Perinatal Psychiatry & Premenstrual Dysphoric Disorder
Timing separates blues, depression, and psychosis, and every prescription treats two patients
Three postpartum mood syndromes
Timing is the key. After delivery, mood symptoms range from a near-universal, self-limited adjustment to a psychiatric emergency. Onset, duration, and the presence of impairment, suicidality, or psychosis separate the three syndromes.
| Feature | Postpartum blues | Postpartum depression | Postpartum psychosis |
|---|---|---|---|
| Frequency | Up to 80% | About 10–15% | About 1–2 per 1,000 deliveries |
| Onset | 2–3 days after delivery; peak days 3–5 | Pregnancy to 12 months postpartum | Usually within the first 2 weeks |
| Course | Resolves within 2 weeks | ≥2 weeks; often months if untreated | Escalates over days |
| Features | Tearfulness, lability, irritability, anxiety; function and bonding intact | Anhedonia, guilt, insomnia even when the baby sleeps, intrusive thoughts; may be suicidal | Insomnia, confusion, shifting mood, hallucinations, delusions about the infant |
| Management | Reassurance, protected sleep, support | Psychotherapy ± SSRI; zuranolone or brexanolone | Emergency admission; antipsychotic ± lithium |
Blues that last beyond 2 weeks, or that include hopelessness or suicidal thoughts, are postpartum depression until proven otherwise.
Postpartum depression: screening and treatment
Definition and risk. Postpartum depression is a major depressive episode (≥2 weeks) that begins in pregnancy or within 12 months of delivery. The DSM-5 "with peripartum onset" specifier formally covers onset in pregnancy or the first 4 weeks postpartum, but clinicians screen and treat throughout the first year. The strongest risk factors are prior depression or depression during pregnancy, poor social support, and major life stressors. Untreated maternal depression impairs bonding and infant development.
Screening. The Edinburgh Postnatal Depression Scale has 10 self-report items, one of them on self-harm, and downweights somatic complaints such as fatigue that are normal after delivery. Screen in pregnancy and after delivery; well-child visits in the first 6 months offer further chances. A positive screen calls for a clinical interview, direct questions about suicide and thoughts of harming the baby, and a TSH to exclude postpartum thyroiditis.
Treatment. CBT or interpersonal therapy suits mild-to-moderate illness; add an SSRI for moderate-to-severe illness. Sertraline is preferred during breastfeeding because milk and infant serum levels are very low, so breastfeeding need not stop; an SSRI that worked before is also reasonable. Doxepin is avoided in nursing mothers because it has caused infant sedation and breathing problems.
Neuroactive steroids. Zuranolone (oral, 14-day course) and brexanolone (60-hour continuous IV infusion) positively modulate GABA-A receptors, are approved specifically for postpartum depression, and act within days. Both sedate heavily: brexanolone requires continuous pulse oximetry in a certified setting, and zuranolone carries a boxed warning against driving or other hazardous activity for at least 12 hours after each dose.
Postpartum psychosis
Presentation. Insomnia, confusion or disorientation, rapidly shifting mood, hallucinations, and delusions about the infant (possessed, replaced, or defective) usually appear within the first 2 weeks. The disorder is strongly linked to bipolar disorder, often as its first episode; a prior postpartum psychosis or a family history of bipolar disorder confers the highest risk. Suicide and infanticide are real dangers.
- Admit immediatelyInvoluntarily if needed; never leave the mother alone with the infant.
- Exclude medical causesThyroid disease, infection, substances, and eclampsia.
- TreatAntipsychotic plus lithium or another mood stabilizer; a benzodiazepine for agitation or insomnia.
- EscalateECT for severe or refractory illness.
Prevention. Women with bipolar disorder, especially after a prior postpartum psychosis, benefit from prophylactic lithium started right after delivery.
Psychotropic drugs in pregnancy and breastfeeding
Weighing risks. Untreated depression brings preterm birth, low birth weight, poor prenatal care, postpartum depression, and suicide, and stopping an antidepressant often triggers relapse. Continue an SSRI that works (sertraline, escitalopram, citalopram, fluoxetine) rather than switching, which exposes the fetus to two drugs.
| Drug | Concern | Management |
|---|---|---|
| SSRIs (late exposure) | Neonatal adaptation syndrome: jitteriness, irritability, poor feeding, tachypnea, hypoglycemia, resolving within about 2 weeks; small absolute rise in PPHN | Continue if effective; alert the pediatric team; no routine late taper, which raises maternal relapse risk |
| Paroxetine | First-trimester cardiac malformations, mainly septal defects | Avoid starting in pregnancy or when planning; consider fetal echocardiography after exposure |
| Lithium | Ebstein anomaly (small absolute risk); newborn hypotonia, hypothyroidism, nephrogenic DI | Fetal echocardiography; frequent levels; cut the dose and hydrate at delivery |
| Valproate, carbamazepine | Neural tube defects and other malformations; valproate also lowers IQ and raises autism risk | Avoid; switch before conception when possible |
| Lamotrigine | Lower malformation risk | Levels fall in pregnancy and rise after delivery; monitor and adjust |
Lithium in detail. In Ebstein anomaly the tricuspid valve is displaced toward the apex, "atrializing" part of the right ventricle. Rising GFR lowers lithium levels during pregnancy, so levels are checked often and doses raised; GFR falls abruptly after delivery, and a dose raised for pregnancy becomes toxic unless it is cut. Breastfeeding on lithium requires infant monitoring and is often avoided.
Other agents. Benzodiazepines late in pregnancy can cause neonatal sedation and withdrawal, and third-trimester antipsychotic exposure can cause transient neonatal extrapyramidal or withdrawal signs. ECT is safe and effective in pregnancy for severe depression, psychosis, or catatonia.
Premenstrual dysphoric disorder
Criteria. In most cycles, at least 5 symptoms appear in the week before menses, improve within a few days of onset, and are minimal the week after. At least one must be affective (lability, irritability, depressed mood, or anxiety); others include loss of interest, poor concentration, fatigue, food cravings, sleep change, feeling overwhelmed, bloating, and breast tenderness. Symptoms impair work or relationships, and 12-month prevalence is about 2–6%.
Confirmation. Prospective daily symptom ratings across at least 2 symptomatic cycles are required because recall is unreliable. Charting separates PMDD from premenstrual worsening of depression or anxiety, in which symptoms persist after menses, and from PMS, which is milder. Hormone levels are normal: PMDD reflects abnormal sensitivity to normal cyclic changes, so estradiol, progesterone, and FSH levels do not help.
Treatment. SSRIs (fluoxetine, sertraline, paroxetine CR, escitalopram) are first line and act within days, unlike in depression, so they work taken continuously or only in the luteal phase. A drospirenone-containing combined oral contraceptive (24/4 regimen) suits women who want contraception. Exercise and CBT are useful adjuncts. GnRH agonists with add-back therapy are reserved for refractory cases, and bilateral oophorectomy is a last resort.