Recurrence Rates and Risk Factors in Perinatal Mood Disorders

Anyone who works regularly with perinatal women will eventually find themselves face to face with a worried mother in their office thinking about becoming pregnant or already pregnant with her second (or third) child. The most likely question that this woman will ask is “What are my chances of getting postpartum depression (anxiety, psychosis) again?” Sheila Marcus, MD, psychiatrist and clinical professor of psychiatry at the University of Michigan, cites the risks as follows: 30% for unipolar depression, 50% for bipolar depression and 70% for postpartum psychosis. Some women have such horrendous mood or psychotic complications that they decide against having another child because for them, it just isn’t worth the risk. While the DSM5 does have a depression modifier for postpartum onset, it restricts onset of depression to one month postpartum. In reality, postpartum mood disorders usually happen between one and six months, with three to four months being the most common time of ons

While many perinatal professionals counsel their patients/clients regularly about the likelihood for recurrence of perinatal mood disorders, a quick review of the literature reveals little, and conflicting, research on this topic. One double-blind study compared a group of women who had suffered postpartum major depression. The women were randomly assigned to either a placebo or Nortriptyline group. No significant results were found with the Nortriptyline group providing no benefits beyond that provided for by the placebo group. A cohort study using Danish medical records comparing recurrence rates of women with perinatal mood and anxiety disorders hospitalized for their first birth found the recurrence rate to be 55.4 per 100 persons for the second birth. For women in this cohort taking postpartum antidepressant medication, the rate was reduced to 35.0 per 100 persons. For non-hospitalized women, the estimated recurrence risk of postpartum affective disorders was 15% for women taking postpartum antidepressant medication subsequent to the first birth and 21% for women not taking psychotropic medication, with the observed risk for depression remaining elevated for several years. Postpartum affective disorders including postpartum depression affect more than one in 200 women with no prior history of mood and anxiety disorders. This raises the risk for subsequent affective disorders.

Literature on the role of bi-polar disorder in perinatal mood disorders is even more sparse. One study sought to determine the recurrence rate of perinatal women with bi-polar disorder who discontinued their medication. For the first 40 weeks after lithium discontinuation, the recurrence rates were nearly identical between pregnant and nonpregnant women but then rose sharply during the postpartum period. The risk of bi-polar symptoms returning lowered significantly when medication was reduced gradually.

Knowledge of known risk factors for perinatal mood and anxiety disorders is also helpful in determining the likelihood of a recurrence in a subsequent pregnancy. A meta-analysis of 84 studies from the 1990’s was completed to determine the main risk factors for postpartum depression. In order of size effect (from greatest to least), these were the risk factors which were found: prenatal depression, self esteem, childcare stress, prenatal anxiety, life stress, marital relationship, history of previous depression, infant temperament, maternity blues, marital status, socioeconomic status and unplanned/unwanted pregnancy. In another comprehensive, more recent study led by Cheryl Beck, depression or anxiety during pregnancy, past history of psychiatric illness, life events, social support, neuroticism, marital relationship, and socioeconomic status were all found to be correlated with recurrence of mood and anxiety disorders during the postpartum period. A large prospective study occurring just last year found similar results but also found that antenatal depressive symptoms were as common as postpartum depressive symptoms in perinatal women with mood disorders.

Much more research is needed to more accurately determine how women will fare with subsequent pregnancies after experiencing anxiety, depression and psychosis during the perinatal period of earlier births. It is helpful to keep in mind that perinatal mood disorders often go unreported. Women of color have higher rates of perinatal depression and anxiety but their needs frequently go unaddressed. While research knowledge slowly grows, the studies do seem to agree that a history of depression and/or anxiety either in one’s history or during pregnancy is a robust predictor for postpartum depression and anxiety. The studies also largely support the use of psychotropic medication as a powerful tool in reducing the recurrence rates of perinatal mood disorders. Finally, studies on perinatal risk factors consistently find that psycho-social factors play an important role in whether or not women develop prenatal and postpartum anxiety and mood disorders. This finding strongly suggests that psychotherapy, support groups and other forms of support (i.e. lactation consultant, doula and family support etc.) may play an important role in helping women recover from the most common side effect of pregnancy, birth and the postpartum period whether the mother is having her first or fourth child.

References

Vann, M., Will Postpartum Depression Return the Second Time Around? Everyday Health.
Postpartum Depression Timeline. Retrieved from https://www.postpartumdepression.org/postpartum-depression/timeline/.
Rasmusen, M-L.Hl, Strom, M. Risk, Treatment Duration and Recurrence Risk of Postpartum Affect Disorder in Women with no Prior Psychiatric History: A Population-Based Cohort Study. https://doi.org/10.1371/journal.pmed.1002392 PLOS-Medicine, Sept. 26, 2017
Viguera, A.C.and Nonacs, R. et al. Risk of recurrence of bipolar disorder in pregnant and nonpregnant women after discontinuing lithium maintenance. American Journal of Psychiatry.2000;157(2):179-84.
Beck, C.T. Predictors of Postpartum Depression: An Update. Nurs Res. 2001; 5(5):275-85.
Robertson, E., Grace, S. et al, Antenatal Risk Factor for Postpartum Depression: A Synthesis of Recent Literature. General Hospital Psychiatry. 2004;26(4):289-295.
Milgrom, J. and Gemmill, A.W. et al., Antenatal Risk Factor for Postnatal Depression: A Large Prospective Study,Journal of Affective Disorders. Journal of Affective Disorders. 2008;108 147-157.
Ford, S. (Ed.) (2011, October 26) Postpartum Depression”Often Unreported”. Retrieved from https://www.nursingtimes.net/clinical-archive/postnatal-depression-often-unreported/5036928.article
Karras, T. PMADs – Such as PPD and Anxiety – in African American Moms: Why Black Women Face a Higher Risk but Receive Less Treatment. Retrieved from https://www.seleRni.org/advice-support/2018/3/16/pmads-such-as-ppd-and-anxiety-in-african-american-moms.
Robertson, E., Grace, S. et al, Antenatal Risk Factor for Postpartum Depression: A Synthesis of Recent Literature. General Hospital Psychiatry. 2004;26(4):289-295.
Field, T. and Diego, M. et al. Yoga and Massage Therapy Reduce Prenatal Depression and Prematurity. Journal of Bodywork and Movement Therapy. 2012;16(2):204-9.

Terri Buysse is a clinical psychologist with a private psychotherapy practice in Edmonds and Everett, Washington. She specializes in perinatal, parenting, and trauma work. She is one of the facilitators for Little Sprouts, a new mothers’ support group in Mountlake Terrace, and is a member of Perinatal Support Washington.