Shaili Patel, MD

Women with postpartum depression frequently experience intrusive, obsessive ruminations that are part of a depressive episode.

 Many women with postpartum depression have significant anxiety, and many reach the level of meeting criteria for full-blown anxiety disorders.

 An anxiety disorder may also precede and contribute to the development of a depressive episode.

Mrs A, a 39-year-old married mother of 3 children aged 5 years, 3 years, and 8 weeks presented to the psychiatric emergency service (PES) with complaints of intrusive thoughts of hurting herself and her children, worsening anxiety, and depression. She reported that her anxiety had started when she learned that she was pregnant and lasted through- out her pregnancy, which was unplanned. She worried constantly about how she would effectively parent 3 children and how she and her husband would cope financially.

Since the infant's birth, she had been experiencing constant obsessive ruminations about her poor mothering skills and about not being able to keep the house clean. During the past week, these thoughts were keeping her up at night: her sleep had decreased to 2 to 3 hours per night. She also started to have intrusive thoughts that she described as "alien" to her. The thoughts included wanting to hurt herself, the baby, and her other children. Although she said that she loved her children and felt that she could never do anything to hurt them, these thoughts were starting to frighten her.

She was beginning to think that her children would be better off without her. She felt "out of control," was tearful, and at times experienced shortness of breath and chest discomfort. She was breast-feeding, which also contributed to her sleep disruption. She stated that she was starting to feel depressed and hopeless, thinking that she "would never get bet-ter." She denied manic or psychotic symptoms.

At the time of presentation, the patient's primary concern was anxiety. Therefore, after the interview, we began the diagnostic process with considerations of generalized anxiety disorder (GAD), panic disorder, and obsessive-compulsive disorder (OCD). GAD was the first consideration, because her excessive anxiety had been occurring for more than 6 months and was beyond normal maternal fears regarding the birth of a child. She did not have recurrent panic attacks or fears of recurrence of an attack despite an occasional severe anxiety attack when she described her worrying as "getting out of control."

To rule out OCD, we had to determine whether her intrusive thoughts were ego-dystonic, whether she had tried unsuccessfully to suppress them, and whether they caused her significant anxiety. While the thoughts about harming her children met these criteria, she clearly related the onset of these thoughts to the past 2 weeks, when she began to experience depressive symptoms as well. Her depressive symptoms consisted of decreased concentration, loss of interest and decreased energy, decreased sleep, depressed mood, hopelessness, and severe guilt about being a terrible mother.

Before a conclusion could be drawn that Mrs A had major depressive disorder (MDD) with postpartum onset and GAD, further evaluation was required to rule out postpartum psychosis--and bipolar disorder in particular. These disorders can masquerade as anxiety and depression, especially in the postpartum period. To fully address these and other possible causes of her severe symptoms, further information was needed regarding any history of these symptoms or other episodes; family history; medical history; thyroid function; and drug, caffeine, tobacco, and alcohol use. Further exploration of psychosocial factors, including intimate partner violence, that might be contributing to her illness was also required.

During further evaluation, Mrs A reported a history of 1 previous episode of depression when she was 22 years old that resolved in 6 months with the help of supportive counseling. She had no history of postpartum depression but report- ed that her mother had suffered from postpartum depression that required a period of inpatient psychiatric hospitalization.

Mrs A admitted to being a "perfectionist" and was often preoccupied with planning and list-making. She said that she had been able to "hold it all together" until her third pregnancy. Early in the pregnancy, her husband had expressed concern that they would be unable to cope financially with the added burden of a third child. She recalled that this was the time when her anxious ruminations became unbearable. Her obstetrician prescribed paroxetine during her seventh month of pregnancy when she reported that she had started feeling more "desperate" because of worsening anxiety. She feared the effects of medication on her developing child and discontinued the medication after 1 week. Her obstetrician prescribed sertraline, 50 mg/d, because of increased crying 1 week before the patient's presentation to the PES. She did not think that the medication was helping and feared the effects on her nursing infant.

A thorough evaluation, including a complete blood cell count, blood chemistry panel, thyroid function tests, tests of vitamin B

 and folate levels, and a physical examination, was noncontributory.

Treatment options for MDD and GAD were reviewed. As part of a thorough risk-benefit analysis, the risks of inadequately treated anxiety and depression were discussed with the patient and her husband, as were the risks of medication for the mother and the nursing infant. The patient and her husband agreed that her high level of anxiety, severity of distress, lack of sleep, and aggressive thoughts were of great concern and warranted immediate attention.

Options for treatment included voluntary inpatient hospitalization, admission to the extended observation unit in the PES, partial hospitalization, or outpatient treatment. Because of her inability to function, her severe sleep disruption, the aggressive thoughts, and severe anxiety, she was admitted to the extended observation unit, where she received medication adjustments under supervision in a safe environment. She was assessed daily for 3 days. Had her symptoms not improved by day 3, admission to the inpatient psychiatric unit might have been necessary.

Medication options were also discussed with the patient. The first recommendation was to increase the sertraline to a therapeutic level. It was explained that although she had not felt any effect yet, she could potentially benefit from an increase in the dosage. Mrs A wished to continue breast-feeding and was concerned about such an increase. A risk-benefit discussion that reviewed the current data regarding the effects of untreated postpartum depression and anxiety on infant development, the benefits and side effects of the medication for the mother, and the limited data on short- and long-term consequences for a breast-fed infant from exposure to the medication was conducted. The patient agreed to increase her dosage of sertraline to 100 mg/d. The risks, benefits, and side effects of benzodiazepines during the nursing period were also discussed. A decision was made to use clonazepam, 0.25 mg 3 times daily, for a short period.

The patient's symptoms decreased significantly during her extended observation stay. She practiced relaxation techniques, such as deep breathing, with a psychiatric nurse practitioner. Her sleep normalized; the intrusive thoughts about hurting her children became less frequent and less prominent. She no longer feared that she would act on these thoughts. Although she continued to have worries, she was future-oriented. She and her husband decided to have her mother come to stay with the family to help with the children, and her husband agreed to help around the house more.

Because of the degree of her symptoms at discharge, the patient was referred to the partial hospitalization program (PHP). In this program, she was able to return home and spend time with her family in the evenings and on weekends but benefited from the increased support, structure, intensive psychotherapy, psychoeducational groups, and skill- building groups provided through the PHP. She also was given the telephone number of a postpartum support group in the community.

During the postpartum period, women are particularly vulnerable to psychiatric disorders, especially depression and anxiety disorders.

 These women often face the dilemma of whether to use psychotropic medications while continuing to breast-feed their infants. The mental health of the mother is extremely important to safeguard in such cases. The potential adverse impact of untreated maternal mental illness on infant attachment and development and the effects of untreated illness on the mother must be addressed.

Although the benefits of breast milk to developing infants are well documented, women must be made aware of alternatives to breast-feeding, such as supplementation with formula and pumping and dumping during peak breast milk medication levels. Understanding alternatives is paramount because breast-feeding requires the mother to be "on call" 24 hours a day. This can put increased pressure on the mother as well as disrupt her sleep cycle. Discussing this with women can help relieve guilt and give them "permission" not to breast-feed their infant or not to do so exclusively.

Data from a recent review by Weissman and colleagues

 suggest that breast-fed infants exposed to nortriptyline, paroxetine, or sertraline seem unlikely to have detectable or elevated plasma levels develop, while infants exposed to fluoxetine appear to be at higher risk for elevated levels developing, especially following prenatal exposure or if drug levels are high in breast milk (Table 1). Citalopram may produce elevated levels in some infants, especially if the maternal dose or breast milk level is high. Short-term, but potentially serious, adverse effects of breast-feeding exposure to antidepressants have been noted in individual case reports.

 Few studies address long-term effects and the impact on brain development of infants exposed to antidepressants through breast milk.

The risk of breast-feeding while using benzodiazepines remains a controversial and underresearched topic. According to the limited data available, diazepam is not recommended during breast-feeding because it can accumulate in the infant and cause lethargy, sedation, and weight loss (Table 2).

 Data on clonazepam and lorazepam suggest that their use is relatively safe during lactation, but concerns about infant and maternal sedation remain a risk that must be discussed.

 The American Academy of Pediatrics Committee on Drugs has classified many anxiolytic medications and antidepressants as "drugs for which the effect on nursing infants is unknown but may be of concern."

 Mothers must be given this information, including the unknown but possible effects on infant neurodevelopment, to make an informed decision.

Many mothers fear that if they are sedated in any way, they will not hear their child cry. Therefore, many mothers refuse to use the medications even in the short term. One recommendation is for the mother to try the medication when her partner or other support is available to attend to the infant in case she becomes sedated. If this does occur, the dose can be tailored to decrease anxiety or improve maternal sleep without oversedation. For depression and anxiety disorders, nonpharmacologic treatment, such as cognitive-behavioral therapy, relaxation techniques, and interpersonal psychotherapy, show promise as augmentation or as primary treatment during the postpartum period.

In cases of severe postpartum depression and anxiety, such as this case, outpatient treatment may not sufficiently ensure the safety of the patient or others. New mothers frequently present to the PES in distress and in need of a higher level of care, but it is important to consider the impact of prolonged hospitalization of the mother on infant development and attachment. Observation for a few days provides a safe alternative: the mother can escape the stressors at home for a brief period, and a plan for increasing supports can then be developed.

Partial hospitalization or day hospital care is often refused by new mothers because such programs separate mother and infant, complicate breast-feeding, and place the responsibility of caring for the baby and other children on the spouse and extended family. Most programs are not designed for peripartum women and therefore may not directly address the special issues of pregnant and postpartum women, such as difficulty in parenting newborns and delineating what is normal adaptation to a new baby. This is another reason that women may refuse or terminate participation in a day treatment program. It should be stressed, however, that these programs can provide the mother with much-needed structure and support while her symptoms are acute and avoid an inpatient admission. When her symptoms stabilize, she can continue in less intensive outpatient treatment.

A few unique programs do offer maternal-child day treatment programs. Expansion of these programs should be considered, because they provide an opportunity for mothers to bond with their infants in a secure and supportive environment while also allowing professionals to observe the parenting by the mother. These programs may also include parenting groups as well as child development groups and provide the needed support of other women who are experiencing the same timing of their depression and anxiety. *

1. Wisner KL, Peindl KS, Gigliotti T, Hanusa BH. Obsessions and compulsions in women with postpartum depression. 

2. Hendrick V, Altshuler L, Strouse T, Grosser S. Postpartum and nonpostpartum depression: differences in presentation and response to pharmacologic treatment. 

3. Davidson J, Robertson E. A follow-up study of post partum illness, 1946-1978. 

4. Kendell RE, Wainwright S, Hailey A, Shannon B. The influence of childbirth on psychiatric morbidity. 

5. Cogill SR, Caplan HL, Alexandra H, et al. Impact of maternal postnatal depression on cognitive development of young children. 

6. Weissman AM, Levy BT, Hartz AJ, et al. Pooled analysis of antidepressant levels in lactating mothers, breast milk, and nursing infants. 

7. Iqbal MM, Sobhan T, Ryals T. Effects of commonly used benzodiazepines on the fetus, the neonate, and the nursing infant. 

8. American Academy of Pediatrics Committee on Drugs. Transfer of drugs and other chemicals into human milk. 

9. Dennis CL. Treatment of postpartum depression, part 2: a critical review of nonbiological interventions. 

10. Malone K, Papagni K, Ramini S, Keltner NL. Antidepressants, antipsychotics, benzodiazepines, and the breastfeeding dyad. 

 2004;40:73-85.11. Chaudron LH, Schoenecker CJ. Bupropion and breastfeeding: a case of a possible infant seizure. 

Articles

Women with postpartum depression frequently experience intrusive, obsessive ruminations that are part of a depressive episode. Many women with postpartum depression have significant anxiety, and many reach the level of meeting criteria for full-blown anxiety disorders. An anxiety disorder may also precede and contribute to the development of a depressive episode.

Shaili Patel, MD

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