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What Is Postpartum Depression?

Postpartum depression (PPD) is a complex mix of physical, emotional, and behavioral changes that happen in some women after giving birth. According to the DSM-5, a manual used to diagnose mental disorders, PPD is a form of major depression that begins within 4 weeks after delivery. The diagnosis of postpartum depression is based not only on the length of time between delivery and onset but on the severity of the depression.

Postpartum depression is linked to chemical, social, and psychological changes that happen when having a baby. The term describes a range of physical and emotional changes that many new mothers experience. PPD can be treated with medication and counseling.

The chemical changes involve a rapid drop in hormones after delivery. The actual link between this drop and depression is still not clear. But what is known is that the levels of estrogen and progesterone, the female reproductive hormones, increase tenfold during pregnancy. Then, they drop sharply after delivery. By 3 days after a woman gives birth, the levels of these hormones drop back to what they were before pregnancy.

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In addition to these chemical changes, the social and psychological changes of having a baby create an increased risk of depression.

Most new mothers experience the "baby blues" after delivery. About 1 out of every 10 of these women will develop a more severe and longer-lasting depression after delivery. About 1 in 1,000 women develop a more serious condition called postpartum psychosis.

Dads aren't immune. Research shows that about 1 in 10 new fathers get depression during the year their child is born.

Postpartum Depression Signs and Symptoms

Symptoms of postpartum depression can be hard to detect. Many women have these symptoms following childbirth:

With PPD, these come along with other symptoms of major depression, which aren't typical after childbirth, and may include:

Being uninterested in your baby or feeling like you're not bonding with them

Crying all the time, often for no reason

Depressed mood

Severe anger and crankiness

Loss of pleasure

Feelings of worthlessness, hopelessness, and helplessness

Thoughts of death or suicide

Thoughts of hurting someone else

Trouble concentrating or making decisions

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Symptoms of obsessive compulsive disorder (OCD) that are new rarely occur in the postpartum period (about 1%-3% of women). The obsessions are usually related to concerns about the baby's health or irrational fears of harming the baby. Panic disorder may also happen. You can have these conditions and depression at the same time.

Untreated postpartum depression can be dangerous for new moms and their children. A new mom should seek professional help when:

Symptoms persist beyond 2 weeks

They can't function normally

They can't cope with everyday situations

They have thoughts of harming themselves or their baby

They're feeling extremely anxious, scared, and panicked most of the day

Postpartum Depression Causes and Risk Factors

If you have PPD, it's not because you did anything wrong. Experts think it happens for many reasons, and those can be different for different people. Some things that can raise the chances of postpartum depression include:

A history of depression prior to becoming pregnant, or during pregnancy

Age at time of pregnancy (the younger you are, the higher the chances)

Ambivalence about the pregnancy

Children (the more you have, the more likely you are to be depressed in a later pregnancy)

Family history of mood disorders

Going through an extremely stressful event, like a job loss or health crisis

Having a child with special needs or health problems

Having twins or triplets

Having a history of depression or premenstrual dysphoric disorder (PMDD)

Limited social support

Living alone

Marital conflict

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There's no one cause of postpartum depression, but these physical and emotional issues may contribute:

Hormones. The dramatic drop in estrogen and progesterone after you give birth may play a role. Other hormones produced by your thyroid gland also may drop sharply and make you feel tired, sluggish and depressed.

Lack of sleep. When you're sleep-deprived and overwhelmed, you may have trouble handling even minor problems.

Anxiety. You may be anxious about your ability to care for a newborn.

Self-image. You may feel less attractive, struggle with your sense of identity, or feel that you've lost control over your life. Any of these issues can contribute to postpartum depression.

Types of Postpartum Depression

There are three terms used to describe the mood changes women can have after giving birth:

The "baby blues" happen to as many as 70% of women in the days right after childbirth. You may have sudden mood swings, such as feeling very happy and then feeling very sad. You may cry for no reason and can feel impatient, cranky, restless, anxious, lonely, and sad. The baby blues may last only a few hours or as long as 1 to 2 weeks after delivery. Usually you don't need treatment from a health care provider for baby blues. Often, joining a support group of new moms or talking with other moms helps.

Postpartum depression (PPD) can happen a few days or even months after childbirth. PPD can happen after the birth of any child, not just the first child. You can have feelings similar to the baby blues -- sadness, despair, anxiety, crankiness -- but you feel them much more strongly. PPD often keeps you from doing the things you need to do every day. When your ability to function is affected, you need to see a health care provider, such as your OB/GYN or primary care doctor. This doctor can screen you for depression symptoms and come up with a treatment plan. If you don't get treatment for PPD, symptoms can get worse. While PPD is a serious condition, it can be treated with medication and counseling.

Postpartum psychosis is a very serious mental illness that can affect new mothers. This illness can happen quickly, often within the first 3 months after childbirth. Women can lose touch with reality, having auditory hallucinations (hearing things that aren't actually happening, like a person talking) and delusions (strongly believing things that are clearly irrational). Visual hallucinations (seeing things that aren't there) are less common. Other symptoms include insomnia (not being able to sleep), feeling agitated and angry, pacing, restlessness, and strange feelings and behaviors. Women who have postpartum psychosis need treatment right away and almost always need medication. Sometimes women are put into the hospital because they are at risk for hurting themselves or someone else.

Postpartum Depression Treatment

Postpartum depression is treated differently, depending on the type of symptoms and how severe they are. Treatment options include anti-anxiety or antidepressant medications, psychotherapy, and participation in a support group for emotional support and education. For severe cases, an IV of a new medication called brexanolone (Zulresso) may be prescribed.

In the case of postpartum psychosis, drugs used to treat psychosis are usually added. Hospital admission is also often necessary.

If you are breastfeeding, don't assume that you can't take medication for depression, anxiety, or even psychosis. Talk to your doctor. Under a doctor's supervision, many women take medication while breastfeeding. This is a decision to be made between you and your doctor.

Postpartum Depression Complications

Postpartum depression that isn't treated can weaken your ability to bond with your baby, and affect the whole family:

You. Postpartum depression that's not treated can last for months or longer, even turning into a chronic depressive disorder. Even with treatment, postpartum depression can make you more likely to have episodes of depression in the future.

The baby's father. When a new mother has depression, the father may be more likely to have depression too.

Children. Children of mothers with postpartum depression are more likely to have problems with sleeping and eating, crying more than usual, and delays in language development.

Postpartum Depression Prevention

If you have a history of depression, tell your doctor as soon as you find out you're pregnant, or if you're planning to become pregnant.

During pregnancy. Your doctor can monitor you for symptoms. You can manage mild depression symptoms with support groups, counseling, or other therapies. Your doctor may prescribe medications, even while you're pregnant.

After your baby is born. Your doctor may recommend an early postpartum checkup to look for symptoms of depression. The earlier you're diagnosed, the earlier you can begin treatment. If you have a history of postpartum depression, your doctor may recommend treatment as soon as you have the baby.

Managing after childbirth
Here are some tips that can help you cope with bringing home a newborn:

Ask for help. Let others know how they can help you.

Be realistic about your expectations for yourself and baby.

Exercise , within the limits of any restrictions your doctor may place on your level of activity; take a walk, and get out of the house for a break.

Expect some good days and some bad days.

Follow a sensible diet; avoid alcohol and caffeine.

Foster the relationship with your partner -- make time for each other.

Keep in touch with family and friends -- don't isolate yourself.

Limit visitors when you first go home.

Screen phone calls.

Sleep or rest when your baby sleeps.

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Postpartum depression (PPD) is a complex mix of physical, emotional, and behavioral changes that happen in some women after giving birth. According to the DSM-5, a manual used to diagnose mental disorders, PPD is a form of major depression that begins within 4 weeks after delivery.

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If pregnancy is an emotional roller coaster, then the postpartum period is an emotional tornado, often full of mood swings, crying jags, and irritability. Not only does giving birth cause your body to go through some major hormonal adjustments, but you also have a whole new human living in your house.

All of that upheaval can initially lead to feelings of sadness, stress, and anxiety rather than the joy and elation you were expecting. Many people experience these " baby blues" as a typical part of postpartum recovery, but they usually go away 1 to 2 weeks after delivery.

However, new parents still struggling beyond the 2-week milestone may have postpartum depression (PPD), which is characterized by more severe symptoms that last much longer than the baby blues.

Here's everything you need to know about how long PPD lasts - and what you can do to feel better faster.

PPD is a form of clinical depression that begins after the birth of a baby.

No one knows for sure what causes PPD, but like any other kind of depression, it's probably several different things.

The postpartum period is an especially susceptible time, during which many of the common causes of clinical depression - such as biological changes, extreme stress, and major life changes - all happen at once.

For example, the following may occur after giving birth:

You don't get as much sleep as before.

Your body is coping with major hormone fluctuations.

You're recovering from the physical event of giving birth, which may have included medical interventions or surgery.

You have new and challenging responsibilities.

You might be disappointed with how your labor and delivery went.

You might feel isolated, lonely, and confused.

For PPD to be diagnosed, symptoms are typically present almost every day and tend to disrupt daily routines. Some of these symptoms include:

depressed mood

loss of interest in things you used to be interested in

insomnia

low self-esteem

guilt

difficulty concentrating

a marked change in weight

hallucinations

thoughts of suicide

These symptoms may lead to difficulty with breastfeeding or chestfeeding and bonding with baby.

If you feel as though you or someone you know could be experiencing these symptoms, it's important to talk with a healthcare professional as soon as possible. PPD is a serious medical condition.

The exact cause of PPD is currently unknown. However, it's thought that a combination of factors may play a role in its development. These factors include:

genetics

hormones

previous psychological issues

life stressors that come with a new baby

Dysregulation of reproductive hormones right after childbirth remains one of the key reasons many doctors believe PPD occurs in some individuals.

Screening for PPD can usually be done 2 to 6 months after childbirth, according to 2021 research.

Your doctor will likely ask you about your current mental and physical health, as well as any medications you may be taking. They may also ask you about your history with other mental health concerns.

They may also use the Edinburgh Postnatal Depression Scale (EPDS), a questionnaire that helps your doctor identify your risk for developing PPD.

If you are having strong feelings of sadness, thoughts of suicide, or finding it difficult to take care of your baby, it's essential that you talk with a healthcare professional as soon as you can - even if it's earlier than the typically recommended 2 to 6 months.

If you need immediate support, you can call the National Suicide Prevention Lifeline at 800-273-8255.

PPD can begin as soon as you give birth, but you probably won't realize it right away since it's expected that you might feel sad, exhausted, and generally "out of sorts" during the first few days after baby arrives.

It may not be until after the typical baby blues timeframe has passed that you realize something more serious is going on.

The postpartum period generally includes the first 4 to 6 weeks after birth, and many cases of PPD begin during that time. But PPD can also develop during pregnancy and up to 1 year after giving birth, so don't discount your feelings if they're happening outside of the typical postpartum period.

Because PPD can appear anywhere from a couple of weeks to 12 months after birth, there's no average length of time it lasts. A 2014 review of studies suggests that PPD symptoms improve over time, with many cases of depression resolving 3 to 6 months after they begin.

That said, in that same review, it was clear that plenty of participants were still dealing with PPD symptoms well beyond the 6-month mark.

Anywhere from 30 to 50 percent met criteria for PPD 1 year after giving birth, while a little less than half of the people studied were still reporting depressive symptoms 3 years postpartum.

The timeline for PPD is different for everyone. If you have certain risk factors, you might find your PPD lasting longer even with treatment. The severity of your symptoms and how long you had symptoms before beginning treatment can affect how long your PPD lasts.

Risk factors include:

a history of depression or other mental health condition

breastfeeding or chestfeeding difficulties

a complicated pregnancy or delivery

a lack of support from your partner or family members and friends

other major life changes occurring during the postpartum period, like a move or loss of employment

a history of PPD after a previous pregnancy

There's no formula to determine who will experience PPD and who won't, or for how long it'll last. But with the right treatment, especially when it's received early, you can find relief even if you have one of these risk factors.

You already know that PPD is causing you some difficult symptoms, and unfortunately, it could also affect your relationships. This isn't your fault. (Read that again, because we mean it.) That's why it's a good reason to get treatment and shorten the duration of your depression.

Asking for help is good for both you and your relationships, including those with:

Your partner. If you've become withdrawn or isolated, your relationship with your partner could be affected. According to the American Academy of Pediatrics (AAP), when a person has PPD, their partner becomes twice as likely to develop it, too.

Your family and friends. Other loved ones may suspect that something is wrong or notice you aren't acting like yourself, but they may not know how to help or communicate with you. This distance can cause increased feelings of loneliness for you.

Your child(ren). PPD can affect your growing relationship with your baby. Aside from affecting the way you physically care for your baby, PPD can affect the way you bond with your baby after birth. It may also cause damage to your existing relationships with older children.

Some researchers even believe that PPD may have long-term effects on a child's social and emotional development. A found that children of study participants who had PPD were more likely to have behavioral problems as young children and depression as adolescents.

If it's been 2 weeks postpartum and you're still experiencing intense feelings of sadness, it's probably not the baby blues. But this doesn't have to be bad news: You can absolutely do something about the way you feel. You don't have to wait it out.

When you do decide to ask for help, be as honest as possible. It can be difficult to talk about the negative emotions associated with new parenthood, and it can be scary to reveal just how much of a hard time you're having.

However, the more open you are about your PPD, the better - and faster - a healthcare professional will be able to help you.

Don't feel as though you need to power through PPD on your own. Receiving help means you'll be able to continue loving and caring for your baby to the best of your ability.

There are several options for PPD treatment, and you may need to utilize more than one strategy. There are also lifestyle changes that may make recovery go faster.

Don't stop until you find a combination of treatments that works for you. Relief from PPD is possible with the right interventions.

Here are some options:

Antidepressants. Your doctor may prescribe a selective serotonin reuptake inhibitor (SSRI) to treat your depression. There are several SSRIs available. Your doctor will work with you to find one that best treats your symptoms with the fewest side effects. Many SSRIs are compatible with breastfeeding or chestfeeding, but make sure your provider knows if you're nursing so they can choose the appropriate medication and dosage.

Counseling. Cognitive behavioral therapy is a frontline strategy for treating depression, including symptoms of PPD. If you need help locating a provider in your area, you can search for one here.

Group therapy. It may be helpful for you to share your experiences with other parents who have had PPD. Finding a support group, either in person or online, can be a valuable lifeline. To locate a PPD support group in your area, try searching by state here.

PPD can affect anyone who has just had a baby - and even the non-birthing parent. It does not mean you've done or are doing something wrong.

If it's been more than 2 weeks since your baby was born and you are dealing with feelings of sadness and fatigue, and are having difficulty bonding with your baby - it's possible you may be dealing with PPD.

Most cases of PPD can last for several months. Depression affects your whole body - not just your brain - and it takes time to feel like yourself again. You can recover faster by getting help for your PPD as soon as possible.

It can feel hard to reach out when you're struggling, but try to communicate with your partner, a trusted family member or friend, or your healthcare professional if you think your depression is affecting your quality of life or your ability to care for your baby.

The sooner you get help, the sooner you'll feel better.

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how long does postpartum depression last

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How Long Does Postpartum Depression Last?

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If pregnancy is an emotional roller coaster, then the postpartum period is an emotional tornado, often full of mood swings, crying jags, and irritability. Not only does giving birth cause your body to go through some major hormonal adjustments, but you also have a whole new human living in your house.

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Common Mental Health Symptoms During Pregnancy

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Although pregnancy has typically been considered a time of emotional well-being, recent studies suggest that up to 20% of women suffer from mood or anxiety disorders during pregnancy. Particularly vulnerable are those women with histories of psychiatric illness who discontinue psychotropic medications during pregnancy. In a recent study which prospectively followed a group of women with histories of major depression across pregnancy, of the 82 women who maintained antidepressant treatment throughout pregnancy, 21 (26%) relapsed compared with 44 (68%) of the 65 women who discontinued medication. This study estimated that women who discontinued medication were 5 times as likely to relapse as compared to women who maintained treatment.

High rates of relapse have also been observed in women with bipolar disorder. One study indicated that during the course of pregnancy, 70.8% of the women experienced at least one mood episode. The risk of recurrence was significantly higher in women who discontinued treatment with mood stabilizers (85.5%) than those who maintained treatment (37.0%).

Although data accumulated over the last 30 years suggest that some medications may be used safely during pregnancy, knowledge regarding the risks of prenatal exposure to psychotropic medications is incomplete. Thus, it is relatively common for patients to discontinue or to avoid pharmacologic treatment during pregnancy.

The New U.S. FDA Pregnancy Labeling and Lactation Rule

In 1975, the U.S. Food and Drug Administration (FDA) provided guidelines to drug companies for labeling medications with regard to their safety during pregnancy. This system of classification used five risk categories (A, B, C, D and X) based on data derived from human and animal studies. While widely used to make decisions regarding the use of medications during pregnancy, many criticized this system of classification, indicating that this type of drug labeling was often not helpful and, even worse, may be misleading.

In an effort to improve the accuracy and usefulness of information regarding the safety of medications used during pregnancy and breastfeeding, the FDA proposed a newly designed system on June 30th 2015. The Pregnancy and Lactation Labeling Rule or PLLR will abolish the letter categories and instead will include more comprehensive information discussing the potential risks and benefits to the mother and the fetus, and how these risks may change during the course of pregnancy.

Companies will be required to remove the pregnancy letter categories from the labeling for all prescription drugs and will have to revise the labeling with updated information. Medications approved before June 30, 2001 are not covered by the PLLR.

Weighing the Risks

Women with histories of psychiatric illness frequently come in for consultations regarding the use of psychotropic medications during pregnancy. Not infrequently, women present with the first onset of psychiatric illness while pregnant. Many pregnancies are unplanned and may occur unexpectedly while women are receiving treatment with medications for psychiatric disorders. Many women may consider stopping medication abruptly after learning they are pregnant, but for many women this may carry substantial risks.

Decisions regarding the initiation or maintenance of treatment during pregnancy must reflect an understanding of the risks associated with fetal exposure to a particular medication but must also take into consideration the risks associated with untreated psychiatric illness in the mother. Psychiatric illness in the mother is not a benign event and may cause significant morbidity for both the mother and her child; thus, discontinuing or withholding medication during pregnancy is not always the safest option.

Depression and anxiety during pregnancy have been associated with a variety of adverse pregnancy outcomes. Women who suffer from psychiatric illness during pregnancy are less likely to receive adequate prenatal care and are more likely to use alcohol, tobacco, and other substances known to adversely affect pregnancy outcomes. Several studies have described low birth weight and fetal growth retardation in children born to depressed mothers. Preterm delivery is another potential pregnancy complication among women experiencing distress during pregnancy. Pregnancy complications related to maternal depression and anxiety in late pregnancy have also been described, including an increased risk for having pre-eclapsia, operative delivery, and infant admission to a special care nursery for a variety of conditions including respiratory distress, hypoglycemia, and prematurity. These data underscore the need to perform a thorough risk/benefit analysis of pregnant women with psychiatric illness, including evaluating the impact of untreated illness on the baby and the mother, as well as the risks of using medication during pregnancy.

What are the Risks of Medication Exposure?

All medications diffuse readily across the placenta, and no psychotropic drug has yet been approved by the Food and Drug Administration (FDA) for use during pregnancy. When prescribing medications during pregnancy, one must consider the following risks associated with prenatal exposure: risk of teratogenesis, risk of neonatal toxicity, and risk of long-term neurobehavioral sequelae.

Risk of Teratogenesis

The baseline incidence of major congenital malformations in newborns born in the United States is estimated to be between 2 and 4%. During the earliest stages of pregnancy, formation of major organ systems takes place and is complete within the first 12 weeks after conception. Therefore, discussion around risks of exposures during pregnancy may be broken down by the timing of exposure or trimester, with particular vigilance around first trimester exposures.

A teratogen is defined as an agent that interferes the in utero development process and produces some type of organ malformation or dysfunction. For each organ or organ system, there exists a critical period during which development takes place and is susceptible to the effects of a teratogen. For example, neural tube folding and closure, forming the brain and spinal cord, occur within the first four weeks of gestation. Most of the formation of the heart and great vessels takes place from four to nine weeks after conception, although the entire first trimester is often considered pertinent.

Risk of Neonatal Symptoms

Neonatal toxicity or perinatal syndromes (sometimes referred to as neonatal "withdrawal") refer to a spectrum of physical and behavioral symptoms observed in the acute neonatal period that can be attributed to drug exposure at or near the time of delivery. Anecdotal reports that attribute these syndromes to drug exposure must be cautiously interpreted, and larger samples must be studied in order to establish a causal link between exposure to a particular medication and a perinatal syndrome.

Risk of Long-Term Effects

Although the data suggest that some medications may be used safely during pregnancy if clinically warranted, our knowledge regarding the long-term effects of prenatal exposure to psychotropic medications is incomplete. Because neuronal migration and differentiation occur throughout pregnancy and into the early years of life, the central nervous system (CNS) remains particularly vulnerable to toxic agents throughout pregnancy. While exposures to teratogens early in pregnancy may result in clear abnormalities, exposures that occur after neural tube closure (at 32 days of gestation) may produce more subtle changes in behavior and functioning.

Behavioral teratogenesis refers to the potential of a psychotropic drug administered during pregnancy to have long-term neurobehavioral effects. For example, are children who have been exposed to an antidepressant in utero at risk for cognitive or behavioral problems at a later point during their development? To date, few studies have systematically investigated the impact of exposure to psychotropic medications in utero on development and behavior in humans.

Antidepressants and Pregnancy

Of all the antidepressants, fluoxetine (Prozac) is the best characterized antidepressant. Data collected from over 2500 cases indicate no increase in risk of major congenital malformation in fluoxetine-exposed infants. One prospective study of 531 infants with first trimester exposure to SSRIs (mostly citalopram, n=375) did not demonstrate an increased risk of organ malformation.

Several meta-analyses combining studies with exposures to SSRIs do not demonstrate an increase in risk of congenital malformation in children exposed to these antidepressants, with the exception of paroxetine (Paxil). There has been particular controversy around paroxetine use in pregnancy, as past reports have suggested that first trimester exposure to paroxetine was associated with an increased risk of cardiac defects including atrial and ventricular septal defects. Other published studies have not demonstrated increased teratogenicity of paroxetine. Importantly, independently conducted meta-analyses of available data sets have consistently found a lack of association between paroxetine exposure and cardiovascular malformations. Even so, these findings prompted the FDA to change the category label of paroxetine from C to D.

Three prospective and more than ten retrospective studies have examined the risk of organ malformation in over 400 cases of first trimester exposure to tricyclic antidepressants of TCAs. When evaluated on an individual basis and when pooled, these studies do not indicate a significant association between fetal exposure to TCAs and risk for any major congenital anomaly. Among the TCAs, desipramine and nortriptyline are often preferred since they are less anti-cholinergic and the least likely to exacerbate orthostatic hypotension that occurs during pregnancy.

Bupropion may be an option for women who have not responded to fluoxetine or a tricyclic antidepressant, as data thus far have not indicated an increased risk of malformations associated with bupropion use during pregnancy. The most recent information from the Bupropion Pregnancy Registry maintained by the manufacturer GlaxoSmithKline includes data from 517 pregnancies involving first trimester exposure to bupropion. In this sample, there were 20 infants with major malformations. This represents a 3.9% risk of congenital malformation that is consistent with what is observed in women with no known teratogen exposure. While this information regarding the overall risk of malformation is reassuring, earlier reports had revealed an unexpectedly high number of malformations of the heart and great vessels in bupropion-exposed infants. A retrospective cohort study including over 1200 infants exposed to bupropion during the first trimester did not reveal an increased risk of malformations in the bupropion-exposed group of infants nor did it demonstrate an increased risk for cardiovascular malformations.

Scant information is available regarding the reproductive safety of monoamine oxidase inhibitors (MAOIs), and these agents are generally not used in pregnancy as they may produce a hypertensive crisis when combined with tocolytic medications, such as terbutaline.

With regard to the newer antidepressants, prospective data on 150 women exposed to venlafaxine (Effexor) during the first trimester of pregnancy suggest no increase in risk of major malformation as compared to non-exposed controls. To date, the literature does not include prospective data on the use of duloxetine (Cymbalta).

Another prospective study assessed outcomes in 147 women taking either nefazodone (n=89) or trazodone (n=58) during their first trimester of pregnancy and compared them to two control groups of women exposed to either non-teratogenic drugs (n = 147) or to other antidepressants (n=147). There were no significant differences among exposed and non-exposed groups with regard to rates of congenital malformations. In another report, there were no differences in malformation rates among women who took mirtazapine (Remeron) (n=104) during pregnancy as compared to women who took other antidepressants or controls exposed to known nonteratogens.

While these initial reports are reassuring, larger samples are required to establish the reproductive safety of these newer antidepressants. It is estimated that at least 500 to 600 exposures must be collected to demonstrate a two-fold increase in risk for a particular malformation over what is observed in the general population. In general, the SSRIs, specifically fluoxetine, citalopram, and sertraline, are the antidepressants most commonly used during pregnancy.

Several recent studies have suggested that exposure to SSRIs near the time of delivery may be associated with poor perinatal outcomes. Attention has focused on a range of transient neonatal distress syndromes associated with exposure to (or withdrawal from) antidepressants in utero. These syndromes appear to affect about 25% of babies exposed to antidepressants late in pregnancy. The most commonly reported symptoms in the newborns include tremor, restlessness, increased muscle tone, and increased crying. Reassuringly, these syndromes appear to be relatively benign and short-lived, resolving within 1 to 4 days after birth without any specific medical intervention.

These studies deserve careful consideration, yet one of the major shortcomings is that most have failed to use raters blinded to the mother's treatment status. The decision to admit a newborn to a special care nursery may represent a reasonable precaution for an infant exposed to medication in utero and may not be an indication of a serious problem. Another limitation is that few studies have attempted to assess maternal mood during pregnancy or at the time of delivery. There is ample evidence to suggest that depression or anxiety in the mother may contribute to poor neonatal outcomes, including premature delivery and low birth weight, and it is important to evaluate the contribution of maternal mood to neonatal outcomes.

Based on these findings, many women are advised to taper or discontinue treatment with SSRIs prior to delivery; however, this strategy has not been shown to change neonatal outcomes. Importantly, neonatal effects have been reported with both untreated mood and anxiety disorders, as well as with medication, and limited studies have adequately teased out these variables. One important consideration is that discontinuation of or reductions in the dosage of mediation in the latter part of pregnancy may increase the risk of postpartum depression, as the postpartum period is a time of increased vulnerability to psychiatric illness and depression or anxiety during pregnancy has been associated with postpartum depression.

Another concern has been that maternal SSRI use may be associated with a higher than expected number of cases of persistent pulmonary hypertension of the newborn (PPHN). In one report, the use of an SSRI antidepressant after the 20th week of gestation was significantly associated with a six-fold greater risk of PPHN. If we assume that these findings are correct, the risk is still relatively small; the authors estimate the risk of PPHN to be less than 1% in infants exposed to SSRIs in utero. Since the initial report on this topic, three studies have found no association between antidepressant use during pregnancy and PPHN, and one study showed a much lower risk than the 1% originally reported. These findings taken together bring into question whether there is an association at all and suggest that, if there is a risk, it is much lower than that reported in the original 2006 report.

To date only two studies have systematically investigated the impact of exposure to antidepressants in utero on development and behavior in humans. The first of these studies followed a cohort of 135 children who had been exposed to either tricyclic antidepressants or fluoxetine (Prozac) during pregnancy (most commonly during the first trimester) and compared these subjects to a cohort of non-exposed controls. Results indicated no significant differences in IQ, temperament, behavior, reactivity, mood, distractibility, or activity level between exposed and non-exposed children followed up to 7 years of age. A more recent report from the same group that followed a cohort of children exposed to fluoxetine or tricyclic antidepressants for the entire duration of the pregnancy yielded similar results. The authors concluded that their findings support the hypothesis that fluoxetine and tricyclic antidepressants are not behavioral teratogens and do not have a significant effect on cognitive development, language or behavior.

Mood Stabilizers

For women with bipolar disorder, maintenance treatment with a mood stabilizer during pregnancy can significantly reduce the risk of relapse. However, many of the medications commonly used to treat bipolar disorder carry some teratogenic risk when used during pregnancy.

Concerns regarding fetal exposure to lithium, have typically been based on early reports of higher rates of cardiovascular malformations (e.g., Ebstein's anomaly) following prenatal exposure to this drug. More recent data suggest the risk of cardiovascular malformations following first trimester exposure to lithium is smaller than previous assessments and is estimated to be between 1 in 2000 (0.05%) and 1 in 1000 (0.1%). Compared to lithium, prenatal exposure to some anticonvulsants is associated with a far greater risk for organ malformation. First trimester use of carbamazepine (Tegretol) has been associated with a 1% risk of neural tube defect. Of all of the medications used for psychiatric disorders, the one with the greatest potential of serious birth defects is valproate (valproic acid, Depakote). Factors which appear to increase the risk for teratogenesis include higher maternal serum anticonvulsant levels and exposure to more than one anticonvulsant. With a risk of neural tube defect ranging from 1 to 6%, this drug is often considered one of last resort in reproductive aged women, since the risk for teratogenicity is high in very early pregnancy, before many women realize they are pregnant.

Prenatal exposure to valproic acid has also been associated with characteristic craniofacial abnormalities, cardiovascular malformation, limb defects and genital anomalies, as well as other central nervous system structural abnormalities. Also, valproate exposure during pregnancy has been associated with poorer neurocognitive development in children followed to three years of age. In the same study, lamotrigine use (discussed below) did not affect neurocognitive development.

While other anticonvulsants are being used more frequently in the treatment of bipolar disorder, there is limited information on the reproductive safety of these newer anticonvulsants, specifically gabapentin (Neurontin), oxcarbazepine (Trileptal), tigabine (Gabitril), levetiracetam (Keppra), zonisamide (Zonegran). One report has raised concerns regarding potential teratogenicity of topiramate (Topamax).

However, there is a growing body of information the reproductive safety of lamotrigine (Lamictal), and this may be a useful alternative for some women. The International Lamotrigine Pregnancy Registry was created by GlaxoSmithKline (GSK) in 1992 to monitor pregnancies exposed to lamotrigine for the occurrence of major birth defects. Data from the Registry did not show an elevated risk of malformations associated with lamotrigine exposure.

Other data from the North-American Anti-Epileptic Drug Registry indicates the prevalence of major malformations in a total of 564 children exposed to lamotrigine monotherapy was 2.7%; however, five infants had oral clefts, indicating a prevalence rate of 8.9 per 1000 births. In a comparison group of 221,746 unexposed births, the prevalence rate for oral clefts was 0.37/1000, indicating a 24-fold increase in risk of oral cleft in infants exposed to lamotrigine. However, other registries have not demonstrated such a significant increase in risk for oral clefts. It is important to put this risk into perspective. If we assume that the findings from the North American registry are true, the absolute risk of having a child with cleft lip or palate is about 0.9%.

Atypical antipsychotic agents (discussed in greater detail below) are commonly used often to manage the acute symptoms of bipolar illness, as well as for maintenance treatment. While the data regarding the reproductive safety of these newer agents is limited, no studies thus far have indicated any teratogenic risk associated with this class of medications. For this reason, some women may choose to use an atypical antipsychotic agent during pregnancy (especially during the first trimester) in order to avoid using a known teratogen, such as lithium or valproic acid.

Anti-Anxiety Medications

The consequences of prenatal exposure to benzodiazepines have been debated for over twenty years. Three prospective studies support the absence of increased risk of organ malformation following first trimester exposure to benzodiazepines. More controversial has been the issue of whether first trimester exposure to benzodiazepines increases risk for specific malformations. Although initial reports suggested that there may be an increased risk of cleft lip and palate, more recent reports have shown no association between exposure to benzodiazepines and risk for cleft lip or palate. This risk- if it exists - is calculated to be 0.7%, approximately a ten-fold increase in risk for oral cleft over that observed in the general population. Nonetheless, the likelihood that a woman exposed to benzodiazepines during the first trimester will give birth to a child with this congenital anomaly, although significantly increased, remains less than 1%.

Currently, no systematic data are available on the reproductive safety of non-benzodiazepine anxiolytic agents such as buspirone and hypnotic agents zolpidem (Ambien) and zalepion (Sonata). Therefore, these medications are not recommended for use in pregnancy.

Anti-Psychotic Medications

In addition to the atypical antipsychotic medications described above, recent studies have not demonstrated teratogenic risk associated with high-or medium-potency neuroleptic medications; however, a recent meta-analysis of the available studies noted a higher risk of congenital malformations after first trimester exposure to low-potency neuroleptic agents. In clinical practice, higher potency neuroleptic agents such as haloperidol (Haldol), perphenazine (Trilafon), and trifluoperazine (Stelazine) are recommended over the lower potency agents in managing pregnant women with psychiatric illness.

Atypical antipsychotic medications are increasingly being used to treat a spectrum of psychiatric disorders, including psychotic disorders and bipolar disorder, as well as treatment refractory depression and anxiety disorders. The first and largest published prospective study on the reproductive safety of the atypical agents provided reassuring data regarding the risk of malformations in the first trimester, although aripiprazole (Abilify) was not among the medications studied. Investigators prospectively followed a group of 151 women taking olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), or clozapine (Clozapine) and compared outcomes to controls without exposure to known teratogens. There were no differences between the groups in terms of risk for major malformations, or rates of obstetrical or neonatal complications.

While this information is reassuring, it is far from definitive, and larger studies are required to provide more information about the reproductive safety of these medications. To this end, the National Pregnancy Registry has been created to prospectively gather information regarding outcomes in infants exposed in utero to these newer atypical antipsychotic medications.

The U.S. Food and Drug Administration (FDA) recently updated labels for the entire class of antipsychotic drugs to include warnings regarding the use of antipsychotic drugs (both the typical and atypical agents) during pregnancy. The new drug labels now contain more details on the potential risk for abnormal muscle movements (extrapyramidal signs or EPS) and withdrawal symptoms in newborns exposed to these drugs during the third trimester of pregnancy. These recommendations were derived from adverse event reporting. While this may signal a potential problem associated with exposure to antipsychotic medications, it does not yield accurate information regarding the prevalence of an adverse event.

For the latest information on psychiatric disorders during pregnancy, please visit our blog.

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Pregnancy Research at the CWMH

Currently we are conducting several studies related to depression and pregnancy. To learn more about this study or to sign up for our research patient registry, please click here

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Although pregnancy has typically been considered a time of emotional well-being, recent studies suggest that up to 20% of women suffer from mood or anxiety disorders during pregnancy. Particularly vulnerable are those women with histories of psychiatric illness who discontinue psychotropic medications during pregnancy.

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Postpartum depression (PPD) is a major form of depression and is less common than postpartum blues. PPD includes all the symptoms of depression but occurs only following childbirth. It can begin any time after delivery and can last up to a year. PPD is estimated to occur in approximately 10 to 20 percent of new mothers.

What are the symptoms of PPD?

Symptoms of PPD are the same as those for clinical depression and may include specific fears such as excessive preoccupation with the child's health or intrusive thoughts of harming the baby. Given the stressful circumstances of caring for a new baby, it is understandable that new mothers may be more tired, irritable and anxious. But when a new mother is experiencing drastic changes in motivation, appetite or mood she should seek the help of a mental health professional. For a clinical diagnosis of postpartum depression to be made, symptoms of PPD generally must be present for more than two weeks following childbirth to distinguish them from postpartum blues.

What are the factors that contribute to PPD?

The causes of PPD are not quite clear but research suggests that the following factors may contribute to the onset of PPD:

Hormonal changes: A woman experiences the greatest hormonal fluctuation levels after giving birth. Intense hormone fluctuations, such as decreased serotonin levels, occur after delivery and may play a role in the development of PPD.

Situational risks: Childbirth itself is a major life change and transition, and big changes can cause a great deal of stress and result in depression. If a major event coincides with childbirth, a mother may be more susceptible than average to PPD.

Life Stresses: Ongoing stressful circumstances can compound the pressures of having a new baby and may trigger PPD. For example, excessive stress at the office added to the responsibilities of being a mother can cause emotional strain that could lead to PPD. The nature of the mother's relationship with the baby's father and any unresolved feelings about the pregnancy might also affect a mother's risk of getting PPD.

What treatments are available?

Taking antidepressant medication may help alleviate the symptoms of PPD and should be combined with ongoing counseling with a therapist trained in issues surrounding childbirth. It is always important for a woman to discuss any potential side effects an antidepressant drug may have on herself or her baby. Studies show that some antidepressant medications have no harmful effects on breastfeeding infants. Psychotherapy alone may also be used to treat PPD. New mothers should be encouraged to talk about their feelings or fears with others. Socializing through support groups and with friends can play a critical role in recovery. Exercise and good nutrition may improve a new mother's mood and also aid in recovery. Caffeine (while tempting to exhausted new moms) should be avoided because it can trigger anxiety and mood changes.

Can PPD lead to other problems?

When a new mother has severe depression, the vital mother-child relationship may become strained. She may be less able to respond to her child's needs. Several studies have shown that the more depressed a new mother is, the greater the delay in the infant's development. A new mother's attention to her newborn is particularly important immediately following birth because the first year of life is a critical time in cognitive development.

Is PPD preventable?

In most cases PPD is preventable; early identification can lead to early treatment. A major part of prevention is being informed about the risk factors and the medical community can play a key role in identifying and treating PPD. Women should be screened by their physician to determine their risk for acquiring PPD. Because social support is also a vital factor in prevention, early identification of mothers who are at risk can enable a woman to seek support from physicians, partners, friends, and coworkers.

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Postpartum depression (PPD) is a major form of depression and is less common than postpartum blues. PPD includes all the symptoms of depression but occurs only following childbirth. It can begin any time after delivery and can last up to a year. PPD is estimated to occur in approximately 10 to 20 percent of new mothers.

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Postpartum depression - Symptoms and causes

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Learn the risk factors and symptoms of depression in new mothers, as well as effective treatment that can help you manage symptoms and bond with your baby.

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Pregnancy brings a mix of feelings, and not all of them are good. If you're feeling worried, you're not alone. Worry is common, especially during a woman's first pregnancy or an unplanned one. It can be even harder if you're dealing with depression or anxiety.

For your health and your baby's, take care of yourself as much as you can. Be sure to eat well, exercise, get enough sleep, and take your prenatal vitamins.

If you're feeling worried, sad, or nervous, talk to someone about it - and know when to reach out for help.

What Feelings Can Happen?

Mood swings are normal during pregnancy. But if you feel nervous or down all the time, it could be a sign of something deeper going on. Stress over being pregnant, changes in your body during the pregnancy, and everyday worries can take a toll.

Some pregnant women may have depression or anxiety:

Depression is sadness or feeling down or irritable for weeks or months at a time. Some women may have depression before getting pregnant. But it also can start during pregnancy for a number of reasons - for example, if a woman isn't happy about being pregnant or is dealing with a lot of stress at work or at home.

Anxiety is a feeling of worry or fear over things that might happen. If you worry a lot anyway, many things can stress you out during pregnancy. You might worry that you won't be a good mother or that you can't afford to raise a baby.

Pregnant women may have other mental health issues, such as:

It's important to treat mental health concerns during pregnancy. Mothers who are depressed, anxious, or have another issue might not get the medical care they need. They might not take care of themselves, or they may use drugs and alcohol during the pregnancy. All of these things can harm a growing baby.

If you have a mental health issue, talk with your doctor so you can get the help you need during and after your pregnancy.

How Can I Get Help?

If you feel anxious or depressed, talk to a doctor, counselor, or therapist, and get help right away. The sooner treatment starts, the sooner you'll feel better.

Also talk to a doctor about your overall health and any mental health issues you've had in the past. It's best for your doctor to know your full medical history, in case anything comes up during or after your pregnancy.

How Are Problems Treated?

Treatment for mental health problems may include:

Prescription medicine. Always talk to a doctor before you start taking - or stop taking - any medicines during your pregnancy. If you take any kind of medicine for a mental health issue and are pregnant or planning to get pregnant, tell your doctor. Don't stop taking it unless your doctor tells you to. Some medicines may cause problems for a growing baby, but stopping your medicine may make things worse. Your doctor can make a treatment plan that is best for you and your baby.

Talk therapy. Talking one-on-one with a therapist can be a great way to manage stress, deal with depression, and ease anxiety during pregnancy. Finding a support group where you can share your concerns with other mothers who know what you're going through also can help. Talking with a social worker or counselor can help you deal with money issues, worries over raising a child, or other stresses in your life.

Other approaches. Many women find comfort in activities like yoga, exercise, and meditation. If you're feeling stressed or overwhelmed, talking to a friend, family member, or faith leader can help you feel better.

Many moms feel anxious or depressed at some point in their pregnancy, and some may even need treatment for it. But a mental health problem doesn't have to be a problem for you or your baby. Get the help you need to feel better, and you'll be doing the best thing for you both.

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Taking Care of Your Mental Health During Pregnancy

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Pregnancy brings a mix of feelings, and not all of them are good. If you're feeling worried, you're not alone. Worry is common, especially during a woman's first pregnancy or an unplanned one. It can be even harder if you're dealing with depression or anxiety.

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Author: Healthwise Staff

Medical Review: Sarah Marshall MD - Family Medicine & Kathleen Romito MD - Family Medicine & Adam Husney MD - Family Medicine & Kirtly Jones MD - Obstetrics and Gynecology

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encounter due to first normal pregnancy supervision

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Pregnancy prompts your body to make lots of hormones. These hormones can affect your mind and your body. It's common to feel tired, forgetful, or moody. And you also may be focused on other things, like body changes, symptoms, money worries, and all the ways your life is about to change.