OFFICIAL ABP TOPIC:

Recognize and manage postpartum depression

BACKGROUND

Postpartum depression (PPD) may occur up to one year after birth, affecting 1 in 5 mothers. Untreated PPD can profoundly impact the mother, infant, and family, leading to impaired bonding, developmental delays, and family dysfunction. Pediatricians play a crucial role in recognizing PPD and facilitating treatment to promote healthy child development.

RISK FACTORS FOR PPD

Several factors increase a mother’s risk for developing PPD:

• Personal or family history of depression, anxiety, or bipolar disorder
• Psychosocial stressors: Financial strain, limited social support, unintended pregnancy
• Obstetric complications: Traumatic birth, preterm delivery, infant NICU stay
• Infant factors: Temperament issues, health problems, neurodevelopmental disorders

Adolescent mothers and mothers of multiples are at particularly high risk for PPD. Additional risk factors include being a single mother, experiencing marital discord or domestic violence, and having a personal history of trauma or adverse childhood experiences.

PPD SCREENING

The AAP recommends routine PPD screening at the 1-, 2-, 4-, and 6-month well-child visits. Screening can also be done at prenatal sibling visits. Validated tools such as the Edinburgh Postnatal Depression Scale (EPDS) or Patient Health Questionnaire-9 (PHQ-9) should be used. Incorporating screening into pediatric care is an important way to support the mother-infant dyad.

IDENTIFICATION AND EVALUATION OF PPD

Recognizing the signs and symptoms of PPD is key for early intervention:

• Emotional: Persistent low mood, feelings of guilt or worthlessness, anhedonia, frequent crying
• Cognitive: Difficulty concentrating, making decisions, or remembering
• Behavioral: Fatigue, changes in sleep or appetite, social withdrawal, difficulty bonding with baby
• Physical: Headaches, digestive problems, muscle aches and pains

While “baby blues” are common and self-limited, PPD symptoms persist beyond 2 weeks postpartum and impair daily functioning. Severe symptoms like suicidal thoughts or psychosis (paranoia, hallucinations, delusions) require emergent evaluation and intervention.

MANAGEMENT OF PPD

Managing PPD requires a collaborative approach involving the pediatrician, the mother’s medical provider, and mental health professionals.

1. For a positive depression screen, assess symptom severity:
   • Evaluate mother’s level of distress and functional impairment
   • Assess for suicidality, psychosis, and any concerns about infant’s safety
2. Develop a management plan based on severity:
   • Mild to moderate: Refer to mental health professional or mother’s PCP or obstetrician, provide support, and psychoeducation resources
   • Severe with psychosis, suicidality, or infanticidal thoughts: Provide crisis resources and facilitate emergency psychiatric evaluation; consider inpatient hospitalization to ensure safety

NON-PHARMACOLOGIC INTERVENTIONS FOR PPD

• Psychotherapy: Cognitive-behavioral therapy and interpersonal therapy are first-line evidence-based treatments for mild to moderate PPD. If there are concerns about attachment and bonding, the mother-infant dyad should be referred for interventions such as child-parent psychotherapy from a mental health professional with expertise in treating young children to improve their relationship.
• Support groups: Postpartum support groups, whether in-person or online, can reduce isolation and provide validation, encouragement, and resources.
• Social support: Engaging the partner, family, and friends to provide practical and emotional support is essential. Encouraging the mother to prioritize self-care, share her feelings openly, and accept help can foster recovery.

PHARMACOLOGIC TREATMENT FOR PPD

• Antidepressants: SSRIs are considered first-line pharmacotherapy for PPD. Sertraline and paroxetine are often preferred in breastfeeding women due to low levels of transfer into breastmilk.
• Treatment duration: Antidepressants are typically continued for at least 6-12 months to prevent relapse.
• Lactation considerations: Breastfeeding is generally encouraged in women taking antidepressants. The risks of untreated maternal depression usually outweigh the risks of infant medication exposure via breastmilk. However, the mother’s provider should carefully weigh the risks and benefits of each medication.

COUNSELING AND PREVENTION

Pediatricians can provide anticipatory guidance about PPD starting in pregnancy and through the first postpartum year. Counseling should address:

• Normalizing the challenges of the postpartum period and encouraging help-seeking
• Developing a postpartum plan that includes mental health support and resources
• Reviewing the signs and symptoms of PPD and when to seek evaluation
• Emphasizing the importance of self-care, including sleep, nutrition, exercise, and stress reduction
• Encouraging utilization of social support from family, friends, and community organizations
• Discussing the benefits of psychotherapy and/or medication in promoting recovery
• Assessing ongoing safety and coordinating follow-up with the mother’s PCP
• Monitoring symptoms and infant’s well-being at follow-up visits

REFERENCES

https://publications.aap.org/pediatrics/article/143/1/e20183259/37241/Incorporating-Recognition-and-Management-of