A closer look at the preventative effect of antidepressants in postpartum depression

Preventing recurrence of postpartum depression by regulating sleep

INTRODUCTION

Women are at a high risk of recurrence of depression in the postpartum period. Given the circumscribed duration of the risk period and knowledge of its triggers, postpartum depression should be easily preventable. However, prophylactic drug studies have reported contradictory findings partly due to the heterogeneity of the disorder. Currently, there are no studies on the efficacy of psychotherapy in the prevention of postpartum depression in women with major depressive or bipolar disorder.

AREAS COVERED

This review evaluates the results of controlled medication and psychotherapeutic studies in the prevention of depression in women with major depressive disorder or bipolar disorder; it further suggests that the management of sleep loss/insomnia may be an effective strategy in the prevention of postpartum depression.

EXPERT OPINION

A thorough understanding of the clinical course of the antecedent mood disorder and historical treatment response is necessary before the implementation of strategies for the prevention of postpartum depression. Targeting disturbed and/or insufficient sleep - a common and early transdiagnostic symptom of peripartum psychiatric disorders - may be a more effective intervention for the prevention of postpartum depression and psychiatric comorbidities in some individuals than the traditional approach of antidepressant use.

Psychiatric visits during the postpartum year in women with eating disorders who continue or discontinue antidepressant treatment in pregnancy

OBJECTIVE

To determine the association between continued antidepressant use in pregnancy and postpartum psychiatric visits for eating (ED) or mood/anxiety disorders in women with preexisting ED.

METHOD

Using Danish health registry data (1998-2015), we identified 3529 pregnancies in women with ED prepregnancy: (i) 564 with continued antidepressant use before and during pregnancy; (ii) 778 with discontinued antidepressants before pregnancy; (iii) 2137 unexposed. Outpatient and inpatient postpartum visits for an ED or a mood/anxiety disorder constituted the outcome measures. We estimated hazard ratios (HRs) and 95% confidence intervals (CI) using Cox regression with inverse probability of treatment weighting, and performed stratified analyses by antidepressant prescription filling in the first 3 months postpartum.

RESULTS

The weighted cumulative incidence for an ED visit at end of follow-up was 4.5% (continued) and 4.8% (discontinued). We found no association between continued antidepressant and postpartum ED visit, relative to discontinued (HR: 0.89, 95% CI: 0.52-1.52). The HR for postpartum mood/anxiety disorder visit was 1.27 (95% CI: 0.68-2.36) with continued antidepressants versus discontinued but decreased if more than two antidepressant prescriptions were refilled. Continued antidepressant use was associated with a 57% reduced likelihood of a postpartum ED visit versus discontinued use in pregnancies with antidepressant prescription refills in the early postpartum.

CONCLUSION

Among women with preexisting ED, there was no association between continued antidepressant use during pregnancy and the likelihood of postpartum psychiatric visits, relative to discontinued antidepressants before pregnancy. Continuation of treatment into the early postpartum is associated with reduced likelihood of postpartum ED visit.

PUBLIC SIGNIFICANCE

Based on data from the Danish registries, we identified 3529 pregnancies among women with preexisting eating disorders before pregnancy. Women with continued antidepressant treatment both before and during pregnancy did not have a lower probability of having postpartum psychiatric visits for an eating disorder or for mood/anxiety disorders (often coexisting with eating disorders), relative to those who discontinued antidepressants before pregnancy. Further continuation of antidepressant treatment into the early postpartum is associated with improved maternal postpartum outcomes. However, residual confounding by disease severity limits confidence in this conclusion.

Association between Antidepressant Treatment during Pregnancy and Postpartum Self-Harm Ideation in Women with Psychiatric Disorders: A Cross-Sectional, Multinational Study

This study sought to estimate whether there is a preventative association between antidepressants during pregnancy and postpartum self-harm ideation (SHI), as this knowledge is to date unknown. Using the Multinational Medication Use in Pregnancy Study, we included a sample of mothers who were in the five weeks to one year postpartum period at the time of questionnaire completion, and reported preexisting or new onset depression and/or anxiety during pregnancy (n = 187). Frequency of postpartum SHI ('often/sometimes' = frequent, 'hardly ever' = sporadic, 'never') was measured via the Edinburgh Postnatal Depression Scale (EPDS) item 10, which reads "The thought of harming myself has occurred to me". Mothers reported their antidepressant use in pregnancy retrospectively. Overall, 52.9% of women took an antidepressant during pregnancy. Frequent SHI postpartum was reported by 15.2% of non-medicated women and 22.0% of women on past antidepressant treatment in pregnancy; this proportion was higher following a single trimester treatment compared to three trimesters (36.3% versus 18.0%). There was no preventative association of antidepressant treatment in pregnancy on reporting frequent SHI postpartum (weighted RR: 1.90, 95% CI: 0.79, 4.56), relative to never/hardly ever SHI. In a population of women with antenatal depression/anxiety, there was no preventative association between past antidepressant treatment in pregnancy and reporting frequent SHI in the postpartum year. This analysis is only a first step in providing evidence to inform psychiatric disorder treatment decisions for pregnant women.

Perinatal depression: Heterogeneity of disease and in animal models

Perinatal depression (PND) can have either an antepartum or postpartum onset. Although the greatest risk factor for PND is previous depression history,de novoPND occurs with the majority of cases occurring in the postpartum. Timing of depression can impact etiology, prognosis, and response to treatment. Thus, it is crucial to study the impact of the heterogeneity of PND for better health outcomes. In this review, we outline the differences between antepartum and postpartum depression onset of PND. We discuss maternal physiological changes that differ between pregnancy and postpartum and how these may differentially impact depression susceptibility. We highlight changes in the maternal steroid and peptide hormone levels, immune signalling, serotonergic tone, metabolic factors, brain morphology, and the gut microbiome. Finally, we argue that studying the heterogeneity of PND in clinical and preclinical models can lead to improved knowledge of disease etiopathology and treatment outcomes.

Emerging issues and questions on peripartum depression prevention, diagnosis and treatment: a consensus report from the cost action riseup-PPD

BACKGROUND

Peripartum depression [PPD] is a public health problem which has been widely studied. Nonetheless, study findings and clinical guidelines for PPD treatment differ among countries and the condition is still underdiagnosed and undertreated, suggesting the importance of a global understanding of PPD. The Riseup-PPD Cost Action aims to establish a Pan-European and multidisciplinary network of researchers dedicated to the global understanding of PPD.

METHODS

A literature search was performed in different databases (e.g., Medline, PsychInfo) including a combination of terms related with PPD diagnosis, prevention, treatment and cost-effectiveness of its management. A narrative synthesis of the literature, together with a critical overview of the current issues/questions to be addressed within the topic of PPD were performed.

RESULTS

Emerging issues include challenges regarding definition and timing of PPD; heterogeneity in severity, timing of onset and assessment tools; comparative effectiveness of preventive and treatment interventions; help seeking for PPD; improving health professional's awareness of PPD; and cost-effectiveness of PPD management.

LIMITATIONS

The main limitation is the non-systematic nature of the literature search.

CONCLUSIONS

The Riseup-PPD network will deal with these challenges through four lines of action: (1)provide an updated and comprehensive synthesis of existing knowledge that can contribute to inform clinical recommendations and guidelines for PPD management; (2) clarify inconsistent findings concerning diagnosis, prevention and treatment of PPD; (3) develop new lines of research in the field of PPD; and (4) develop international recommendations for PPD diagnosis, prevention and treatment, ultimately influencing maternal mental health policymaking at global and local levels.

Antidepressants and recurrence of depression in the postpartum period

To examine postpartum recurrence rates of depression comparing women receiving antidepressant treatment to women not being treated with psychotropic medication. This was a prospective study of 130 women with major depressive disorder (MDD) who attended a tertiary care perinatal clinic during and after pregnancy. Depression recurrence was defined as a score of 13 or more on the Edinburgh Postnatal Depression Scale (EPDS) or a score of greater than 13 on the Hamilton Depression Rating Scale (HDRS). Over half of women (56.9%) were not receiving medication during pregnancy to treat their mood disorder, with the rate of medication use increasing over the 1-year postpartum period. When comparing women being treated with antidepressant medication (monotherapy or combination therapy) to women receiving no psychotropic medication, no significant differences in recurrence rates were observed during the postpartum period. However, we did observe that the occurrence of depression in our sample fluctuated between rates comparable to general population estimates to rates that were at times more than twofold higher, regardless of treatment with antidepressant medication. The findings of this study align with research which suggests that the postpartum period is a particularly vulnerable time for recurrence of depression. Moreover, our results suggest that this remains the case regardless of antidepressant treatment.