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Major depressive disorder (MDD) and postpartum depression (PPD) are two types of depression that can significantly impact an individual’s mental health and emotional well-being. While MDD and PPD share many similarities regarding symptoms experienced by patients, they differ in their onset, risk factors, and treatment approaches. PPD is not distinctively defined under its own section in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5); rather, it is listed under depressive disorders with a specifier of peripartum onset, with symptoms occurring during pregnancy and within 4 weeks following delivery.^1,2 Outside of the DSM-5, PPD is often defined with the onset of symptoms occurring up to 1 year following delivery.³ Additionally, the DSM-5 helps to clarify that PPD is a type of MDD with distinct onset.² To meet the criteria for MDD, 5 or more symptoms, such as a depressed mood, loss of interest or pleasure in activities, difficulty sleeping, difficulty concentrating, appetite changes, loss of energy, feelings of worthlessness, and suicidal thoughts must be present for at least 2 weeks, with at least 1 of the symptoms being either depressed mood or loss of interest or pleasure.¹ Due to the connection between MDD and PPD, some studies have suggested that women with a history of depressive disorder may be at an increased risk of developing PPD.⁴

For example, in a meta-analysis of 28 articles from various studies worldwide, as many as 19.2% of new mothers experienced either major or minor depression within the first 3 months following delivery, with as many as 7.1% experiencing major depression.⁵ However, due to the wider-than-preferred 95% confidence intervals for the period-prevalence estimates (percentage of the population with depression over a period of time), the true prevalence remains unclear.⁵ Incidence estimates from the same study, however, showed that up to 14.5% of women had a new depressive episode within the first 3 months after delivery, of whom 6.5% had major depression.⁵ The authors concluded, however, that there was not enough evidence to suggest that the prevalence of depression before or after childbirth was higher during pregnancy or at any particular month within the first year after delivery.⁵

In a more recent study, researchers took a different approach in attempting to establish a causal connection between MDD and PPD. They looked at the predictive factors for PPD, rather than prevalence and incidence estimates as in the previous study. Subsequently, they identified that prior history of psychiatric disorder assessment was one of the greatest predictors of PPD both before and during pregnancy.⁶ Additionally, increases in adverse life events, such as childhood trauma, were also associated with increased risk for PPD.⁶ Given that various predictors for PPD, such as genetic predisposition and hormonal, molecular, and social-economic stressors, were also discussed in this study, the majority of the focus was on the effect that psychiatric history had on patients developing PPD.⁶ However, recent findings suggest that PPD has a higher heritability—approximately 50%—than MDD, indicating a more uniform type of depression.⁶ Psychiatric disorder history, PPD history, or family history of postpartum psychosis, may be considered the best current predictors of PPD.⁶  Many non-psychiatry clinicians often forget or neglect to routinely screen for psychiatric disorder history, whether by reviewing patient charts, diagnostic interviews, or patient-reported assessments.⁶ Incorporating such psychiatric screening, including the utilization of the Edinburgh Postnatal Depression Scale (EPDS) within the Consultation Liaison in Mental Health and Behavior (CLIMB) initiative, a program that emphasizes the importance of effective screening and intervention strategies for addressing pregnancy-related depression (PRD) in pediatric primary care, may also help to encourage strong collaborative relationships between families, primary care providers, and mental health providers, fostering a better understanding of the connection between PDD and MDD.^6,7
 
Various attempts have not successfully established a causal connection between MDD and PPD, which is the depression experienced by women after giving birth. This relationship is complex and can be influenced by several factors, including the stigma women may feel when they are not happy about their newborn or experience negative emotions during this period. Understanding this intricate relationship is crucial for the development of effective prevention and treatment strategies. In one of the largest cohort studies conducted on minority women with PPD, psychiatric history and exposure to adverse life events were the main predictors of PPD when examined together with genetic history, family history, previous PPD event, and other risk factors.⁸ Therefore, conducting a single assessment of a patient’s prior psychiatric and trauma history before and after childbirth, along with routine tests for mood changes, may increase a clinician’s ability to predict the onset of PPD and prevent the impacts of a depressive period in a time when bonding with others and child is formative to long-term development.⁸

References:

1.    American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Publishing; 2013.

2.    Hutchens BF, Kearney J. Risk factors for postpartum depression: an umbrella review. J Midwifery Womens Health. 2020;65(1):96-108. doi:10.1111/jmwh.13067

3.    Postpartum depression. National Library of Medicine. Updated July 28, 2022. Accessed March 29, 2023. https://medlineplus.gov/ency/article/007215.htm.

4.    Marcus SM, Flynn HA, Blow FC, Barry KL. Depressive symptoms among pregnant women screened in obstetrics settings. J Womens Health (Larchmt). 2003;12(4):373-380. doi:10.1089/154099903765448880

5.    Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G, Swinson T. Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol. 2005;106(5 Pt 1):1071-1083. doi:10.1097/01.AOG.0000183597.31630.db

6.    Guintivano J, Manuck T, Meltzer-Brody S. Predictors of postpartum depression: a comprehensive review of the last decade of evidence. Clin Obstet Gynecol. 2018;61(3):591-603. doi:10.1097/GRF.0000000000000368   

7.    Lovell JL, Roemer R, Talmi A. Pregnancy-related depression screening and services in pediatric primary care. American Psychological Association. Published May 2014. Accessed May 19, 2023. https://www.apa.org/pi/families/resources/newsletter/2014/05/pregnancy-depression

8.    Guintivano J, Sullivan PF, Stuebe AM, et al. Adverse life events, psychiatric history, and biological predictors of postpartum depression in an ethnically diverse sample of postpartum women. Psychol Med. 2018;48(7):1190-1200. doi:10.1017/S0033291717002641