Postpartum depression is a common type of mental disorder occurring during the postpartum period, characterized by persistent and severe depressive moods along with a range of symptoms. In addition to causing significant distress for the mother, postpartum depression can adversely affect the infant's health and development. The condition has a relatively high incidence rate, typically presenting within the first two weeks after delivery.
Clinical Manifestations
The primary clinical features include:
- Mood Changes: Feelings of depression, emotional indifference, or even anxiety, fear, and irritability, often worse in the morning and better in the evening. Some individuals may experience loneliness, a reluctance to engage with others, sadness, or frequent crying.
- Low Self-Esteem: Feelings of worthlessness, self-abandonment, and guilt, often accompanied by hostility towards those around them and strained relationships with family members and the partner.
- Impaired Creative Thinking: Reduced initiative and diminished ability to engage in creative or purposeful thoughts.
- Loss of Confidence in Life: A sense that life is meaningless, together with symptoms such as loss of appetite, sleep disturbances, fatigue, and reduced sexual desire. In severe cases, feelings of despair may lead to suicidal thoughts or infanticidal tendencies, with some individuals experiencing confusion or a stuporous state.
Diagnosis
There is currently no universally accepted diagnostic criterion for postpartum depression. The criteria most commonly used are those established in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), published by the American Psychiatric Association (APA) in 2013. According to the DSM-5, the diagnostic criteria for postpartum depression are as follows:
The presence of five or more of the following symptoms on most days for at least two consecutive weeks, with at least one of the first two symptoms being required:
- Depressed mood.
- Markedly diminished interest or pleasure in most or all activities.
- Significant weight loss or gain.
- Insomnia or hypersomnia.
- Psychomotor agitation or retardation.
- Fatigue or loss of energy.
- Feelings of worthlessness or excessive guilt.
- Diminished ability to think, concentrate, or make decisions.
- Recurrent thoughts of death, suicidal ideation, or attempts.
Symptoms do not meet the criteria for other psychiatric disorders.
Symptoms interfere with occupational, academic, or social functioning.
Symptoms are not directly caused by a substance or medication.
Onset of symptoms occurs within four weeks postpartum.
Differential Diagnosis
It is necessary to exclude organic mental disorders and depression caused by psychoactive substances or non-addictive substances. A distinction must also be made between postpartum blues (baby blues) and postpartum psychosis.
Management
Management includes both psychological therapy and pharmacological treatment.
Psychological Therapy
Psychological therapy serves as an essential approach to treatment. It includes psychological support, counseling, and social interventions. Strategies such as psychoeducation and cognitive-behavioral therapy can help mothers modify unhealthy thought and behavior patterns, thereby improving emotional well-being and functionality while also preventing infant-related issues. Emotional and social support should be provided to postpartum women.
Pharmacological Treatment
Pharmacological treatment is appropriate for moderate to severe depression or for patients who do not respond to psychological therapy. Medications should be used under the guidance of a specialist physician, taking into account previous treatment efficacy and individual patient characteristics. Selective serotonin reuptake inhibitors (SSRIs) are the first-line drugs, with preference given to antidepressants that do not excrete into breast milk.
Selective Serotonin Reuptake Inhibitors (SSRIs)
Paroxetine Hydrochloride
The starting and effective dose is 20 mg, taken once daily with breakfast. If there is no improvement after 2–3 weeks and no significant side effects, the dose may be increased by 10 mg increments, up to a maximum of 50 mg per day (40 mg for individuals with low body weight). Use with caution in patients with liver or kidney dysfunction. Abrupt discontinuation should be avoided.
Sertraline Hydrochloride
The initial dose is 50 mg daily, taken once with food. After several weeks, the dose may be increased to 100–200 mg daily. The usual dose ranges from 50–100 mg daily, with a maximum dose of 150–200 mg daily (not to be used continuously for more than 8 weeks at this dose). For long-term use, the lowest effective dose is recommended.
Tricyclic Antidepressants:
Amitriptyline
The initial dose is 25 mg, taken 2–3 times daily. Depending on the clinical response and tolerance, the dose can gradually be increased to 150–250 mg daily, divided into three doses. The maximum dose should not exceed 300 mg per day. Maintenance doses typically range from 50–150 mg daily.
Prevention
The development of postpartum depression is influenced by social, psychological, and pregnancy-related factors, emphasizing the need for enhanced mental health care for pregnant and postpartum women. All healthcare providers should remain vigilant regarding the mental health of women during each interaction.
Channels such as antenatal classes can be used to disseminate knowledge about pregnancy and childbirth, thereby reducing anxiety and fear related to these events and encouraging self-care practices.
Postpartum depression screening can be conducted. Commonly used tools include the Edinburgh Postnatal Depression Scale (EPDS) and the Patient Health Questionnaire-9 (PHQ-9).
Discussions regarding the risks and benefits of medication, as well as the potential risks of not treating depression, should be undertaken with patients to enable informed and individualized decision-making.
Women should be encouraged to participate in social activities that promote health and well-being.
Prognosis
Postpartum depression episodes typically last an average of 3–6 months. However, approximately 30% of women remain in a depressive state one year after delivery. The recurrence rate in subsequent pregnancies is about 20%–40%. The cognitive abilities of the next generation may be affected to some extent.