive or mood disturbance beginning within four weeks of delivery.  Research shows that post-partum depression is much more common in women who do not breast feed and more common in women having C-section deliveries.  If these cases are removed, depressive disorders are actually less common during the post-partum period that at other times in a woman's life.  This is understandable since the post-partum period is a time of unusual joy with a new member having been added to the family.  Female hormones associated with breast-feeding and the act of breast-feeding itself may be other sources of pleasure, helping reduce depressive feelings.

The treatment for post-partum depression is unusual in that estrogen hormones appear unusually effective.  I don't think that they are used very often, but the research certainly supports their effectiveness.  Most anti-depressant medications are also fairly safe during breast-feeding should these prove necessary.  Of course, a physician should carefully evaluate each situation, but breast feeding is so important for both disease prevention and brain development for the child.  Breast-feeding should not be stopped without some clear evidence of harm or very good reason, since stopping it will cause harm to large percentage of children. 

Depression Only Slightly Higher Postpartum: Lack of Breast-Feeding & C-Sections are Causes: A large study of 2730 Norwegian women found the prevalence of depression 60% higher in the postpartum period after controlling for risk factors of depression. Without controlling for these factors, depression was actually a little higher in the non-postpartum women (13.4% vs. 8.9%). Depression in postpartum and non-postpartum women: prevalence and risk factors. M Eberhard-Gran, A Eskild, K Tambs, SO Sanuelsen, S Opjuordsmoen. Acta Psych Scan 2002, 106:426. Other studies are mixed although this study is one of the few with a control group. 

Breastfeeding women were much less likely to be depressed (OR 12.4) in the Norwegian study. Having a past history of depression, a poor partner-relationship, more stressful life events, and 1st delivery all associated with depression. None of the other three studies with a control group from the same population found higher postpartum depression. Higher depression was also found with C-section vs. vaginal delivery in this study. Similar findings for both lack of breast feeding and C-section were reported in:  Links between early postpartum mood and postnatal depression. P Hannah, D Adams, A Lee, V Glover, M Sandler. Brit J Psychiatry 6/92;160:777-780. Surprisingly, a past history of pressured or forced intercourse was not associated with depression in either group in the Norwegian study.

Estrogen Patch Helps Post-Partum Depr: 61 Women with major depr within 3 mo of delivery Rx DB PC study with estrogen patch (transdermal 17 beta-oestradiol 200 micrograms daily alone, then 3 months with added cyclical dydrogesterone 10mg daily for 12 days each month). England, Transdermal oestrogen for treatment of severe postnatal depression. Gregoire AJ, Kumar R, Everitt B, Henderson AF, Studd JW. Lancet ’96;347:930

Estrogen:  Post-Partum Depression Prevented by Estrogen: Prophylactic estrogen in recurrent postpartum affective disorder. Biol Psych 95;38:814

Estrogen: Postpartum Psychosis Rx Estradiol: 10 Finnish with psychosis emerging average of 12 days post-partum referred after 73 days of symptoms. Several had progressed to florid psychosis over many months. 4 had neuroleptics. Serum estradiol at baseline 14 pg/mL (reference range 30-400). Rx 6 weeks sublingual 17 Beta-estradiol, 1 mg 3-6 times per day (mean 4.7) to target blood level of 109 pg/ml (1/3 of normal peak during menstrual cycle). Patients symptoms gone by end of week 2. Ahokas, J Clin Psych 00;61:166

Estrogen: Post-Partum Depression Rapidly Helped: Sublingual 17beta-estradiol (Estrofem) 23 MDD within 6 months post-partum all suspected estrogen deficiency. serum estradiol <55pg/mL in all with mean 22. 1 mg 3-8 times/d target level 109 pg/mL. Allowed breastfeed. 8 wk f/u. 91% responded after 1 week and by week 8 all remitted! Ahokas A, Kaukoranta J, Wahlbeck K, Aito M: Estrogen deficiency in severe postpartum depression: successful treatment with sublingual physiologic 17beta;estradiol: a preliminary study. J Clin Psyc 01;62:332-6. U Helsinki.

Estrogen Increases Benefit of Sertraline: 34 sertraline depr women on estrogen replacement therapy did better than 93 without ERT in 12 week, DB with 79% vs 58% much improved. 9 pt on both ERT and medroxyprogesterone were excluded. Lon Schneider, USC, APA 5/30/98

Estrogen-progesterone HRT Increases Breast CA: JAMA (Apr 00) U Mass study found after 10 yr on combo had 80% increased risk of breast CA. Those on estrogen only had 10% increase risk after 10 yr. In US, 8 million on combo and 12 million estrogen alone. Off estrogen for 5 years, bones return to way would have been. Estrogen is no benefit for already established Alzheimers although may lower its risk (JAMA Feb 2000)

Estradiol Patch Helps Perimenopausal in DB: transdermal patches of 17beta-estradiol (100 microgram) or placebo in a 12-week, double-blind, placebo-controlled study. A 4-week washout period followed the 12-week treatment phase. Outcome measures were the Montgomery-Asberg Depression Rating Scale and Blatt-Kupperman Menopausal Index scores. RESULTS: Fifty women 40-55yo with FSH>25 and irreg periods were enrolled in the study; 26 met DSM-IV criteria for major depressive disorder, 11 for dysthymic disorder, and 13 for minor depressive disorder. Remission of depression was observed in 17 (68%) women treated with 100 mcg 17beta-estradiol compared with 5 (20%) in the placebo. MGH, Efficacy of estradiol for the treatment of depressive disorders in perimenopausal women: a double-blind, randomized, placebo-controlled trial. Soares CN, Almeida OP, Joffe H, Cohen LS., Arch Gen Psychiatry 2001 Jun;58(6):529-34

Estradiol Helps Perimenopausal in DB: 34 female subjects, 16 received estradiol first and 18 received placebo first. After 3 weeks of estradiol, standardized mood rating scale scores and visual analog scale symptom scores (eg, sadness, anhedonia, and social isolation) were significantly decreased compared with baseline scores (P <.01) and were significantly lower than scores in women receiving placebo (P <.01), who showed no significant improvement. Neither the presence of hot flushes nor the duration of treatment (3 weeks vs 6 weeks) influenced outcome. A full or partial therapeutic response was seen in 80% of subjects receiving estradiol and 22% of those receiving placebo. NIMH, Estrogen replacement in perimenopause-related depression: a preliminary report. Schmidt PJ, Nieman L, Danaceau MA, Tobin MB, Roca CA, Murphy JH, Rubinow DR., Am J Obstet Gynecol 2000 Aug;183(2):414-20

Estradiol No Diff From Placebo: DB PC 69 45-60yo women MDD 3-month treatment with transdermal oestradiol [Estraderm TTS (ETTS) 50 micrograms, applied twice weekly] or placebo. Both groups improved. Double-blind, placebo-controlled, hormonal, syndromal and EEG mapping studies with transdermal oestradiol therapy in menopausal depression. Saletu B, Brandstatter N, Metka M, Stamenkovic M, Anderer P, Semlitsch HV, Heytmanek G, Huber J, Grunberger J, Linzmayer L, et al. Psychopharmacology (Berl) 1995 Dec;122(4):321-9

Estrogen Patch Helps Post-Partum Depr: Women with major depr within 3 mo of delivery Rx DB PC study with estrogen patch. England, Lancet ’96;347:930

Estrogen: Post-Partum Depression Prevented by Estrogen: Prophylactic estrogen in recurrent postpartum affective disorder. Biol Psych 95;38:814

Estrogen: Postpartum Psychosis Rx Estradiol: 10 Finnish with psychosis emerging average of 12 days post-partum referred after 73 days of symptoms. Several had progressed to florid psychosis over many months. 4 had neuroleptics. Serum estrdiol at baseline 14 pg/mL (reference range 30-400). Rx 6 weeeks sublingual 17 Beta-estradiol, 1 mg 3-6 times per day (mean 4.7) to target blood level of 109 pg/ml (1/3 of normal peak during menstrual cycle). Patients symptoms gone by end of week 2. Ahokas, J Clin Psych 00;61:166

Fish: No Benefit Rx Mothers Post-Partum DHA in DB Study: 52 breast feeding women Rx DB with half Rx DHA suppl 1st 12 wk post-partum. Infant DHA strongly related to maternal DHA but no benefit visual or neurol testing out to two years. Gibson, Adelaide, Eur J Clin Nutr 9/97;51:578

Fish: Less Post-Partum Depression with Higher Fish and Higher Breast Milk DHA: Published prevalence data for postpartum depression were included that used the Edinburgh Postpartum Depression Scale (n=14532 subjects in 41 studies). These data were compared to the DHA, eicosapentaenoic acid (EPA) and arachidonic acid (AA) content in mothers' milk and to seafood consumption rates in published reports from 23 countries. RESULTS: Higher concentrations of DHA in mothers' milk (r=-0.84, p<0.0001, n=16 countries) and greater seafood consumption (r=-0.81, p<0.0001, n=22 countries) both predicted lower prevalence rates of postpartum depression in simple and logarithmic models, respectively. The AA and EPA content of mothers' milk were unrelated to postpartum depression prevalence. J Affect Disord 2002 May;69(1-3):15-29, Hibbelm, NIAAA

Fluoxetine or CBT Helped in DB: 80% of 3000 consecutive maternity patients screened 6-8 weeks post-discharge. 10% depressed and half agreed to participate. DB PC All groups improved considrably tho fluoxetine or 6 session CBT improved more but no added benefit to combo. Appleby L, et al: A controlled study of fluoxetine and cognitive-behavioral counselling in the treatment of postnatal depression. BMJ 97;314:932-6, U Manchester

Frequency: Post-Partum Anxiety & Depression Uncommon in ND Study: 68 North Dakota women interviewed 8 weeks after delivery. 3 GAD, 2 MDD, 19 had some anxiety. Prevalence of generalized anxiety at eight weeks postpartum. Wenzel A, Haugen EN, Jackson LC, Robinson K. Arch Women Ment Health. 2003 Feb;6(1):43-9

Infant: Post-Partum Depr Linked to Infant Insecurity: 136 women assessed before and at 4 wk and 4 mo post-partum. 20% were depressed at one of the two measurements. Children of those mothers showed decreased secure attachments at 12 months (33% vs. 60%). Cassidy, Toronto, APA 5/30/98 Toronto

Lithium: Relapse After D/C Lithium Equal in Preg and Non-Preg, Higher Post-Partum: Retrospective study 42 bipolar d/c within 6 weeks of conception vs 59 who stopped for other reasons. Relapse in 1st 40 weeks same 52% in pregnant v 58% in non-pregnant. Both groups only 21% relapse rate in year before d/c lithium. Relapse after 40 weeks 2.9 times higher in postpartum v nonpregnant (70% v 24%). None of 9 on lithium during pregnancy relapsed but 3 did within 2 weeks of delivery despite staying on lithiu. Women who d/c lithium rapidly (1-14 days) 63% relapse rate v those d/c gradually (15-30 days) and shorter interval to recurrence (8 v 20 weeks). Therefore, if d/c, do so gradually. Viguera, MGH, AJP 00;157:179

Midwifery No Benefit Psychiatrically: 98 pt with hx MDD random assigned. Can we prevent postnatal depression? A randomized controlled trial to assess the effect of continuity of midwifery care on rates of postnatal depression in high-risk women. Marks MN, Siddle K, Warwick C. J Matern Fetal Neonatal Med. 2003 Feb;13(2):119-27

Nortriptyline as Good as SSRIs: In an 8-week DB study of 109 women with moderate to severe postpartum depression without another Axis I disorder, sertraline did no better than nortriptyline.  At week 4, 46% of sertraline and 56% of nortriptyline patients achieved a 50% reduction in symptoms. By 8 weeks, 94% of completers had a positive response. The number of side-effects were similar in degree, but different in type: dry mouth and constipation for nortriptyline vs. headache, perspiration, and hot flashes for sertraline. Wisner KL, et al. University of Pittsburgh. J Clin Psychopharm 2006;26:353-60.

Nortriptyline Didn’t Help Prevent Post Partum: In a DB PC study of 51 patients with post-partum depression, six relapsed in each group. Case Western. Prevention of recurrent postpartum depression: a randomized clinical trial. Wisner KL, et al. J Clin Psychiatry 2001 Feb;62(2):82-6

Venlafaxine Appeared to Help in Open Trial: 15 pt aver. 165mg/d. 12 remitted fairly quickly. Venlafaxine in the treatment of postpartum depression. Cohen LS, Viguera AC, Bouffard SM, Nonacs RM, Morabito C, Collins MH, Ablon JS. Harvard MGH: J Clin Psychiatry 2001 Aug;62(8):592-6

Violence in Children at Age 11 Linked Post-Partum Depression in Small Study: 122 families in South London. Mothers were interviewed while they were pregnant, at three months postpartum, and again when the child was 1, 4 and 11 years old. Mothers, teachers and children were interviewed about violent behavior when the child was 11.  More violent behavior was identified in children whose mothers had been depressed in the months following childbirth, especially if depression occurred at three months postpartum and at least once again after that.  Violence was more common in boys and mostly involved fighting with peers. The fighting often resulted in injury and suspension from school. Dale F. Hay, Cardiff University, Developmental Psychology 11/03. (Ed: This is an extremely small study.  I strongly doubt that these findings will hold up when larger numbers of mothers are studied.  I am troubled by the author's claim that his small study "clearly show that a mother's mental state after childbirth is an easily identifiable risk factor for a child's intellectual and social development.")