Round 1: How Should the Postpartum Period Be Defined?

In the first round of this debate, our participants address the question: How should the postpartum period be defined?

Transcript:

Nicole Cirino, MD: Alright, so let's jump right into addressing our first topic, which is how should the postpartum period be defined? Dr Barrett, can you give us an overview of how postpartum depression is currently classified?

Melanie Barrett, MD: Yes. So, expert opinions do vary on the onset of PPD and how the postpartum period should be defined. So according to the APA, the American Psychiatric Association, and the American College of Obstetricians and Gynecologists, ACOG, postpartum depression is a type of major depressive episode of major depressive disorder. So, if we look at the DSM-IV, it included distinct timing of major depression with a postpartum onset, which included an onset of a depressive episode within 4 weeks after birth, after delivery. So now we look at the DSM-V, and it has included episodes that begin during pregnancy. So, with a peripartum onset, it still includes that 4 weeks after delivery, right? So, we're talking about postpartum onset, peripartum onset, postpartum depression, but we can also scale back and look at, okay, perinatal depression. And that typically refers to depression that starts during pregnancy or up to 12 months postpartum.

So ACOG defines postpartum depression onset to occur during pregnancy or within 12 months postpartum. And the World Health Organization states that onset of PPD occurs within 12 months postpartum without any mention of onset during pregnancy. We also know that elevated depressive symptoms, if untreated or undertreated, can persist for years beyond the postpartum period. So, really, the argument for broadening the definition of postpartum depression to include onset during pregnancy like the DSM-V and the first year postpartum, like the World Health Organization, allows us to capture a wider range of women suffering from depression across this stage of the reproductive cycle. And that's a really a strong positive. The broad definition also likely benefits aspects of community health. We're thinking about screening clinician education, access to care, and available social support structures.

Nicole Cirino, MD: No, absolutely. That's very fair, and thank you for that overview. Certainly, there've been many different opinions over the last several years, and I think this very important question is important. The future of our field of perinatal mental health. Just reflecting back, remember it was only in 1994, 25 or more years ago, when, according to DSM-IV, postpartum depression wasn't even considered to be a thing. There wasn't even a specifier at all. So, that is not even very long ago in the history of psychiatry, where it was not recognized. So, I think where I would disagree here is that, in my opinion, lumping all the depressive disorders that occur over this highly variable period into one single category negatively affects our ability to scientifically study and understand the heterogeneity of this illness. So, I think to obtain a better scientific understanding of the condition of PPD, we need to recognize the subtypes of the condition, and those should be in our definitions of the condition.

For instance, an episode of depression that occurs in a 16-week pregnant mother who has no past psychiatric history after her child is diagnosed with an anomaly, is really not likely the same condition then the postpartum mother who has a history of PMDD, who now experiences new onset PPD within 72 hours after delivery. And I just wonder, in the future, will we be assessing or even treating these two conditions in the same way? There is also a form of the illness that may have onset during pregnancy but then continues in the postpartum period. Is that the same condition? And furthermore, a postpartum depression with anxious and obsessional features, as we know, is common in postpartum depression. Is that ideologically different from an anergic postpartum depression? From a clinical public health standpoint? Yes, I support the broad definition of PPD to include pregnancy in the first year postpartum. However, in my opinion, organizations such as the APA and their subsequent DSM classifications should further delineate PPD to include categories such as onset during pregnancy, or onset within the first 8 weeks postpartum, or onset during the first year because I think they probably are distinct conditions.

Melanie Barrett, MD: So, I'd like to make the point that the time of onset of postpartum depression does not always equate to the time that someone is seen in the office and receives a diagnosis of postpartum depression. So also, symptoms of PPD are not always obvious to the patient at the time of symptom onset. For various reasons, there may be a significant delay in time from actual onset of symptoms to the time that someone recognizes that something is not right and also has the ability to access care. We need to think about the question regarding the timing of onset of PPD from different perspectives: from a biological perspective, from an access to care perspective, and from a clinical assessment and treatment perspective. So, as Dr Cirino emphasized, perinatal depression is a heterogeneous illness. I agree that, as a field, we need to further delineate PPD to better be able to understand the nuances that may impact treatment recommendations. But I'm also advocating for an overarching, broad definition of perinatal depression to include onset during pregnancy and up to 1 year after delivery. We need to reduce barriers to accessing care and treatment for our patients, not restrict it. So, we know that undertreated, untreated postpartum depression can persist for years, and we also know that PPD impacts not only the patient but baby and the whole family. So, it's crucial to identify and treat postpartum depression whenever the onset as quickly as possible.

Nicole Cirino, MD: Well, thank you, Dr Barrett, and thank you all for watching. Be sure to stick around for our next in this debate whether the timing of onset for postpartum depression is relevant from a biological perspective.