Severe major postnatal depression develops within the first few weeks after delivery. It usually has an insidious onset, unlike puerperal sepsis which has a sudden onset.

Incidence:

Severe major postnatal depression affects about 3 to 5 % of women delivered.

It is more common in women who have undergone stressful childbirth and its aftermath. The stress on the mother includes the stress of feeding the baby, blood loss, painful breasts, lack of support from the spouse, insomnia and deficiency of mothering skills.

Clinical features of severe major postnatal depression:

Only a third of the patients present in the first three weeks following delivery.The remaining two-thirds present later(Usually between 10 and 12 weeks postpartum). The patients presenting in the first three weeks following delivery, present with the severe form of the illness.

The clinical features can be summarized as follows:

i)Classical features of severe depression such as early morning waking, mood which is worst in the morning and gradually improves as the day passes,(diurnal variation of mood) and impaired appetite.

ii)Impaired concentration

iii) Feelings of guilt and worthlessness.

iv)Patients are usually from low socio-economic status.

v) Anxiety and/or ruminative worry. Some may even suffer from panic attacks.

vi) Disturbed sleep is common.

vii) Inability to feel pleasure or enjoyment in life (Anhedonia).

In most African and Asian countries, the prevalence of postnatal depression is low. This low prevalence is probably due to support and care of the new born from the extended family.

Probable causes of severe postnatal depression:

i) Stress of delivery and disordered interpersonal relationship with partner/spouse.

ii)It could also be endogenous in nature -there is response to electroconvulsive therapy and antidepressent medication.

What is the risk of relapse of severe major postnatal depression?

For women who have postpartum illness only, the risk of relapse is about 1:2 to 1:3.

The risk of recurrence outside childbirth is low. Medication should be provided for at least six months. Some women may require longer duration of treatment.

Management of Severe Major Postnatal Depression

Antidepressants and hormones are useful in the management of depression.

Antidepressants should be the first line of treatment of depression. Hormonal treatment is useful if antidepressants are ineffective or are not tolerated.

Antidepressants:

Tricyclic antidepressants should be the treatment of choice. Tricyclic antidepressants are also relatively safer during breastfeeding. Some of the metabolites of these drugs have been detected in breast milk, but clinical neurotoxic features in breast fed infants of mothers who are taking tricyclics is very rare and therefore there is no justification for avoidance of the drugs when there is a clear indication for its use.

Examples of tricyclic antidepressants are: imipramine, amitriptyline, doxepin,dosulepin hydrochloride (dothiepin) and minaserin.

A suggested regime is dothiepin starting at 75mg nocte (at night ) and gradually increasing over a few days to 150mg nocte.

Improvement should be expected within 2 to 4 weeks and resolution of the illness takes 4 to 6 weeks. However antidepressants should be taken for six months after recovery, before reducing gradually.

References:

Pages 233 to 236,Psychiatric aspects of obstetrics and gynaecology. Chapter 11 ,Psychiatry and Medicine. Psychiatry, Oxford Core Texts.2nd Edition by Michael Gelder, Richard Mayou and John Geddes. 1999.

Pages 326 to 327. Severe Major Postnatal Depression. Chapter 21, Psychiatric Disorders in Pregnancy and the Puerperium. Obstetrics by Ten Teachers. 17th edition edited by Stuart Campbell and Christoph Lees.2003.

Textbook of Obstetrics and Gynaecology for Medical Students by Akin Agbola et al. Ist Edition, Volume 2 ,Obstetrics.

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