Advertisement

Current Psychiatry Reports

, 17:76 | Cite as

Is Postpartum Depression a Distinct Disorder?

  • Arianna Di Florio
  • Samantha Meltzer-Brody
Women's Mental Health (CN Epperson, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Women's Mental Health

Abstract

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.

Keywords

Postpartum depression Pregnancy Nosology Validity Timing Phenotype 

Notes

Compliance with Ethics Guidelines

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.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington: American Psychiatric Association; 2013.Google Scholar
  2. 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. 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. 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
  5. 5.
    Wisner KL, Moses-Kolko EL, Sit DKY. Postpartum depression: a disorder in search of a definition. Arch Womens Ment Health. 2010;13:37–40.PubMedCentralCrossRefPubMedGoogle Scholar
  6. 6.
    Kendler KS. Toward a limited realism for psychiatric nosology based on the coherence theory of truth. Psychol Med. 2015;45:1115–8.CrossRefPubMedGoogle Scholar
  7. 7.
    Insel T, Cuthbert B, Garvey M, Heinssen R, Pine DS, Quinn K, et al. Research domain criteria (RDoC): toward a new classification framework for research on mental disorders. Am J Psychiatry. 2010;167:748–51.CrossRefPubMedGoogle Scholar
  8. 8.
    Cuthbert B, Insel T. Classification issues in women’s mental health: clinical utility and etiological mechanisms. Arch Womens Ment Health. 2010;13:57–9.CrossRefPubMedGoogle Scholar
  9. 9.
    Kendell R, Jablensky A. Distinguishing between the validity and utility of psychiatric diagnoses. Am J Psychiatry. 2003;160:4–12.CrossRefPubMedGoogle Scholar
  10. 10.
    Munk-Olsen T, Laursen TM, Pedersen CB, Mors O, Mortensen PB. New parents and mental disorders. JAMA, J Am Med Assoc. 2006;296:2582–9.CrossRefGoogle Scholar
  11. 11.
    Eberhard-Gran M, Eskild A, Tambs K, Samuelsen SO, Opjordsmoen S. Depression in postpartum and non-postpartum women: prevalence and risk factors. Acta Psychiatr Scand. 2002;106:426–33.CrossRefPubMedGoogle Scholar
  12. 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. 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
  14. 14.
    Sharma V, Khan M. Identification of bipolar disorder in women with postpartum depression. Bipolar Disord. 2010;12:335–40.CrossRefPubMedGoogle Scholar
  15. 15.
    Cooper PJ, Murray L. Course and recurrence of postnatal depression. Evidence for the specificity of the diagnostic concept. Br J Psychiatry J Ment Sci. 1995;166:191–5.CrossRefGoogle Scholar
  16. 16.
    Bloch M, Daly RC, Rubinow DR. Endocrine factors in the etiology of postpartum depression. Compr Psychiatry. 2003;44:234–46.CrossRefPubMedGoogle Scholar
  17. 17.
    Bloch M, Schmidt PJ, Danaceau M, Murphy J, Nieman L, Rubinow DR. Effects of gonadal steroids in women with a history of postpartum depression. Am J Psychiatry. 2000;157:924–30.CrossRefPubMedGoogle Scholar
  18. 18.
    Forty L, Jones L, Macgregor S, Caesar S, Cooper C, Hough A, et al. Familiality of postpartum depression in unipolar disorder: results of a family study. Am J Psychiatry. 2006;163:1549–53.CrossRefPubMedGoogle Scholar
  19. 19.
    Treloar SA, Martin NG, Bucholz KK, Madden PA, Heath AC. Genetic influences on post-natal depressive symptoms: findings from an Australian twin sample. Psychol Med. 1999;29:645–54.CrossRefPubMedGoogle Scholar
  20. 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.
  21. 21.
    Byrne EM, Carrillo-Roa T, Penninx BWJH, Sallis HM, Viktorin A, Chapman B, et al. Applying polygenic risk scores to postpartum depression. Arch Womens Ment Health. 2014;17:519–28.CrossRefPubMedGoogle Scholar
  22. 22.
    Diseases of Poverty—InternationalPolicyNetwork.pdf [Internet]. [cited 2015 Jun 10]. Available from: http://www.who.int/intellectualproperty/submissions/InternationalPolicyNetwork.pdf
  23. 23.
    Martín-Santos R, Gelabert E, Subirà S, Gutierrez-Zotes A, Langorh K, Jover M, et al. Research letter: is neuroticism a risk factor for postpartum depression? Psychol Med. 2012;42:1559–65.PubMedCentralCrossRefPubMedGoogle Scholar
  24. 24.
    Monk C, Leight KL, Fang Y. The relationship between women’s attachment style and perinatal mood disturbance: implications for screening and treatment. Arch Womens Ment Health. 2008;11:117–29.PubMedCentralCrossRefPubMedGoogle Scholar
  25. 25.
    Simpson JA, Rholes WS, Campbell L, Tran S, Wilson CL. Adult attachment, the transition to parenthood, and depressive symptoms. J Pers Soc Psychol. 2003;84:1172–87.CrossRefPubMedGoogle Scholar
  26. 26.
    Phillips J, Sharpe L, Matthey S, Charles M. Subtypes of postnatal depression? A comparison of women with recurrent and de novo postnatal depression. J Affect Disord. 2010;120:67–75.CrossRefPubMedGoogle Scholar
  27. 27.
    Jones L, Scott J, Cooper C, Forty L, Smith KG, Sham P, et al. Cognitive style, personality and vulnerability to postnatal depression. Br J Psychiatry J Ment Sci. 2010;196:200–5.CrossRefGoogle Scholar
  28. 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. 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. 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. 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
  32. 32.
    Jones I, Cantwell R. The classification of perinatal mood disorders—suggestions for DSMV and ICD11. Arch Womens Ment Health. 2010;13:33–6.CrossRefPubMedGoogle Scholar
  33. 33.
    Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry J Ment Sci. 1987;150:782–6.CrossRefGoogle Scholar
  34. 34.
    Meltzer-Brody S, Brandon AR, Pearson B, Burns L, Raines C, Bullard E, et al. Evaluating the clinical effectiveness of a specialized perinatal psychiatry inpatient unit. Arch Womens Ment Health. 2014;17:107–13.PubMedCentralCrossRefPubMedGoogle Scholar
  35. 35.
    Munk-Olsen T, Laursen TM, Meltzer-Brody S, Mortensen PB, Jones I. Psychiatric disorders with postpartum onset: possible early manifestations of bipolar affective disorders. Arch Gen Psychiatry. 2012;69:428–34.CrossRefPubMedGoogle Scholar
  36. 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
  37. 37.
    Sharma V, Xie B, Campbell MK, Penava D, Hampson E, Mazmanian D, et al. A prospective study of diagnostic conversion of major depressive disorder to bipolar disorder in pregnancy and postpartum. Bipolar Disord. 2014;16:16–21.CrossRefPubMedGoogle Scholar
  38. 38.
    Bergink V, Koorengevel KM. Postpartum depression with psychotic features. Am J Psychiatry. 2010;167:476–7. author reply 477.CrossRefPubMedGoogle Scholar
  39. 39.
    Sharma V, Burt VK, Ritchie HL. Bipolar II postpartum depression: detection, diagnosis, and treatment. Am J Psychiatry. 2009;166:1217–21.CrossRefPubMedGoogle Scholar
  40. 40.
    Di Florio A, Jones L, Forty L, Gordon-Smith K, Craddock N, Jones I. Bipolar disorder, miscarriage, and termination. Bipolar Disord. 2015;17:102–5.CrossRefPubMedGoogle Scholar
  41. 41.
    Godderis R. Iterative generation of diagnostic categories through production and practice: the case of postpartum depression. Cult Med Psychiatry. 2011;35:484–500.CrossRefPubMedGoogle Scholar
  42. 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
  43. 43.
    Schiller CE, Schmidt PJ, Rubinow DR. Allopregnanolone as a mediator of affective switching in reproductive mood disorders. Psychopharmacology (Berl). 2014;231:3557–67.CrossRefGoogle Scholar
  44. 44.
    Craddock N, Owen MJ. Data and clinical utility should be the drivers of changes to psychiatric classification. Br J Psychiatry J Ment Sci. 2010;197:158. author reply 158–9.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  1. 1.Department of PsychiatryUniversity of North Carolina at Chapel HillChapel HillUSA
  2. 2.Institute of Psychological Medicine and Clinical NeuroscienceCardiff UniversityCardiffUK

Personalised recommendations