Christina Sommerdyk

Are Antidepressants Effective in the Treatment of Postpartum Depression? A Systematic Review

Objective: In spite of the paucity of randomized controlled trials of antidepressants in postpartum depression, these drugs are the most commonly used agents in the pharmacologic treatment of postpartum depression. This article reviews the literature on the efficacy of antidepressants in randomized controlled trials of postpartum depression. Data Sources: Four electronic databases, MEDLINE/PubMed (1966–2013), PsycINFO (1806–2013), EMBASE (1980–2013), and the Cochrane Database of Systematic Reviews, were searched using a combination of the keywords antidepressive agents/therapeutic use, antidepressant drugs, antidepressant agent/drug therapy, depression, postpartum/drug therapy, postpartum depression, and puerperal depression/drug therapy. Study Selection: The reference lists of articles identified were also searched. All relevant articles published in English were included. A total of 124 articles were identified. The efficacy of antidepressants has been studied in 6 randomized controlled trials, of which 3 were placebo-controlled studies. Results: Placebo-controlled randomized data do not support the notion that antidepressants are efficacious in postpartum depression. However, the methodological flaws of studies have to be kept in mind while interpreting the results of these studies. Conclusions: Due to the paucity of controlled data and methodological limitations of studies, the question about the efficacy of antidepressants in postpartum depression cannot be answered unequivocally.

Pharmacotherapy of bipolar II disorder during and after pregnancy

OBJECTIVES The objective of this study was to evaluate the pharmacotherapy of bipolar II disorder during pregnancy and the postpartum period. METHODS The use of psychotropic drugs and recurrence risk during and after pregnancy was studied in a prospective, observational study of 37 women with bipolar II disorder. RESULTS During pregnancy the majority of participants (54.0%) were not on any psychotropic medication, approximately one third (32%) received monotherapy, and the rest were on combination therapy. In comparison, during the postpartum period only 14% of participants were not on any psychotropic medication, approximately 35% received monotherapy, and over 50% were on combination therapy. While only 13.5% of participants were on 3 or more psychotropic drugs during pregnancy, 21.6% required 3 or more psychotropic drugs after childbirth in order to manage their symptoms. During pregnancy, 51 % of women had a mood episode compared to a recurrence rate of 70% in the postpartum period. LIMITATIONS Small sample size, lack of a control group, and absence of random treatment assignment. CONCLUSIONS The findings of this prospective, observational study indicate that the recurrence risk is much higher after childbirth than during pregnancy in spite of higher utilization of psychotropic drugs in the postpartum period.

Postpartum psychosis: what is in a name?

The term postpartum mood disturbance generally refers to maternity blues, postpartum depression and postpartum psychosis (PP). PP is the most serious but rare complication of childbirth that follows 0.1–0.2% of deliveries. The typical clinical picture of PP has been described as a woman with ‘an odd affect, withdrawn, distracted by auditory hallucinations, incompetent, confused and catatonic; or alternatively elated, labile or rambling in speech, agitated or excessively active’ (Brockington et al., 1981). Psychotic features can occur alone or in combination with rapidly fluctuating mood symptoms. Co-occurrence of manic and depressive symptoms with psychotic features has also been noted. Confusion and perplexity are often mentioned as distinctive features of PP but these symptoms may be a consequence of the severity and/or acuity of the postpartum episode. The risk for PP is increased in women with a personal or family history of bipolar disorder (BD) and/or PP. The risk of recurrence of a postpartum episode with psychotic features is between 30% and 50% (American Psychiatric Association, 2013). Owing to its acute onset, rapidly escalating symptoms, and association with maternal suicide and infanticide, PP is a psychiatric emergency that often requires psychiatric hospitalization. For some women the psychotic episode is limited to the postpartum period, but the majority of women have both puerperal and non-puerperal recurrences. Psychosis limited to the postpartum period has a distinct risk profile and phenomenology compared to PP occurring as part of BD. Despite lack of acceptance of PP by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as a separate diagnostic entity and lack of consensus about its definition, the term PP remains widely used by clinicians and researchers alike (American Psychiatric Association, 2013). The debate about its definition has centered on the diagnostic composition of PP, the duration of the postpartum period, and whether or not to include disorders with prepartum onset (Chaudron and Pies, 2003). In this paper, we discuss the limitations of using PP as a diagnostic label. We argue that the term ‘postpartum psychosis’ should be dropped and replaced with more specific diagnostic entities.

Lithium Treatment of Chronic Nail Biting

To the Editor: Nail biting or onychophagia has been variously described as a habit to release tension, self-mutilation behavior, or an impulse control disorder. In the DSM-5, nail biting is classified as an obsessive-compulsive and related disorder.1 Studies have found that between 28% and 33% of children between ages 7 and 10 years, 44% of adolescents, and 19%–29% of young adults engage in nail biting.2 Nail biting usually occurs in combination with other problematic body-focused repetitive behaviors such as hair pulling disorder and skin picking disorder. Nail biting in adults is underrecognized because patients often fail to seek help due to feelings of shame and embarrassment, and, consequently, the disorder has received little attention in the psychiatric literature. In most cases, nail biting seems to be only a cosmetic issue, and no treatment is required. But, in severe cases, untreated nail biting can result in a host of complications such as severe damage to the cuticles and nails, paronychia and secondary bacterial infection, dental problems, and temporomandibular dysfunction.3 Studies on drug treatment of nail biting are sparse and limited to antidepressants and N-acetylcysteine.4 We present a case of chronic, severe onychophagia comorbid with bipolar II disorder and substance use disorder and discuss the successful treatment of these disorders with lithium monotherapy. Case report. Ms A, a 28-year-old woman, was referred by her family physician for assessment and management of depression. She met DSM-5 criteria for bipolar II disorder and was noted to be in remission for substance use disorder (alcohol dependence and cocaine use). At the time of initial assessment, Ms A endorsed various symptoms of depression including thoughts of suicide. Due to concerns regarding her safety, lithium 900 mg daily was started, and the dose was optimized to achieve a serum level of 0.7 mmol/L. Within 2 months of lithium treatment, Ms A experienced remission of depression and has been symptom free for 2 years. A serendipitous finding was remission of symptoms of chronic nail biting that Ms A had struggled with since she was 12 years old. Various strategies including habit reversal training, self-monitoring, and competing response had been ineffective.5 The condition was severe because Ms A had to regularly cover the nail beds with Band-Aids to control the bleeding. Moreover, it affected her self-esteem and caused a great deal of emotional distress. The marked improvement following lithium treatment was noted by Ms A’s family and friends, who had not seen her undamaged nails in at least 15 years. Clomipramine and selective serotonin reuptake inhibitors are generally recommended in severe cases of nail biting, but the use of these drugs can cause treatment-emergent mania in individuals with bipolar disorder. Thus, the drug choice for onychophagia should be informed by the nature of the comorbid psychiatric disorder. There are reports of effectiveness of lithium in body-focused repetitive behaviors such as hair pulling disorder and skin picking disorder with comorbid bipolar disorder. It is not known if lithium is effective in patients with onychophagia in the absence of bipolar disorder. To our knowledge, this is the first reported case of lithium effectiveness in nail biting. Studies are needed to clarify the role of lithium in the management of severe nail biting in the absence of comorbid bipolar disorder.

Antidepressants and recurrence of depression in the postpartum period

To examine postpartum recurrence rates of depression comparing women receiving antidepressant treatment to women not being treated with psychotropic medication. This was a prospective study of 130 women with major depressive disorder (MDD) who attended a tertiary care perinatal clinic during and after pregnancy. Depression recurrence was defined as a score of 13 or more on the Edinburgh Postnatal Depression Scale (EPDS) or a score of greater than 13 on the Hamilton Depression Rating Scale (HDRS). Over half of women (56.9%) were not receiving medication during pregnancy to treat their mood disorder, with the rate of medication use increasing over the 1-year postpartum period. When comparing women being treated with antidepressant medication (monotherapy or combination therapy) to women receiving no psychotropic medication, no significant differences in recurrence rates were observed during the postpartum period. However, we did observe that the occurrence of depression in our sample fluctuated between rates comparable to general population estimates to rates that were at times more than twofold higher, regardless of treatment with antidepressant medication. The findings of this study align with research which suggests that the postpartum period is a particularly vulnerable time for recurrence of depression. Moreover, our results suggest that this remains the case regardless of antidepressant treatment.

Post-abortion mania

We describe case histories of three women with post-abortion mania, including two women who underwent a change in diagnosis from bipolar II to bipolar I disorder and another woman who had no prior history of psychiatric disturbance. It is argued that the study of post-abortion mania should provide an opportunity to better understand the aetiology of puerperal mania.