Postpartum depression is a common psychiatric disorder that affects 10-15% of women during the first year after childbirth. Women with postpartum depression are more susceptible to recurrent depressive episodes in subsequent pregnancies and show higher levels of depression during the years after giving birth. Children born to mothers with postpartum depression show greater difficulties in cognitive development and more behavioral and emotional problems.
Postpartum depression is also associated with long-term relationship problems that are a risk factor for perinatal depression and prolonged courses of postpartum depression. Persistent postpartum depression is associated with increased risk for child development, while remission of symptoms is associated with normalization of behavioral problems and psychopathology in exposed children.
The effectiveness of antidepressants in the treatment of postpartum depression has been supported by data from randomized clinical trials (RCTs). Selective serotonin reuptake inhibitors (SSRIs) are the preferred option due to better safety and tolerability profiles compared to other antidepressants. However, there is insufficient evidence on the long-term consequences of postnatal SSRI use in mothers and children.
Furthermore, conflicting evidence on the association between prenatal exposure to SSRIs and increased risk of psychiatric problems in offspring may raise concerns about possible negative effects associated with postnatal exposure to SSRIs. This conceptual gap contributes to a lack of trust in the medicalization of postpartum depression among physicians and affected women. Suboptimal treatment is harmful because poorly controlled postpartum depression is associated with many negative outcomes in mothers and children.
The current study examined maternal mental health outcomes along with child developmental outcomes associated with postpartum depression through the fifth postpartum year. We explored whether postnatal treatment with SSRIs moderated any observed associations.
| Methods |
Data were obtained from the Norwegian MoBa prospective cohort study. This study recruited women who attended for routine ultrasound during the 17th to 18th week of pregnancy from 1999 to 2008. More than 95,000 women and 114,000 children were enrolled. Participating families received questionnaires on child development and maternal health conditions at several assessments from the 17th gestational week until the last follow-up.
The current study included women with data on depression symptoms at the 30th week of gestation and the 6th month postpartum, as well as data on self-reported medication use for mental health problems at the 6th month postpartum.
Prenatal maternal factors included self-reported history of current and/or previous depression, educational level, and income at 17 gestational week. Maternal educational level was reported on a scale of 1 to 6, where 1 indicated secondary education and 6 indicated higher education (college and higher). Income was maternal gross annual income.
Data on previous alcohol consumption were collected at week 30 of gestation. The response was categorized based on consumption in any of the 3 trimesters of pregnancy. Tobacco use was defined as tobacco use during the last 3 months of pregnancy reported in the 6th postpartum month. Prenatal maternal depression symptoms were assessed with the 8-item version of the SCL-8 questionnaire at week 30 of gestation.
The diagnosis of postpartum depression was based on EPDS-6 scores measured at the 6th postpartum month for each pregnancy. A cut-off threshold of 7 or more was used to define the diagnosis, which had already been validated in previous studies. Additionally, the SCL-8 was used as a measure of postnatal depression symptomatology in the 6th month postpartum.
Mothers were asked to report any medications they had taken in the 6th month postpartum. The current study focused exclusively on postnatal use of SSRIs. Mothers with postpartum depression who reported treatment with anxiolytics, hypnotics, or non-SSRI antidepressants were excluded.
If the mother with postpartum depression reported SSRI use, she was classified as having postpartum depression treated with SSRIs; if she did not report SSRI use, she was classified as having postpartum depression not treated with SSRIs. Three groups of mother-child dyads were included in the main analyses: no postpartum depression, postnatal depression not treated with SSRIs, and postpartum depression treated with SSRIs.
Maternal outcomes included maternal depression assessed with SCL-8 at 1.5, 3, and 5 years postpartum. Satisfaction with the couple’s relationship was assessed using a relationship satisfaction scale in the 6th month and at 1.5 and 3 years postpartum.
Children’s internalizing and externalizing behaviors in the MoBa were measured with selected items from the Child Behavior Checklist (CBCL) at ages 1.5, 3, and 5 years. Motor and language development were measured with the Ages and Stages Questionnaire at ages 1.5 and 3 years, respectively.
Based on a review of the literature, the authors selected several prenatal factors measured in MoBa as potentially associated with postnatal depression diagnosis and postnatal SSRI treatment. Univariate and multiple logistic regressions were performed to establish how these factors behaved in the sample. Associations between depression symptomatology measured with the SCL-8 at the 6th postpartum month and study outcomes were examined.
| Results |
Of a total of 61,081 mother-infant dyads, 8,671 (14.2%) met the criteria for the diagnosis of postpartum depression, and 177 (2%) received postnatal treatment with SSRIs. Lower educational attainment, lower income level, prenatal tobacco use, history of prior depression, and higher levels of prenatal depression differentiated women with postpartum depression from those without.
Prenatal factors associated with SSRI treatment in women with postpartum depression included lower parity, lower educational level, higher level of prenatal depression, and history of previous depression. Eighty of 177 women (45%) in the SSRI-treated postpartum depression group received SSRIs during pregnancy compared with 352 of 8,494 (4%) in the non-SSRI-treated postpartum depression group.
Severity of postpartum depression was associated with higher levels of maternal depression during the 1.5 to 5 years postpartum and worse relationship satisfaction during the 6th month to 3rd year postpartum. Postpartum depression severity was associated with higher levels of child internalizing and externalizing behaviors, measured between 1.5 and 5 years, worse motor and language development between 1.5 and 3 years, and deficit symptoms. attention/hyperactivity disorder (ADHD) at 5 years old.
Postnatal SSRI treatment moderated the associations between postpartum depression and maternal postpartum depression at 1.5 and 5 years postpartum and relationship satisfaction at month 6 and at 1.5 and 3 years postpartum.
Postnatal treatment with SSRIs also moderated the associations between postpartum depression and childhood externalizing behaviors at 1.5 and 5 years and ADHD at 5 years. Analyzes focusing solely on postpartum depression dyads indicated that postnatal SSRI treatment attenuated the negative associations between depression and maternal relationship satisfaction at month 6 and at 1.5 and 3 years postpartum, and for childhood ADHD at 5 years.
Associations between postpartum depression and maternal and infant outcomes were similar after controlling for prenatal SSRI use. A moderation analysis showed that postnatal SSRI treatment mitigated the negative association between postpartum depression symptoms and maternal depression in the fifth postpartum year even when the level of postpartum depression did not reach the diagnostic threshold.
| Discussion |
Analyzes suggested that postnatal treatment with SSRIs was associated with a reduced risk of subsequent maternal depression and postpartum depression-related childhood externalizing behaviors and ADHD. We found no evidence to suggest that postnatal SSRIs conferred an increased risk of childhood psychopathology or motor and language delay in mother-child dyads affected by postpartum depression.
This study and previous literature suggest that depression and anxiety during pregnancy and a prior history of depression confer the greatest risks for postpartum depression, more so than other factors such as pregnancy-related complications and socioeconomic adversity. The strong risk associated with a prior depression diagnosis was observed regardless of the level of prenatal depression in the current sample. These findings suggest that prenatal screening for a history of depressive disorder may be useful in flagging an increased risk of postnatal depression.
Lifetime history of depression was also independently associated with the likelihood of postnatal SSRI use in women with postpartum depression. Additionally, lower parity and lower levels of maternal education were found to be associated with postnatal SSRI use. This suggests that the use of SSRIs for postpartum depression also depends on social and personal factors, such as awareness of mental health problems and the availability of other non-pharmacological interventions.
Greater postpartum depression symptomatology was associated with elevated levels of maternal depression and relationship dissatisfaction up to 5 years postpartum. Dissatisfaction in the relationship is an established risk factor for the onset and persistence of postpartum depression. Associations were identified between postpartum depression and cognitive, emotional, and behavioral impairment in children exposed during childhood.
Proper treatment of postpartum depression is important given its negative outcomes on mothers, children, and the family as a whole. However, limited evidence on the long-term consequences of postnatal SSRI use on offspring may make treatment hesitant. The low prevalence of SSRI use in women with postpartum depression suggests possible inadequate treatment of the condition.
This study provides evidence that postnatal treatment with SSRIs mitigated the negative associations between postpartum depression and ADHD symptoms in children born to mothers with more pronounced postpartum depression symptoms. We found no evidence that SSRIs were associated with an increased risk of delayed motor and language development associated with postpartum depression up to 5 years of age.
| Conclusions |
Postpartum depression was associated with worse maternal and infant outcomes up to the fifth year postpartum. However, associations between postpartum depression and some unfavorable outcomes were attenuated by SSRI treatment. These findings need to be replicated.
