Pregnancy and Childbirth

Although pregnancy has typically been considered a time of emotional well-being, recent studies suggest that about 20 percent of pregnant women experience mood or anxiety disorders and about 10 percent develop major depression during pregnancy. Women with histories of mood or anxiety disorders who discontinue psychiatric medications during pregnancy are particularly vulnerable.

During the postpartum period, about 85 percent of women experience some type of mood disturbance. For most women, the symptoms are mild and short-lived; however, 10 to 15 percent of women develop more significant symptoms of depression or anxiety. Postpartum psychiatric illness is typically divided into three categories: postpartum “blues,” postpartum depression, and postpartum psychosis.

It may be useful to think of these disorders on a spectrum, where postpartum blues is the mildest and postpartum psychosis is the most severe form of postpartum psychiatric illness.

• Postpartum “blues” are experienced by about 50 to 85 percent of women during the first few weeks after delivery. This type of mood disturbance is so common that it may be more accurate to consider the blues as a normal experience following childbirth rather than a psychiatric illness. Women with postpartum blues commonly report ups and downs in their mood, plus tearfulness, and anxiety or irritability. These symptoms typically peak on the fourth or fifth day after delivery and may last for a few hours or a few days, disappearing spontaneously within two weeks of delivery.
  
  
• Postpartum depression (PPD) typically emerges during the first two to three postpartum months but may occur at any point after delivery. Some women actually note the onset of milder depressive symptoms during pregnancy.
  
  Postpartum depression is clinically indistinguishable from depression that occurs at other times in a woman’s life. The symptoms of postpartum depression include: depressed or sad mood, tearfulness, loss of interest in usual activities, feelings of guilt, feelings of worthlessness or incompetence, fatigue, sleep disturbance, change in appetite, poor concentration, and suicidal thoughts. Significant anxiety symptoms may also occur. Generalized anxiety is common, but some women also develop panic attacks or hypochondriasis (persistent and unresolvable worries about an imagined health problem). Postpartum obsessive-compulsive symptoms have also been reported, where women report disturbing and intrusive thoughts of harming their infant.
  
  
• Postpartum psychosis is the most severe form of postpartum psychiatric illness. It occurs rarely, in approximately 1-2 individuals per 1000 women following childbirth. Its emergence is often dramatic, with onset of symptoms as early as the first 48 to 72 hours after delivery. The majority of women with psychosis following delivery develop symptoms within the first two weeks following childbirth.
  
  In many cases, postpartum psychosis may actually represent an episode of bipolar disorder, and the symptoms of psychosis following delivery most closely resemble those of a manic or mixed episode (see the section above on bipolar disorder). The earliest signs are restlessness, irritability, and insomnia. Women with this disorder exhibit a rapidly changing depressed or elated (happy) mood, disorientation or confusion, and erratic or disorganized behavior. Delusions (beliefs that are untrue that cannot be reassured or dispelled) are common and often center on the infant. Auditory hallucinations (voices) that instruct the mother to harm herself or her infant may also occur. For these reasons, there is often high risk for suicide as well as risk of harm to the newborn from the mother in postpartum psychosis. A woman who has delusions or hallucinations following childbirth requires immediate attention from a trained professional.

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Treatments During & After Pregnancy

A woman who is pregnant, or planning to become pregnant, should consult her doctor about the risks and benefits of treatment during and after pregnancy.

• Pregnancy. Data accumulated over the last 30 years suggest that certain psychiatric medications may be used to treat mood or anxiety disorders during pregnancy without significant risk to the fetus. Treatment decisions vary and depend on the woman’s overall health, any history of previous mental health disorders, and the perceived benefits and risks of treatment. Psychotherapy may be helpful for alleviating symptoms of depression and anxiety and may allow a woman to discontinue treatment with medications. However, women with severe or recurrent depression may elect to maintain treatment with medication throughout pregnancy. Electroconvulsive therapy is sometimes used during pregnancy, instead of medication, for those with severe or difficult to treat depression.
  
  
• Postpartum "blues." While these symptoms are unpredictable and often unsettling, they do not interfere with a woman’s ability to function. No specific treatment is usually required; however, it should be noted that sometimes these changes in mood herald the development of a more significant mood disorder, particularly in women who already have a history of depression. If symptoms of the blues last for longer than two weeks, an evaluation to rule out a more serious mood disorder is warranted.
  
  
• Postpartum Depression (PPD). Treatment for postpartum depression may involve the use of antidepressants, anti-anxiety medications, psychotherapy, or a combination of these. Women who are breast-feeding should consult a trained specialist regarding the relative risks and benefits of using medications for mood and anxiety disorders during breast-feeding; the overall risk of adverse events appears to be relatively low.
  
  
• Postpartum psychosis. The treatment of postpartum psychosis often involves the use of antipsychotic medications. Women who are breast-feeding should consult a trained specialist about the risks and benefits of using medications during breast-feeding to treat the disorder.

Helpful information about specific medications can be found at www.medlineplus.gov (click on "Drugs and Supplements").

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