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The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of .25 AMA PRA category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.

Melanie Cole (Host):  Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I’m Melanie Cole. Today we’re discussing postpartum depression. We’re going to learn the difference between postpartum blues and postpartum depression. We’re going to examine treatment options for and help identify the risk, benefit, alternatives and indicators for selective serotonin reuptake inhibitors in the treatment of postpartum depression. Joining me is Dr. Dikea Roussos-Ross. She’s the Associate Professor in the department of Obstetrics and Gynecology and the department of Psychiatry, at the UF College of Medicine.

Welcome to the show Dr. Roussos-Ross. Thank you for joining us. Tell us a little bit about the incidence of postpartum blues and depression. What are we seeing in the trends?

Dikea Roussos-Ross, MD (Guest):  When we look at the incidence of postpartum depression, the incidence is actually pretty staggering. It’s up to 20% of all women who are pregnant will have postpartum depression. That in fact, is two our of ten women. So, despite the fact that a lot of times we may not note it in our clinical practice; it doesn’t mean it doesn’t exist in our clinical practice. It just means that we haven’t identified it. There are certainly many reasons for that lack of identification and there are many things that we can do to improve that.

Host:  Well then let’s start with the difference between the various postpartum mood disorders. Tell us about postpartum blues, and postpartum depression and give us a little overview of the difference.

Dr. Roussos-Ross:  So, postpartum blues is extremely common. Up to 85% of women will have postpartum blues. So, about eight to nine out of ten women in the postpartum period. The most important thing to remember about postpartum blues is that it really does always go away as long as it remains postpartum blues and doesn’t develop into postpartum depression or wasn’t misclassified as blues when it was actually depression.

The symptoms of postpartum blues look very similar to the symptoms of postpartum depression. Women are frequently crying, they may irritable, they are not sleeping well, they are not eating well, they may not be able to concentrate well or do things that bring joy to them. Many times, because they’re overwhelmed because they have a new baby at home and it certainly changes family dynamic. If it’s their first child, it changes dynamic in the home between they and their partner or if they are on their own a new sort of person to take care of. If they have other children in the home, again, there’s a change in dynamic. So, anytime there’s a new stressor in this case a happy stressor of having a baby; there can be symptoms that happen that bring on that postpartum blues.

Usually those symptoms will show up around day two to three to four of life of the baby and always they should be gone by two weeks postpartum. I like to always offer clinical pearls to people and the one main clinical pearl that I can offer when you’re trying to determine between postpartum blues and postpartum depression; there is only one thing that you could ask. That would be for me, 51% of the time are you happy or sad. If women say 51% of the time in that first two week postpartum period, they are happy, odds are that their symptoms are probably just postpartum blues. If 51% of the time or more they feel like they are sad, then you really need to look further, and you really need to investigate postpartum depression. Perhaps their symptoms were ongoing during pregnancy, but they didn’t talk to you about them. Maybe they showed up late in that third trimester and didn’t realize what was happening. But very important to ask that question in my opinion.

Now the good news with postpartum blues is again, it will resolve on its own, but it does involve some things that we could help patients with. Social support is very important. And being able to help the patient identify people in their lives that might be able to help is crucial. So, doing things like even using paper plates and plastic forks and knives where they don’t have to worry about doing dishes. Asking people form their community to help with meal prep. Anything like that can also be helpful. Letting them know that they don’t have to be perfect and that their home doesn’t have to be spotless. All those things are really, really important. Having family members or family or friends that can help watch the baby so mom can get a little bit of sleep is also imperative. Sleep is one of the most important things that are overlooked as far as mood disorders go. And having good sleep really will help people be able to work through and deal with the stressors that are ongoing.

Now you contrast that with postpartum depression which really meets criteria for depression, mild, moderate or severe depression in the general population. Those symptoms again, should be ongoing for at least a two week period. Additionally, one of those symptoms that they are having should be depressed mood or anhedonia. Anhedonia really means a decrease in interest. And then other symptoms may include changes in their sleep, changes in their appetite, poor concentration, poor interest, feelings of guilt. It can also include psychomotor agitation or retardation and that means just either feeling really fidgety and busy or feeling like you just can’t get off the couch or feel like a bump on a log. And certainly, if they have any symptoms of suicidality, thoughts of hurting themselves or hurting someone else; all those symptoms are really important.

In order to meet criteria for depression, patients have to have five of nine symptoms for at least a two week period. Again, one of those five being depressed mood or anhedonia. There are different ways that we can screen women to determine whether they have symptoms congruent with depression. That would make us want to look further and actually do an actual diagnosis of. These questionnaires that are offered to patients are for example, the Edinburgh Postnatal Depression Scale, the PHQ9 is also another good alternative.

The important thing and the helpful thing for clinicians is that these are self-administered patient questionnaires. Meaning that the clinician doesn’t have to be in there asking the patients the questions. The patient can actually do that while they are in the waiting room or while they’re waiting for the provider to enter the exam room. These questionnaires are easily scored by either medical assistant, nurse or the provider themselves. And there’s very good literature and very good data out there showing that the scores really are indicative of patients who end up having depression in the future or based on that questionnaire. So, for example, on the Edinburgh Postnatal Depression Scale, a score of 12 or higher should really alert the physician to the fact that this patient likely does have depression and so that would prompt them to ask those questions that we discussed earlier to see if they meet criteria for.

And then once we identify a woman, then there’s lots of different forms of treatment that we can offer. Depending on the severity of her depression, depending on what sort of treatment she would be interested in and certainly depending on what she can do. A lot of times, women may or may not be able to attend therapy because of their work schedule or because of funding and so, there’s lots of different options for treatment of depression. In my opinion, for the treatment of mild depression, therapy would be first line. For the treatment of moderate to severe depression; I recommend a combination of medication management and therapy.

Regarding therapy, interpersonal therapy is really the gold standard for postpartum depression, but cognitive behavioral therapy or CBT is also an excellent form of treatment. Ideally, women would be able to see providers who are focused on postpartum depression. That may not always be available in all communities. Thus having a therapist of any type really doing those main types of therapy interpersonal therapy or cognitive behavioral therapy would be ideal.

Now with regards to medication management; the standard is really to use an SSRI or serotonin reuptake inhibitor in order to treat women with postpartum depression. The reason we choose these as first line is because they’ve been extensively studied in pregnant and postpartum women. They also are less likely to have side effects as compared to other medications that have similarly been studied such as TCAs or tricyclic antidepressants.

With regards to SSRIs in pregnancy, many time patients will certainly be concerned about exposing their newborn or their fetus to antidepressants. And so, it’s important for the clinician to feel comfortable and well-versed in treatment options and into the possible risks of placing a woman on medication management for her depression. Additionally, the clinician needs to consider how lactation may play a role in this. Many times, if women are breastfeeding in the postpartum period; they may be concerned about the baby being exposed to medications through the breast milk.

With regards to that, there are excellent studies available that really show that the SSRIs in general, go through the breast milk at very, very low to undetectable levels. Thus there is no reason to pump and dump. There is no reason to avoid medications in lactating women for fear of exposure. Always, it’s important for the mother to allow the pediatrician to know that she is breastfeeding and using and antidepressant for that rare situation where there might be some sort of side effect to the baby. But again, that would be an extremely rare situation.

With regards to things that the clinician should discuss with a mother related to risks and benefits of antidepressant use in pregnancy or postpartum; there are four main things that we like to discuss. And those are the risk of congenital malformation in the baby is they are exposed in utero, the risk of neonatal adaptation syndrome or withdrawal type syndrome if again, they are using the antidepressant in the third trimester and then the baby doesn’t have exposure after delivery, the risk of persistent pulmonary hypertension of the neonate and learning or behavioral neural behavioral affects of the newborn.

So, in the general population, not exposed to any antidepressants in pregnancy the risk of congenital malformations is around two to four percent. Patients exposed to antidepressants in pregnancy, the risk of congenital malformation in the newborn is anywhere from two to four percent to three to five percent. So, essentially no change from the baseline.

With regards to neonatal adaptation syndrome or withdrawal type syndrome; I like to quote approximately 30% or three out of ten babies may have this neonatal adaptation syndrome. And that typically looks like a baby who might be a little bit jittery, have a little issue with tone, maybe some feeding difficulties. The important thing to note with this is that always those symptoms are self-limited, and they always go away by day three to five of life. And so, mom at this point really needs to decide for herself what worse for her. Is it worse for her to be exposed to an antidepressant and potentially have a baby that may have this neonatal adaptation syndrome or is it worse for her to give birth at the time where she’s moderately to severely depressed which may affect her ability to bond with the baby, attach with the baby and cause other issues.

With regards to the persistent pulmonary hypertension of the neonate; which simply is a heart lung sort of disorder; in the general population, about one to two out of 1000 babies may have this without any exposure to any antidepressant. In babies exposed to antidepressants in utero; depending on the study anywhere from one to twelve out of 1000 babies may have this. Again, not a very large change and maybe up to a 1% increased risk but again, this is a pretty rare occurrence.

Finally, with regards to neurobehavioral effects; this is really important. There’s very good studies that show that if a mom gives birth to a baby while mom is moderately to severely depressed; that baby again will have problems with bonding, attachments and learning. Not because mom doesn’t love that baby and want to nurture and teach that baby but because she’s not doing well herself and so she doesn’t have the ability to kind of nurture and respond to the baby as she otherwise would. So, then what about if we expose that baby to an antidepressant? Is that baby more likely to have behavioral issues or learning issues or psychiatric issues? And the answer to that is no, we’ve got really good data to show longitudinally that babies exposed to antidepressants in pregnancy have no more of an increased risk of depression or anxiety and in fact, they have no change in their IQ whereas babies born to moms who are untreated may have a decrease in their IQ. And so, overall, it is my opinion, that medication management with an SSRI would actually be appropriate and would be deemed in general, safe in pregnancy and in lactation and in the postpartum period.

Again, this isn’t a decision that we can make for mom. Our role is to educate mom so that she can make the best decision for herself and her baby.

Host:  Thank you so much Doctor, for joining us today and sharing your incredible expertise for other providers. That concludes today’s episode of UF Health MedEd Cast with UF Health Shands Hospital. To learn more about this and other healthcare topics at UF Health Shands Hospital please visit www.ufhealth.org/medmatters to get connected with one of our providers. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. For more health tips and updates follow us on your social channels. I’m Melanie Cole.