Evidence-Based Reviews

Postpartum depression or medical problem?

Current Psychiatry. 2006 September;5(9):62-75

References

1. Miller LJ. Postpartum depression. JAMA 2002;287:762-5.

2. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000:204.

3. Burt V, Hendrick V. Clinical manual of women’s mental health. Arlington, VA: American Psychiatric Publishing; 2005:79-100.

4. Franko DL, Blais MA, Becker AE, et al. Pregnancy complications and neonatal outcomes in women with eating disorders. Am J Psychiatry 2001;158:1461-6.

5. Berga SL, Parry BL, Cyranowski JL. Psychiatry and reproductive medicine. In: Sadock BJ, Sadock VA, eds. Comprehensive textbook of psychiatry, 8th ed. Philadelphia: Lippincott Williams & Wilkins; 2005.

6. Altshuler LL, Hendrick V, Cohen L. An update on mood and anxiety disorders during pregnancy and the postpartum period. Prim Care Companion J Clin Psychiatry 2000;2:217-22.

7. Chaudron LH. Pies RW: The relationship between postpartum psychosis and bipolar disorder: A review. J Clin Psychiatry 2003;64:1284-92.

8. Cox JL, Holden JM, Sagvosky R. Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987;150:782-6.

9. Atkinson LS, Baxley EG. Postpartum fatigue. Am Fam Physician 1994;50:113-18.

10. Kaaja RJ, Greer IA. Manifestations of chronic disease during pregnancy. JAMA 2005;294:2751-7.

11. Stagnaro-Green A. Postpartum thyroiditis. Best Pract Res Clin Endocrinol Metab 2004;18:303-16.

12. Stowell CP, Barnhill JW. Acute mania in the setting of severe hypothyroidism. Psychosomatics 2005;46:259-61.

13. Sadock BJ, Sadock VA. Consultation-liaison psychiatry (Chapter 284). In: Synopsis of psychiatry, 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2003:844-7.

14. Karnad DR, Guntupalli KK. Neurologic disorders in pregnancy. Crit Care Med 2005;33:S362-S371.

15. Vukusic S, Confavreux C. Multiple sclerosis and pregnancy. Rev Neurol 2006;162:299-309.

16. Kaufman DM. Clinical Neurology for Psychiatrists. Philadelphia: WB Saunders; 2001.

17. Ramirez C, de Seze J, Delrieu O, et al. [Myasthenia gravis and pregnancy: clinical course and management of delivery and the postpartum phase.] Rev Neurol (Paris) 2006;162:330-8 (French).

18. Weitzner MA, Kanfer S, Booth-Jones M. Apathy and pituitary disease: it has nothing to do with depression. J Neuropsychiatry Clin Neurosci 2005;17:159-66.

19. Peselow E. Other pharmacological and biological therapies. In: Sadock BJ, Sadock VA, eds. Comprehensive textbook of psychiatry, 8th ed. Philadelphia: Lippincott Williams & Wilkins; 2005.

20. Kasper DL, Braunwald E, Fauci A, et al. Harrison’s principles of internal medicine, 16th ed. New York: McGraw-Hill; 2004.

21. Ohba K, Omagari K, Kusakari C, et al. Flare-up of autoimmune hepatitis after delivery in a patient with primary biliary irrhosis: postpartum overlap syndrome of primary biliary cirrhosis and autoimmune hepatitis. Dig Dis Sci 2005;50:201-6.

Recognizing the following disorders’ physical signs is key to uncovering a medical cause for postpartum depressive symptoms.

Thyroid disease. Postpartum thyroiditis (PPT) can occur 1 to 3 months after delivery,¹⁰ often recurs after subsequent pregnancies,¹¹ and can progress to permanent hypothyroidism within 5 years.¹⁰ Hypothyroidism can cause cognitive slowing, depression, and psychosis, and acute mania has been reported with severe hypothyroidism secondary to PPT.¹²

Find out if the patient tested positive early in gestation for thyroid antibodies, as this may predict postpartum depression.

Multiple sclerosis (MS) can cause anxiety, mania, depression, and cognitive impairment.¹³ Drugs used to treat MS—such as steroids or interferon—can induce depression.

Relapses are infrequent during pregnancy but increase significantly within 3 months after giving birth¹⁴ in about one-third of women with active MS before pregnancy.¹⁵ Gait ataxia, sensory loss, numbness, hyperactive reflexes or spasticity, bladder dysfunction, visual impairment, disordered ocular motility, and fatigue are prominent clinical signs of MS.¹⁶

Myasthenia gravis (MG). Women who become pregnant within 1 year after diagnosis run a high risk of MG exacerbation.¹⁷

Fatigue and muscular weakness caused by MG can mimic depression, and adjusting to this debilitating illness can cause depression. Double vision, droopy eyelids, and muscle weakness alleviated by rest but worsened by activity are pathognomonic signs.¹⁶

Other neurologic diseases. Pre-existing seizure disorders can worsen after giving birth and cause depression.¹⁴

Subtle presentations of brain tumors include cognitive deficits, mood disturbance, and personality change. A left frontal lobe tumor can cause depression.

Ask the patient if she has had headaches, visual symptoms, vomiting, seizures, or focal neurologic deficits—any of these could signal a primary brain tumor or intracranial hemorrhage.

Prolactinomas, the most common pituitary tumor in pregnant and postpartum women, enlarge during pregnancy and regress after delivery.¹⁴ Depression, anxiety, apathy, and personality changes may stem from the pituitary tumor, its treatment, or changes in the hypothalamic-pituitary-end organ axis.¹⁸ Typical amenorrhea-galactorrhea syndrome resembles postpartum physiologic changes.

Headaches are common, and compression of the optic chiasm with macrodenomas causes visual field changes.

Systemic lupus erythematosus (SLE), most prevalent in young women, might flare during pregnancy and within 6 weeks after giving birth.¹¹ Headaches, seizures, or cerebrovascular events with comorbid mood disorders, delirium, dementia, psychosis, or anxiety can signal SLE.¹³

Suspect SLE if the patient presents with fatigue, “butterfly” face rash, or joint pain. Test for renal or cardiopulmonary involvement.

Rheumatoid arthritis (RA). Because inflammatory activity is heightened after childbirth, postpartum women—particularly after bearing a first child—face a five-fold risk of RA compared with other women.¹¹ Breast-feeding might worsen RA, presumably by increasing prolactin production.

Physical limitations caused by RA can cause depression. Symmetric joint pain associated with morning stiffness—especially in the fingers, hands, or knees—might signal RA.

Anemia. Increased need for iron and folic acid during pregnancy can lead to anemia. Neuropsychiatric manifestations of folate deficiency range from mild irritability to severe depression, dementia, psychosis, and confusion.¹⁹ Vitamin B12 deficiency can lead to megaloblastic anemia or neurologic problems such as peripheral neuropathy, as well as depression, delirium, or dementia.¹⁹

Ask the patient about:

alcohol dependence, malnourishment, chronic illness, inflammatory bowel disease, gastric bypass or other gastric surgery, which can impair vitamin B12 absorption
use of anticonvulsants such as carbamazepine or valproic acid, which can decrease folate.

Hypotension mimics anergia. Postpartum hypotension can cause partial or total necrosis of the anterior pituitary gland. This leads to panhypopituitarism (Sheehan’s syndrome)—a rare complication characterized by failure to lactate, amenorrhea, hypothyroidism, and adrenal insufficiency.

When not in hypotensive circulatory shock, patients with adrenal insufficiency might present with depression, delirium, or psychosis.¹³ Ask the patient if she is having lactation problems and irregular periods, which could signal a pituitary problem.

Peripartum cardiomyopathy—an acute dilated cardiomyopathy— appears ≤6 months after delivery and may cause fatigue.^10,20 Check for shortness of breath at night and with exertion, palpitations, and extremity swelling.

Gestational diabetes. Pregnancy-induced insulin resistance leads to gestational diabetes mellitus. Women with gestational diabetes can develop type 2 diabetes after giving birth.¹⁰

Blood sugar fluctuations can cause depression, irritability, or memory problems. Depression can sabotage adherence to diet and treatment, leading to poor glycemic control.

Ask the patient if she was diagnosed with gestational diabetes and if she is experiencing fatigue, excessive thirst, frequent urination, blurred vision, headaches, excessive hunger, or unexplainable weight loss.

Primary biliary cirrhosis is most prevalent in women ages 35 to 60 and may cause depression.²⁰ Pruritus, fatigue, jaundice, and liver abnormalities point to this autoimmune disease, and postpartum exacerbations have been reported.²¹

HIV infection often leads to cognitive loss and depression with suicidal thoughts.¹³ Highly active antiretroviral medications commonly cause agitation, pain, mood changes, and insomnia.