Perinatal and Postpartum Mood and Anxiety Disorders

Peripartum depression, also known as major depressive disorder with peripartum onset, and previously known as postpartum depression, is a type of depressive disorder that occurs during pregnancy or during the four weeks following delivery.

First, let’s briefly review the physiology of some hormonal fluctuations that take place in the perinatal period. During pregnancy, the placenta releases hormones, including human placental lactogen, estrogen, and progesterone; while the pituitary gland releases prolactin, among others. These hormones travel through the bloodstream to their specific areas of action to regulate body functions during the pregnancy.

Then, during labor, the pituitary gland secretes another hormone called oxytocin, which stimulates uterine muscle contractions to facilitate delivery. Once the baby’s delivered, most of these hormones start to decrease.

Now, the exact cause of peripartum depression isn’t completely understood, but it’s likely multifactorial. It can be related to changes in hormone levels, as well as an imbalance of neurotransmitters like GABA, serotonin, dopamine, and glutamate that help regulate mood, reward-motivated behavior, appetite, and sleep.

Some of the major risk factors include having a family or personal history of depression, as well as social factors like intimate partner violence, poor socioeconomic support, single marital status, undesired pregnancy, or age younger than 25 years.

So, it’s thought that individuals who develop peripartum depression have an increased sensitivity to the hormonal fluctuations that occur during the perinatal period. This, alongside the psychological impacts of having a baby, such as anxiety, fatigue, and sleep deprivation, can all play a role in the pathology of peripartum depression.

Clinical manifestations of peripartum depression typically include feelings of extreme sadness, fatigue, and anhedonia, which is a diminished interest in everyday activities that used to be pleasurable. Appetite could either increase or decrease, which can lead to weight gain or loss. Other symptoms include sleeping too much or too little; difficulty concentrating; feelings of worthlessness; excessive guilt; and recurrent thoughts of death or suicide.

Symptoms last for at least two weeks, significantly impair daily functioning, and may negatively affect both the birthing parent, the baby, and attachment and bonding. Peripartum depression should be differentiated from postpartum blues, which is more common, and may cause milder feelings of depressed mood, mood swings, irritability, crying outbursts, and lethargy or fatigue; which typically resolve within two weeks after delivery.

Now, the diagnosis of peripartum depression primarily involves the patient’s history and physical assessment. Screening for this condition should be done in all individuals in the perinatal period, using the PHQ-9 depression questionnaire, or the Edinburgh Postnatal Depression Scale. Next, diagnosis includes meeting certain criteria outlined in the Diagnostic and Statistical Manual for Mental Disorders, fifth edition, or DSM-5 for short, where peripartum depression is classified as a type of major depressive disorder.

Okay so, the treatment of peripartum depression can be challenging. Milder cases can be managed with psychotherapy, including cognitive behavioral therapy, family therapy, and support groups, as well as healthy lifestyle modifications, like increasing the level of physical activity. For more severe cases, medications like selective serotonin reuptake inhibitors or SSRIs, such as fluoxetine and sertraline; and serotonin and norepinephrine reuptake inhibitors, or SNRIs, like venlafaxine can be used.