Postpartum depression

Female gender Prior history of depression Family history of depression Active substance abuse Recent stressful life event Poor social supports Previous suicide attempt Postpartum period Chronic medical illness... 

Adults 25 to 100 mg IM as pre- and postoperative/pre- and postpartum adjunctive medication to permit reduction of narcotic dosage. Reduce dosage of concomitant CNS depressants by 50%. 

Gotlib, I.H., Whiffen, V.E., Mount, J.H., Milne, K., and Cordy, N.I. (1989) Prevalence rates and demographic characteristics associated with depression in pregnancy and the postpartum. / Consult Clin Psychol. 57 269-274. 

Neroli depression, sadness, irritability, panic attacks, postpartum depression... 

Case Example A 28-year-old woman had been stable on lithium treatment for several years. When she became pregnant, her lithium was discontinued, and within a few weeks she was hospitalized for a severe exacerbation of mania unresponsive to CPZ in doses up to 1,200 mg/day. After a course of ECT she became euthymic and was adequately maintained on lower doses of CPZ (i.e., 50 to 100 mg/day) for the remainder of her pregnancy. The delivery and the immediate postpartum period went well, but lithium was not resumed because she opted to nurse her infant. Several weeks later, she was rehospitalized for an episode of depression, which also responded to a course of ECT. She then agreed to discontinue nursing her child and resume lithium. The patient was doing well at follow-up 1 year later. 

Those with a prior history may be more susceptible to postpartum depression, and maintenance antidepressant therapy should be carefully considered. 

Finally, sex steroids are also implicated in the pathophysiology of depression. Estrogen deficiency states, which occur in the postpartum and postmenopausal periods, are thought to play a role in the etiology of depression in some women. Likewise, severe testosterone deficiency in men is sometimes associated with depressive symptoms. Hormone replacement therapy in hypogonadal men and women may be associated with an improvement in mood and depressive symptoms. 

It is very difficult to evaluate any behavioral or emotional effects of these compounds in humans. Although the incidence of pronounced changes in mood, affect, and behavior appears to be low, milder changes are commonly reported, and estrogens are being successfully employed in the therapy of premenstrual tension syndrome, postpartum depression, and climacteric depression. 

Electroconvulsive therapy is especially useful when rapid onset of clinical effect is desired and when patients are refractory to a number of antidepressant drugs. It is also very helpful in psychotic and bipolar depression and in postpartum psychosis. If the mechanism of the therapeutic action of ECT could be unraveled, it might lead to a new antidepressant drug capable of rapid onset of antidepressant effects or with special value for refractory patients. Until then, ECT will remain a valuable member of the therapeutic armamentarium for depression. 

FIGURE 14-28. Several issues of importance in assessing women s vulnerability to the onset and recurrence of depression are illustrated here. These include first onset in puberty and young adulthood premenstrual syndrome (PMS) and menstrual magnification as harbingers of future episodes or incomplete recovery states from prior episodes of depression and two periods of especially high vulnerability for first episodes of depression or for recurrence if a woman has already experienced an episode, namely, the postpartum period and the perimenopausal period. 

Alternatively, it is possible that maternal depressive symptoms contribute to the severity of their infant s sleep disturbance. For example, infants of depressed mothers may sleep poorly because they are distressed, not sufficiently active during the day, or receive insufficient environmental cues to entrain their circadian rhythms (115). In addition, the observed increase in sleep disturbance in infants of depressed mothers may simply reflect a reporting bias in that postpartum women with current or past MDD are awake during the night more than women without MDD (31) and might, therefore, be more aware of, and more likely to report, infant sleep disturbances than nondepressed mothers. 

Wolfson A, Crowley SJ, Anwer U, Bassett JL. Changes in sleep patterns and depressive symptoms in first-time mothers last trimester to 1-year postpartum. Behav Sleep Med 2003 1 54-67. 

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