episode. Women with both prior puerperal depression and a current episode of "maternity blues" carry an inordinately high risk for major depression. Indeed, 2 to 9 months postpartum, assistance with postpartum depression was the fourth most common challenge identiied in women in the Pregnancy Risk Assessment Monitoring System-PRAMS (Kanotra, 2007).
Postpartum depression is generally underrecognized and undertreated. Major depression during pregnancy or after delivery can have devastating consequences for afected women, their children, and families. One of the most significant contributions to the mortality rate among new mothers is suicide, which is most frequent among women with mental illness (Koren, 2012; Palladino, 2011). If left untreated, up to 25 percent of women with postpartum depression will be depressed 1 year later. As the duration of depression increases, so too does the number of sequelae and their severity. Maternal depression during the first weeks and months after delivery can lead to insecure attachment and later behavioral problems in the child.
Therapy for mood disorders during pregnancy and postpartum has undergone a significant evolution during the past decade. Babbitt (2014) and Pozzi (2014) and their associates have reviewed principles of antenatal and intrapartum care of women with major mental disorders. In general, for mild and mild-moderate depression, psychological treatment options, such as cognitive behavioral therapy, are considered irst (Yonkers, 2011). Antidepressant medications together with some form of psychotherapy are indicated for moderate to severe depression during pregnancy or the puerperium (American College of Obstetricians and Gynecologists, 2016b).
Shown in Figure 61-1 is one algorithm regarding treatment of mood disorders. Some of these medications are listed in 1 able 61-3. For women with severe depression, a selective sero tonin-reuptake inhibitor (SSRI) is selected initially. In contrast, tricyclic antidepressants and monoamine oxidase inhibitors are infrequently selected in contemporary practice. If depressive symptoms improve during a 6-week trial, the medication is continued for a minimum of 6 months to prevent relapse (Wisner, 2002). At least 60 percent of women taking antidepressant medication before pregnancy have symptoms during pregnancy. According to Hayes and colleagues (2012), approximately three fourths of women taking antidepressants before pregnancy stopped taking them before or during early pregnancy. For those who discontinue treatment, almost 70 percent have a relapse compared with approximately 25 percent who continue therapy. If the response is suboptimal or a relapse occurs, another SSRI is substituted, or psychiatric referral is considered.
Various dietary deiciencies have suggested links to perinatal depression (Yonkers, 2011). Supplements that include omega-3 fatty acids, iron, folate, ribolavin, vitamin D, calcium, and docosahexaenoic acid (DHA) have been studied (Keenan, 2014; Miller, 2013). However, evidence currently is insuicient to support use of these dietary supplements for this purpose.