Timing of depression recurrence in the first year after birth

doi:10.1016/S0165-0327(02)00305-1

Journal of Affective Disorders

Volume 78, Issue 3, March 2004, Pages 249-252

https://doi.org/10.1016/S0165-0327(02)00305-1 Get rights and content

Abstract

Background: Women who have suffered from one episode of postpartum-onset major depression (PPMD) experience increased risk for recurrence in the year following another birth. Methods: Non-depressed women (N=51) who had at least one past episode of PPMD were recruited during pregnancy. After birth, subjects were assessed prospectively each week for 20 weeks with the Hamilton Rating Scale for Depression and Research Diagnostic Criteria for recurrence of major depression. Evaluations were carried out at 24, 36, and 52 weeks to assess for episodes beyond 20 weeks postpartum. Results: The data revealed a clustering of cases, with five of the 21 recurrences (24%) occurring in the first 2 weeks. Thirteen of the 21 recurrences (67%) and 19/21 recurrences (90%) occurred in the first 20 and 28 weeks following birth, respectively. Limitations: Although it is unusual for studies of this type to be prospective, the sample size is relatively small. Conclusions: The 1-year recurrence rate was 21/51 or 41%, with a clustering of cases near delivery. All recurrences except two occurred by 28 weeks postpartum.

Introduction

The postpartum period is associated with an increase in risk for the onset of mood disorders. Kendell et al. (1987) found a rise in the rate of psychiatric admission in the first 3 months following childbirth, with a dramatic peak in the first 30 days. Cox et al. (1993) reported that 16 postpartum women developed episodes within 5 weeks of birth, compared with only five control women during the corresponding time period. This threefold higher rate of depression onset within 5 weeks of delivery also demonstrated a clustering of new cases after birth. Like other investigators (O’Hara et al., 1990), Cox and colleagues failed to find a significant difference in the point prevalence of depression later in the postpartum year. Women at 6 months postpartum exhibited a prevalence of depression similar to controls (9.1 and 8.2%, respectively).

These data have implications for the definition of postpartum onset, which is a longitudinal course modifier in the Diagnostic and Statistical Manual (DSM-IV; American Psychiatric Association, 1994) to describe an episode of major depression that begins within 4 weeks of birth. The International Classification of Diseases (ICD-10) permits designation as mental and physical disorders associated with the puerperium only if the disorders begin within the first 6 weeks post-birth and do not meet criteria for other disorders (Elliott, 2000). However, investigators’ definitions vary, and lengths of time up to a year following birth have been used (Kendell et al., 1987). In this study, we prospectively assessed the timing and pattern of recurrence of depression during the first postpartum year in high-risk women who had prior episodes of postpartum major depression (PPMD).

Section snippets

Methods

Women in the study (N=51) from which this report was derived (Wisner et al., 2001) were treated with nortriptyline or placebo postpartum to prevent recurrence of PPMD. The Randomized Clinical Trial (RCT) began immediately after delivery. Subjects were aged 21–45 years and had at least one past episode of PPMD with onset of symptoms within the first 3 months after a live birth (Wisner et al., 2001). The past episode had to fit Research Diagnostic Criteria (RDC; Spitzer et al., 1978) for definite

Results

There were 21 recurrences in 51 subjects in the first postpartum year. In Fig. 1, we display the 19 recurrences that were clustered in the first 28 weeks. Only two additional recurrences (at weeks 50 and 52) were observed.

Discussion

Although our sample was a high-risk group of women with previous episodes of PPMD, we found a pattern of recurrence remarkably similar to that reported in the large epidemiologic study by Kendell et al. (1987). Of 257 women who were admitted to a psychiatric hospital in the first year after birth, 68 (26%) were admitted in the first month. In our investigation, five of the 21 women (24%) who suffered recurrences in the first postpartum year experienced onset in the first month. The majority of

Acknowledgments

Supported by National Institute of Mental Health grants #57102 and #60335 to Drs Wisner and Perel. Also supported by the National Institute of Mental Health Clinical Pharmacology Core (#30915) to Dr Perel.

References (10)

American Psychiatric Association, 1994. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. American...
M. Bloch et al.
Effects of gonadal steroids in women with a history of postpartum depression
Am. J. Psychiatry
(2000)
J.L. Cox et al.
A controlled study of the onset, duration and prevalence of postnatal depression
Br. J. Psychiatry
(1993)
S. Elliott
Report on the Satra Bruk workshop on classification of postnatal mental disorders November 7–10, 1999, convened by Birgitta Wickberg, Philip Hwang and John Cox with the support of Allmanna Barnhuset represented by Marina Gronros
Arch. Womens Mental Health
(2000)
M. Hamilton
A rating scale for depression
J. Neurol. Neurosurg. Psychiatry
(1960)

There are more references available in the full text version of this article.

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Major depressive disorder (MDD) is a debilitating and recurrent disorder that affects approximately 264 million people worldwide (James et al., 2018). While the first onset of MDD commonly occurs during late adolescence and young adulthood (Kessler et al., 2005; Breslau et al., 2017), this recurrent disorder also presents at other life stages, including in middle age and late life (Wisner et al., 2004; Wang et al., 2017; Byers and Yaffe, 2011). Because effective treatment requires knowledge of risk factors and their neurobiological mechanisms, the study of structural brain alterations has been critical in advancing our understanding of the capacity for neuroplasticity in MDD and its implications for treatment (Albert, 2019; Joshi et al., 2016; Korgaonkar et al., 2015).
Major depressive disorder (MDD) is a complex disorder that affects nearly 264 million people worldwide. Structural brain abnormalities in multiple neuroanatomical networks have been implicated in the etiology of MDD, but the degree to which MDD affects brain structure during early to late adulthood is unclear.
We examined morphometry of brain regions commonly implicated in MDD, including the amygdala, hippocampus, anterior cingulate gyrus, lateral orbitofrontal gyrus, subgenual cortex, and insular cortex subregions, from early to late adulthood. Harmonized measures for gray matter (GM) volume and cortical thickness of each region were estimated cross-sectionally for 305 healthy controls (CTLs) and 247 individuals with MDD (MDDs), collated from four research cohorts. We modeled the nonlinear associations of age with GM volume and cortical thickness using generalized additive modeling and tested for age-dependent group differences.
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Postpartum depression often resolves spontaneously within a few months (a remission rate of 53% within one year in the case of untreated depression in adult samples – Whiteford et al., 2013). However, about 30% of women feel worse even more than a year after having a baby, and there is a high risk (about 40%) of relapses (see: Goodman, 2004; Wisner et al., 2004). Psychiatric disorders are one of the leading indirect causes of maternal morbidity and one of the main causes of death in the postpartum period (Knight et al., 2017; Wisner et al., 2019).
Before January 2019, no established solutions regarding the screening, assessment, and treatment of patients suffering from perinatal depression existed in Poland. From 2019, a new standard of perinatal care has imposed the obligation to monitor the mental state of women during pregnancy and in the postpartum period on the healthcare providers (mainly on midwives). Thus, our study aimed to evaluate midwives’ knowledge about prenatal and postnatal mental health disorders in the first six months of implementing the new standard of perinatal care in Poland.
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Brief reportTiming of depression recurrence in the first year after birth

Abstract

Introduction

Section snippets

Methods

Results

Discussion

Acknowledgments

Effects of gonadal steroids in women with a history of postpartum depression

Am. J. Psychiatry

A controlled study of the onset, duration and prevalence of postnatal depression

Br. J. Psychiatry

Report on the Satra Bruk workshop on classification of postnatal mental disorders November 7–10, 1999, convened by Birgitta Wickberg, Philip Hwang and John Cox with the support of Allmanna Barnhuset represented by Marina Gronros

Arch. Womens Mental Health

A rating scale for depression

J. Neurol. Neurosurg. Psychiatry

Brief report
Timing of depression recurrence in the first year after birth