Is Postpartum Depression a Distinct Disorder?
The nosology of postpartum depression (PPD) is controversial. We review the evidence and arguments for and against the recognition of PPD as a distinct disorder and discuss the etiopathogenic and diagnostic validity of PPD as a distinct disorder, including its utility and indications for further research. Although multiple epidemiological and clinical studies have found that depression is more common following childbirth than at other times in a woman’s life, there is conflicting evidence for the validity of PPD as a distinct disorder. PPD is likely to be a complex phenotype, encompassing several disorders with different disease pathways. It is plausible that for a sub-group of vulnerable women, childbirth triggers episodes of depression. However, even within this group, the mechanisms underpinning the mood disturbances are likely complex and heterogeneous. The distinction between depression occurring in the perinatal period and depression at other times is important for both research and clinical practice. Research should differentiate between episodes that begin during pregnancy and postpartum, as the pathogenetic factors involved may differ and require specialized treatment.
KeywordsPostpartum depression Pregnancy Nosology Validity Timing Phenotype
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Conflict of Interest
Arianna Di Florio declares that she has no conflict of interest.
Samantha Meltzer-Brody has received research grant support from Sage Pharmaceuticals.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
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- 1.American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington: American Psychiatric Association; 2013.Google Scholar
- 2.American Psychiatric Association, DSM-IV APATF on. Diagnostic and statistical manual of mental disorders: DSM-IV-TR. American Psychiatric Pub; 2000.Google Scholar
- 3.World Health Organization. ICD-10 : the ICD-10 Classification of Mental and Behavioural Disorders : clinical descriptions and diagnostic guidelines. World Health Organization; 1992.Google Scholar
- 4.Di Florio A, Seeley J, Jones I. Diagnostic assessment of depression, anxiety, and related disorders. In: Milgrom J, Gemmill AW, editors. Identifying Perinat. Depress. Anxiety Evid.-Based Pract. Screen. Psychosoc. Assess. Manag. John Wiley & Sons; 2015.Google Scholar
- 12.•Di Florio A, Forty L, Gordon-Smith K, Heron J, Jones L, Craddock N, et al. Perinatal episodes across the mood disorder spectrum. JAMA Psychiatry Chic Ill. 2013;70:168–75. PPD affects over 40% of deliveries in women with major depression and over 1 in 4 deliveries in women with bipolar disorder. A specific association between depression and childbirth was observed for women with unipolar depression, but not in those with bipolar disorder. CrossRefGoogle Scholar
- 13.•Depression P. Action Towards Causes and Treatment (PACT) Consortium. Heterogeneity of postpartum depression: a latent class analysis. Lancet Psychiatry. 2015;2:59–67. PPD is a heterogeneous disease entity. The most severe cases began during pregnancy and had obstetric complications. CrossRefGoogle Scholar
- 20.•Viktorin A, Meltzer-Brody S, Kuja-Halkola R, Sullivan PF, Landén M, Lichtenstein P, et al. Heritability of Perinatal Depression and Genetic Overlap with Non-perinatal Depression. Am. J. Psychiatry [Internet]. In press [cited 2015 Apr 16]; Available from: http://www.dol.gov/whd/regs/statutes/fmla.htm. Conducted on 3427 female twins who completed a self-rated scale for screening PPD and a population-based cohort of 580,006 sisters with clinical diagnosis of PPD, it estimated that the hereditability of PPD is about 40% (95% CI 31–49%) and that 14% of the variance (one third of the total hereditability estimate) of perinatal depression was explained by genetic factors not shared with depression occurring at other times.
- 22.Diseases of Poverty—InternationalPolicyNetwork.pdf [Internet]. [cited 2015 Jun 10]. Available from: http://www.who.int/intellectualproperty/submissions/InternationalPolicyNetwork.pdf
- 28.Antenatal and postnatal mental health: clinical management and service guidance | 1-recommendations | Guidance and guidelines | NICE [Internet]. [cited 2015 Apr 23]. Available from: http://www.nice.org.uk/guidance/cg192/chapter/1-recommendations
- 29.Guideline No 60: Postnatal Depression and Puerperal Psychosis [Internet]. [cited 2015 Jun 9]. Available from: http://www.sign.ac.uk/guidelines/fulltext/60/section2.html
- 30.Bauer A, Parsonage M, Knapp M, Iemmi V, Adelaja B. Costs of perinatal mental health problems [Internet]. 2014 [cited 2015 Feb 13]. Available from: http://www.centreformentalhealth.org.uk/
- 31.Beyondblue (Organisation), National Health and Medical Research Council (Australia). Clinical practice guidelines for depression and related disorders—anxiety, bipolar disorder and puerperal psychosis—in the perinatal period : a guideline for primary care health professionals/Australian Institute of Health and Welfare. Melbourne: Beyondblue; 2011.Google Scholar
- 36.•Wisner KL, Sit DKY, McShea MC, Rizzo DM, Zoretich RA, Hughes CL, et al. Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings. JAMA Psychiatry. 2013;70:490–8. Only 40% of episodes of PPD began in the postpartum. 22.6% of women screening positive for PPD had bipolar disorder. PubMedCentralCrossRefPubMedGoogle Scholar
- 42.Cantwell R, Clutton-Brock T, Cooper G, Dawson A, Drife J, Garrod D, et al. Saving mothers’ lives: reviewing maternal deaths to make motherhood safer: 2006–2008. The eighth report of the confidential enquiries into maternal deaths in the United Kingdom. BJOG Int J Obstet Gynaecol. 2011;118(1):1–203.CrossRefGoogle Scholar