We thank Froeliger et al for their comprehensive review of maternal mental health complications after cesarean delivery, including their discussion of childbirth-related posttraumatic stress disorder (PTSD) alongside postpartum depression. We offer 3 points for consideration.
Childbirth-related PTSD and postpartum depression are commonly reviewed separately, but their interplay is clinically important. Existing studies suggest high comorbidity between childbirth-related PTSD and postpartum depression, possibly higher than the documented co-occurrence in non–postpartum populations.
Recent evidence strongly supports substantial shared genetic liability between PTSD and depression, suggesting that these conditions are not simply co-occurring but arise from a shared diathesis. When cesarean delivery is experienced as traumatic, particularly when unexpected or emergent, both conditions may be conceptualized as arising after trauma exposure and sharing cross-disorder risk factors. Although 1 disorder may increase the risk of the other, PTSD is the most common disorder resulting from trauma in accordance with psychiatric nosology.
In addition, evidence suggests that depression often emerges secondary to PTSD, underscoring PTSD as the primary posttraumatic mental health condition.
Comorbid childbirth-related PTSD and postpartum depression may represent a higher-order construct of trauma-related psychopathology. In the field of psychiatry, diagnostic boundaries are being debated. Individuals exposed to trauma may exhibit a unified traumatic stress and depressive response, which has been reported in postpartum women. Trauma-related depression has demonstrated poorer response to conventional antidepressant treatment.
Accurate diagnosis is essential for effective care. Because screening for postpartum depression is commonly implemented in postpartum medical settings, use of a depression screener without assessment of PTSD symptoms after traumatic childbirth, such as an unscheduled or emergent cesarean delivery, may result in misdiagnosis and ineffective treatment. Although further research is needed to untangle the complex relationship between PTSD and depression, for postpartum women who undergo a traumatic cesarean delivery, an initial focus on PTSD screening using a brief self-report measure, followed by evaluation of depressive symptoms when dysphoric features are endorsed as part of PTSD assessment, may be warranted.
Finally, distinguishing the traumatic events defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, that may lead to PTSD from the broader concept of a “traumatic childbirth experience” is essential. Some reports of PTSD after elective cesarean delivery may not meet Criterion A for PTSD. Failure to differentiate these entities may inflate prevalence estimates and obscure the substantial PTSD burden associated with cesarean deliveries occurring during labor, which represent a high risk of PTSD and necessitate timely, evidence-based mental health intervention.
The authors report no conflict of interest.
S.D. was supported by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)/ National Institutes of Health (NIH) (grant numbers: R01HD108619 and R21HD109546). S.D. and F.H. were supported by NICHD/NIH (grant number: R01HD119967). The sponsor was not involved in the decision to submit this response.
References
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