Postpartum Depression

There has been considerable clinical and research interest in postpartum depression. This has been largely provoked by the accumulating evidence that postpartum depression is associated with disturbances in child socioemotional development. This evidence has renewed concern about the epidemiology of postnatal depression, its etiology, methods of prediction and detection, and the most appropriate form of management.

The Nature of Postpartum Depression

Postpartum depression must be distinguished from two other mood disorders which occur after the birth of a child. The first is the maternity blues, a common disturbance in mood, which arises in the first few days following delivery and usually remits within a week or two, and is characterised by marked swings in mood (lability). It is not, in itself, of psychiatric significance. The second category of disorder is the postpartum psychoses which arise in the early weeks following delivery. These disorders affect around one in one thousand postpartum women. They cover a wide spectrum of psychiatric conditions, the most common being manic in form. They are of major psychiatric significance and frequently require hospital admission. In terms of severity, postpartum depression lies between these two classes of disturbance. The clinical profile is the same as depressions arising at other times (Cooper et al. 1988; O'Hara 1997). Thus, central to the depression is a protracted period of low mood accompanied, in varying combinations and to varying degrees, by a loss of interest and pleasure, sleep and appetite disturbance, concentration problems, irritability, feelings of guilt and worthlessness, anxiety symptoms, and, on occasion, suicidal thoughts.

Epidemiology and Course

Epidemiological studies of postpartum samples have consistently revealed that approximately 10 percent of women experience a non-psychotic major depressive disorder in the early weeks following delivery (O'Hara 1997). Although this does not represent an increase over the non-postpartum rate (Cooper et al. 1988; O'Hara et al. 1990), the inception rate for depression in the first three months postpartum does appear to be elevated compared to the succeeding nine months. The duration of postpartum depression is similar to that of depressions arising at other times; in other words, episodes typically remit spontaneously within two to six months. Some residual depressive symptoms are, however, not uncommon, and can persist up to a year following delivery (O'Hara et al. 1990; Cooper et al. 1988). Some cultural variation in the rate of postpartum depression is apparent. Thus, although a rate similar to that found in Western groups has been reported for a Chinese sample (Lee et al. 2001) and for a Nigerian sample (Aderbrigbe, Gureje, and Omigbodun 1993), a substantially lower rate has been found in a Malaysian sample (Grace et al. 2001), and in an indigent urban South African postpartum sample the rate was found to be as high as 34 percent (Cooper et al. 1999). The high prevalence in the latter sample probably reflects a response to the endemic levels of extreme socioeconomic adversity.

Etiology

There is little evidence to support a biological cause for postpartum depression (O'Hara 1997). Despite extensive research on steroid hormones in women after birth, no firm evidence has emerged linking these hormones to the development of postpartum depression

Several studies have found that the presence of maternity blues in the immediate postpartum period is related to the subsequent development of postpartum depression, but no hormonal basis to this association has been identified (O'Hara 1997). Obstetric factors are important in a vulnerable subgroup of women: amongst those with a previous history of depressive disorder, delivery complications are associated with a raised rate of postpartum depression (Murray and Cartwright 1993; O'Hara 1997).

Epidemiological studies have consistently shown that the major factors of etiological importance are largely psychosocial (O'Hara 1997). Thus, the occurrence of stressful life events, including unemployment, a dysfunctional marital relationship, and the absence of support from family and friends, has been found to raise the risk of postpartum depression. A psychiatric history is also commonly reported to be a risk factor for postnatal depression, especially a history of depressive disorder. The importance of this latter association was clarified in a five-year follow-up study of two subgroups of primiparous women who had had a postpartum depression: those for whom the postpartum depression was a recurrence of previous non-postpartum mood disorder, and those for whom the postpartum depression was their first experience of affective disturbance (Cooper and Murray 1995). The former group was found to be at raised risk for subsequent non-postpartum depression, but not to be at risk for depression following a subsequent delivery. Conversely, the latter group was found to be at raised risk for subsequent postpartum depression but not for subsequent non-postpartum depression. This suggests that for a subgroup of those with postpartum depression the birth of a child carries specific biological or psychological risks.

Prediction

Although a number of studies have reported on antenatal factors associated with postpartum depression, the samples used have usually been too small to derive a reliable predictive index. By the end of the twentieth century the only large-scale predictive study conducted revealed that the most reliable predictors of postpartum depression—such factors as the absence of social support or a previous history of depression—each approximately doubled the odds over the base rate risk (Cooper et al. 1996). The predictive index derived from this study is somewhat useful: at a cutoff score of twenty-six about a third of those who will develop postpartum depression are identified, and about a third of those scoring above this cutoff become depressed. It is unlikely, given the modest elevation of odds conferred by all antenatal risk factors identified to date, that an antenatal predictive index could be produced with substantially better predictive power.

The prediction of postpartum depression could probably be improved if account were taken of certain postpartum factors. For example, a study that examined the impact of early postpartum factors on the course of maternal mood (Murray et al. 1996b) found that, beyond the predictive contribution of antenatal factors, both a high maternity blues score and certain neonatal factors (infant irritability and poor motor control) were significantly related to the onset of postnatal depression. Because both the maternity blues and the neonatal infant factors contribute predictively over and above antenatal variables, the predictive value of critical antenatal factors could be improved by taking account of these postpartum variables.

Detection

Although postpartum depression is frequently missed by the primary care team (Seeley, Murray, and Cooper 1996), its detection does not present any special clinical problem. As noted above, the disorder's symptoms are not distinctive and its assessment is straightforward. Indeed, a simple self-report measure, the Edinburgh Postnatal Depression Scale (EPDS), has been developed as a screening device (Cox, Holden, and Sagovsky 1987). The questionnaire has sound psychometric properties (Murray and Carothers 1990), is easy to administer and simple to interpret, and could readily be incorporated within the routine services provided to all postpartum women. Sensitive clinical inquiry with those who have high EPDS scores would be sufficient to confirm the presence of a depressive disorder.

Impact on Family Life, Parenting, and Child Outcome

Little research has been conducted on the impact of postpartum depression on family life. However, in a study of a non-postpartum group of depressed patients, the impact on partners was found to be considerable and far-reaching, including restrictions in social and leisure activities (going out less frequently, seeing people less often), a fall in family income, and a considerable strain on the marital relationship (Fadden, Bebbington, and Kuipers 1987). A questionnaire study of a small sample found the same adverse impact in the case of postpartum depression (Boath, Pryce, and Cox 1998). Interestingly, the partners of women with postpartum depression have been found to have a significantly elevated rate of depression themselves (Ballard et al. 1994).

There have been a number studies on the impact of postpartum depression on the early mother-infant relationship. These have consistently shown difficulties in the interactions between depressed mothers and their infants, most notably either withdrawn and disengaged behavior in the mother, or intrusive and hostile mother-infant communication (Field et al. 1990). These difficulties are most apparent in groups with high adversity levels, but even in low risk samples depressed mothers have been found to respond less sensitively to their infants than well mothers (Murray et al. 1993; Murray et al. 1996a), particularly when the mood disturbance persists (Campbell, Cohn, and Meyers 1995). Follow-up studies also indicate an association between the maternal mood disorder and aspects of child development. Thus, one study conducted in Cambridge, U.K., found an adverse effect on child cognitive performance among eighteen-month-old infants of mothers who had had a postpartum depression (Murray 1992; Murray et al. 1996b). Although cognitive disturbance was not found to persist in this study, two London studies found cognitive deficit persisting in boys of mothers with postpartum depression when the children were aged four to five (Cogill et al. 1986; Sharp et al. 1995). Poor emotional adjustment in children has reliably been shown to be associated with postpartum depression. Thus, the majority of studies which have systematically examined infant attachment in the context of postpartum depression have found an elevated rate of insecure attachments (Martins and Gaffan 2001). There is evidence that these emotional problems persist into later childhood. A follow-up study of the Cambridge cohort found that the five-year-old children of mothers who had had postpartum depression were significantly more likely than controls to be rated—by both their teachers and their mothers—as behaviorally disturbed (Sinclair and Murray 1998; Murray et al. 1999). One major conclusion from these studies is that the mechanism mediating the association between postpartum depression and adverse child developmental outcome is the impaired pattern of communication between the mother and her infant.

Treatment

There has been little systematic research on pharmacological treatment of postnatal depression. Although progesterone treatment has been enthusiastically advocated (Lawrie, Herxheimer, and Dalton 2000), there has been no systematic evaluation of its clinical utility. By the end of the twentieth century, there has been only one controlled trial of an antidepressant medication, and it showed significant antidepressant effect for both the active drug and the comparison psychological treatment (Appleby et al. 1997). However, there was no additive effect of the two treatments, and the drug treatment was not found to be superior to the psychological treatment. It should be noted that less than half of those invited to take part in the study agreed, mainly because of reluctance to take the medication. This suggests that this line of treatment is not appropriate as a first line treatment, especially in view of the positive results obtained using other forms of intervention which are highly acceptable to women, and that pharmacological treatment should be reserved for those with particularly severe depression or those whose mood disturbance fails to respond to other measures.

There have been a number of controlled trials of psychological treatment of postpartum depression. In an early study, whose findings were later replicated, Holden and her colleagues (Holden, Sagovsky, and Cox 1989) found that improvement in maternal mood in women visited an average of nine times in thirteen weeks by Health Visitors trained in non-directive counselling was substantially greater than in the control group who received routine primary care. Similar positive benefits to maternal mood have been reported for other forms of psychological intervention, such as cognitive behavior therapy, psychodynamic therapy (Cooper and Murray 1997; Cooper and Murray 2001), and interpersonal psychotherapy (O'Hara et al. 2000).

Few studies have examined the impact of treating postpartum depression on the quality of the mother-infant relationship and child development. One controlled psychological treatment trial found that intervention was associated with significant improvement in maternal reports of infant problems, both immediately after treatment (4 to 5 months postpartum) and at a follow-up at eighteen months postpartum; these benefits were confirmed by independent teacher reports of behavior problems at age five (Cooper and Murray 1997; Murray and Cooper 2001). Moreover, early remission from depression, itself significantly associated with treatment, was related to a reduced rate of insecure infant attachment at eighteen months. Similar benefits have been reported in a study of Health Visitor practice (Seeley, Murray, and Cooper 1996). Training was provided to all the Health Visitors working in one National Health Service sector and a cohort study was conducted to assess Health Visitors' clientele before their training and then during a post-training period. Again, significant benefits were apparent in terms of both maternal mood and maternal reports of the quality of the mother-infant relationship.

Marital therapy has been proposed as a treatment for postpartum depression (Apfel and Handel 1999) and as "the treatment of choice" in cases where the marital relationship is in crisis because of the partner's inability to respond empathically to their spouse's distress (Whiffen and Johnson 1998). However, there is no reliable evidence to support such a proposal. Indeed, such an approach is likely to be appropriate only in a selected subgroup of those with postpartum depression where the spouse is available and willing to engage in a therapeutic process of this sort.

Conclusion

Postpartum depression has a significant adverse impact, not just on the affected woman, but on her partner and the family as a whole. This is of special importance to the infant who is so dependent on the mother for its care. It is of great concern that follow-up studies of the children of mothers who have experienced postpartum depression reveal an enduring adverse impact on the child's socioemotional development. It appears that these adverse child outcomes are driven by disturbances in the mother-child relationship which begin in the early postpartum period. This highlights the importance of early detection and treatment by the primary care health team. It also suggests that efforts should be directed to the identification of high risk samples and to the development and evaluation of preventive interventions.

See also:Attachment: Parent-Child Relationships; Depression: Adults; Loneliness

Bibliography

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peter j. cooper lynne murray

POSTPARTUM DEPRESSION

The postpartum period is a time of unrivaled demands and unique stresses, and is a developmentally challenging time for new parents even in the best of circumstances. During a normal postpartum experience, it is not unusual for new parents to experience heightened family and family-of-origin issues associated with the transition to parenthood. For example, adjustments usually need to be made in areas such as sleep schedules, employment, and role allocation. And, even for seasoned parents, there is the adventure of understanding the particular infant's unique temperament, needs, vulnerabilities, and strengths. The experience of depression in the mother during the postpartum period transforms an already challenging adventure into a potentially overwhelming one.

What Is Postpartum Depression?

There are three forms of postpartum depression, which vary greatly in terms of severity, duration, and impairment. The least severe (and most common) type is known as the "baby blues." This is a mild syndrome occurring in up to 80 percent of new mothers. It usually starts within the first few days following childbirth and may last from a few hours to several days. Although distressing, the symptoms (which generally include episodes of crying, mood swings, and worry) do not cause significant impairment for the mother. On the other hand, "postpartum psychosis" is a rare yet very severe psychiatric illness. In such cases, the symptoms, which include mood disturbances along with hallucinations or delusions, cause major impairment in the new mother's ability to function. This illness usually requires that the mother be hospitalized.

The third type of depression, known as "postpartum depression," occurs in approximately 15 to 20 percent of women following childbirth. It is a psychiatric syndrome, defined by the Diagnostic and Statistical Manual of Mental Disorders: DSM-IV as dysphoric mood (or loss of pleasure or interest in usual activities), coupled with symptoms such as sleep and appetite changes, cognitive disturbances, loss of energy, and/or recurrent thoughts of death, which co-occur for at least a two-week period. These symptoms cause significant distress and/or impairment in the new mother's functioning. It is important to note that these are the same symptoms used to diagnose a major depression at anytime during a person's life. The depressive syndrome is labeled a postpartum depression if the symptoms begin within the first three months following childbirth. On average, postpartum depression lasts for about four months, although it can vary considerably in length.

What Causes Postpartum Depression?

Depression during the postpartum period can best be considered an accident of timing; research has suggested that the rates, antecedents, course, and quality of depression during the postpartum period are similar to episodes experienced at other times in a woman's life. Although some research has suggested that negative life events during pregnancy and following delivery (such as financial difficulties, unemployment, and poor marital adjustment) may be associated with the onset of postpartum depression in new mothers, research in the late 1990s identified a previous instance of major depression as the most salient risk factor for postpartum depression.

What Are the Consequences of Postpartum Depression?

There has been an abundance of research on the influence of maternal depression in general on child outcome. This is for good reason—such research generally supports the notion that parental psychological distress (such as depression) is related to the development of negative parent-child interaction and family relationship patterns, which are associated with poor child outcomes. Depressed mothers as a group provide more negative self-reports regarding various aspects of family life, including dissatisfaction in relationships with their spouses and children, as well as stress and uncertainty regarding their own role as parents. Maternal depression has also been associated with disruptions in family unit functioning.

Not only are mothers affected by postpartum depression, the children of depressed mothers also exhibit a variety of impairments in social, psychological, and emotional functioning. More specifically, maternal depression during the postpartum period has been associated with problems for infants such as increased levels of distress/irritability, protest, withdrawal, and avoidance of social interaction. Maternal postpartum depression has been related to insecure parent-infant attachment in some studies but not others. Researchers need to provide a better understanding of how the timing, chronicity, and intensity of the mother's depression are related to the infant's development. In general, even though maternal depression in the postpartum period has been found to be problematic for mothers and infants, it is important to keep in mind that depressed mothers "don't always look as bad as they feel" (according to researchers Karen Frankel and Robert Harmon) and that they likely have the ability in most cases to provide "good enough" parenting to their young children.

Are Interventions Effective in Treating Postpartum Depression?

There have been two main approaches for treating postpartum depression, neither of which has had much empirical testing. The first strategy is to focus directly on the individual woman, with the main goal of reducing her depressive symptoms. As discussed above, postpartum depression is by definition a major depression that occurs during the postpartum period. There is ample evidence to suggest that major depression can effectively be treated with psychopharmacological intervention (i.e., antidepressant medication). Mothers (and physicians) are generally reluctant, however, to use medication during the postpartum period given potential complications associated with breast-feeding. Alternatively, individual psychotherapy has been used to help improve the moods of depressed women. For example, Michael O'Hara and his colleagues reported in 2000 that interpersonal psychotherapy (IPT) was an effective treatment for reducing depressive symptoms, and improving social adjustment, in women with postpartum depression. Initially, IPT involves identifying depression as a medical disorder that occurs within an interpersonal context. The next stage of treatment focuses on current interpersonal challenges identified by the patient (i.e., difficulties with a partner or extended family, role transitions, and/or losses related to the birth). The final stage of treatment consists of reinforcing the patient's competence related to symptom reduction, as well as future-oriented problem solving related to the potential recurrence of depressive symptoms.

The second general strategy for treatment is to focus on maladaptive relationship patterns or parenting practices that are often associated with maternal postpartum depression, in order to improve and enhance parent-infant interactions. There are a number of techniques that have been examined, including relationship-based intervention conducted in the family's home, interaction guidance, and touch or massage therapy for infants. Although these approaches vary in technique, all are generally designed to enhance maternal sensitivity, responsivity to infant cues, and positive parent-infant interaction. Primary outcomes are examined in terms of improvement in factors such as infant regulatory capacities, social-emotional development, and parent-infant attachment. In addition, reduction in maternal depressive symptoms is usually reported, although this is not the direct focus of the intervention. Overall, improvements are noted, although minimal information is available to determine the duration or the specific effects.

Summary

There are several important points to consider in regard to postpartum depression. First, postpartum depression has been linked to adverse infant and family outcomes. Postpartum depression has been associated with problematic infant development, poor parent-child interactions, and unhealthy family functioning. Recent research has suggested that it is the quality of family functioning that is the key to promoting positive child outcomes.

Second, the best intervention for postpartum depression is early identification. Women at risk for postpartum depression can be identified early (even during pregnancy) by determining whether the woman has a history of depression. Past history of depression is one of the most consistent findings for the prediction of postpartum depression.

Third, once the risk for maternal depression has been identified, steps can begin immediately to prevent adverse outcomes for mother and child. Early identification of depression is most critical—that is, before the baby is born. Even prior to the onset of full-blown disorder, services can be put in place to facilitate parenting competence, enhance parent-child relationship quality, and/or reduce intensity of depressive symptoms by connecting mothers with appropriate community services.

Finally, interventions are effective in ameliorating symptoms of postpartum depression. Much research has focused on the treatment of mothers' depressive symptoms. Treatment strategies for post-partum depression also need to include family development plans that account for each family's unique strengths and needs, an emphasis on strengthening family relationships by highlighting the role of fathers and other important caregivers, and the promotion of positive parenting and parental competence. Without question, giving support to families who are experiencing significant risks such as maternal depression is ultimately in the best interest of children.

See also:BIRTH; PARENTING; PREGNANCY

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SusanDickstein

Postpartum depression

Definition

Postpartum depression is a mood disorder that begins after childbirth and usually lasts at least six weeks.

Description

Postpartum depression, or PPD, affects approximately 15% of all childbearing women. The onset of postpartum depression tends to be gradual and may persist for many months, or develop into a second bout following a subsequent pregnancy . Mild to moderate cases are sometimes unrecognized by women themselves. Many women feel ashamed and may conceal their difficulties. This is a serious problem that disrupts women's lives and can have effects on the baby, other children, her partner, and other relationships. Levels of depression for fathers can also increase significantly.

Postpartum depression is often divided into two types: early onset and late onset. Early-onset PPD most often seems like the "blues," a mild brief experience during the first days or weeks after birth. During the first week after the birth, up to 80% of mothers will experience the "baby blues." This period is usually a time of extra sensitivity; symptoms include tearfulness, irritability, anxiety , and mood changes, which tend to peak between three to five days after childbirth. The symptoms normally disappear within two weeks without requiring specific treatment apart from understanding, support, skills, and practice. In short, some depression, fatigue , and anxiety may fall within the "normal" range of reactions to giving birth.

Late-onset PPD appears several weeks after birth. It involves slowly growing feelings of sadness, depression, lack of energy, chronic fatigue, inability to sleep, change in appetite, significant weight loss or gain, and difficulty caring for the baby.

Causes & symptoms

At present, experts cannot always say what causes postpartum depression. Most likely, it is caused by a combination of factors that vary from person to person. Some researchers think that women are vulnerable to depression at all major turning points in their reproductive cycle, childbirth being only one of these markers. Factors before the baby's birth that are associated with a higher risk of PPD include severe vomiting (hyperemesis), premature labor contractions, and psychiatric disorders in the mother. In addition, new mothers commonly experience some degree of depression during the first weeks after birth. Pregnancy and birth are accompanied by sudden hormonal changes that affect emotions. Additionally, the 24-hour responsibility for a newborn infant represents a major psychological and lifestyle adjustment for most mothers, even after the first child. These physical and emotional stresses are usually accompanied by inadequate rest until the baby's routine stabilizes, so fatigue and depression are not unusual.

In addition to hormonal changes and disrupted sleep, certain cultural expectations appear to place women from those cultures at increased risk of postpartum depression. For example, women who bear daughters in societies with a strong preference for sons are at increased risk of postpartum depression. In other cultures, a strained relationship with the husband's family is a risk factor. In Western countries, domestic violence is associated with a higher rate of PPD.

Experiences of PPD vary considerably but usually include several symptoms.

Feelings:

• persistent low mood
• inadequacy, failure, hopelessness, helplessness
• exhaustion, emptiness, sadness, tearfulness
• guilt, shame, worthlessness
• confusion, anxiety, and panic
• fear for the baby and of the baby
• fear of being alone or going out

Behaviors:

• lack of interest or pleasure in usual activities
• insomnia or excessive sleep, nightmares
• not eating or overeating
• decreased energy and motivation
• withdrawal from social contact
• poor self-care
• inability to cope with routine tasks

Thoughts:

• inability to think clearly and make decisions
• lack of concentration and poor memory
• running away from everything
• fear of being rejected by partner
• worry about harm or death to partner or baby
• ideas about suicide

Some symptoms may not indicate a severe problem. However, persistent low mood or loss of interest or pleasure in activities, along with four other symptoms occurring together for a period of at least two weeks, indicate clinical depression, and require adequate treatment.

There are several important risk factors for postpartum depression, including:

• stress
• lack of sleep
• poor nutrition
• lack of support from one's partner, family, or friends
• family history of depression
• labor/delivery complications for mother or baby
• premature or postmature delivery
• problems with the baby's health
• separation of mother and baby
• a difficult baby (temperament, feeding, sleeping problems)
• pre-existing neurosis or psychosis

Diagnosis

Diagnosis of postpartum depression can be made through a clinical interview with the patient to assess symptoms.

Treatment

Postpartum depression can be effectively alleviated through counseling and support groups, so that the mother does not feel she is alone in her feelings. Acupuncture , Chinese herbs, and Western herbs can all help the mother suffering from postpartum depression return to a state of balance.

Recommended herbal remedies to ease depressive episodes may include damiana (Turnera diffusa ), ginseng (Panax ginseng ), lady's slipper (Cypripedium calceolus ), lavender (Lavandula angustifolia ), oats (Avena sativa ), rosemary (Rosmarinus officinalis ), skullcap (Scutellaria laterifolia ), St. John's wort (Hypericum perforatum ), and vervain (Verbena officinalis ). Women who are breastfeeding or are suffering from a chronic medical condition should consult a healthcare professional before taking any herbal remedies.

Some strategies that may help new mothers cope with the stress of becoming a parent include:

• Valuing her role as a mother and trusting her own judgment.
• Making each day as simple as possible.
• Avoiding extra pressures or unnecessary tasks.
• Trying to involve her partner more in the care of the baby from the beginning.
• Discussing with her partner how both can share the household chores and responsibilities.
• Scheduling frequent outings, such as walks and short visits with friends.
• Sharing her feelings with her partner or a friend who is a good listener.
• Talking with other mothers to help keep problems in perspective.
• Trying to sleep or rest when the baby is sleeping.
• Taking care of her health and well being.

Allopathic treatment

Several treatment options exist, including medication, psychotherapy , counseling, and group treatment and support strategies, depending on the woman's needs. One effective treatment combines antidepressant medication and psychotherapy. These types of medication are often effective when used for three to four weeks. Any medication use must be carefully considered if the woman is breastfeeding, but with some medications, continuing breastfeeding is safe. Nevertheless, medication alone is never sufficient and should always be accompanied by counseling or other support services.

Expected results

With support from friends and family, mild postpartum depression usually disappears quickly. If depression becomes severe, a mother cannot care for herself and the baby, and in rare cases, hospitalization may be necessary. However, medication, counseling, and support from others usually work to cure even severe depression in three to six months.

Prevention

Exercise can help enhance a new mother's emotional well-being. New mothers should also try to cultivate good sleeping habits and learn to rest when they feel physically or emotionally tired. It is important for a woman to learn to recognize her own warning signs of fatigue and respond to them by taking a break.

Resources

BOOKS

Murray, Lynne, and Peter J. Cooper, eds. Postpartum Depression and Child Development. New York: Guilford Press, 1999.

Sebastian, Linda. Overcoming Postpartum Depression and Anxiety. LPC, 1998.

PERIODICALS

Burt, V. K., and K. Stein. "Epidemiology of Depression Throughout the Female Life Cycle." Journal of Clinical Psychiatry 63 (2002, Supplement 7): 9–15.

Danaci, A. E., G. Dinc, A. Deveci, et al. "Postnatal Depression in Turkey: Epidemiological and Cultural Aspects." Social Psychiatry and Psychiatric Epidemiology 37 (March 2002): 125–129.

Josefsson, A., L. Angelsioo, G. Berg, et al. "Obstetric, Somatic, and Demographic Risk Factors for Postpartum Depressive Symptoms." Obstetrics and Gynecology 99 (February 2002): 223–228.

Patel, V., M. Rodrigues, and N. DeSouza. "Gender, Poverty, and Postnatal Depression: A Study of Mothers in Goa, India." American Journal of Psychiatry 159 (January 2002): 43–47.

ORGANIZATIONS

Depression After Delivery (D.A.D.). P.O. Box 1282, Morrisville, PA 19067. (800) 944-4773. <http://www.depressionafterdelivery.com>.

Postpartum Support International. 927 North Kellog Avenue, Santa Barbara, CA 93111. (805) 967-7636. <http://www.postpartum.net>.

Paula Ford-Martin

Rebecca J. Frey, PhD

Postpartum depression

Definition

Postpartum depression (PPD) is a major depressive episode that occurs after childbirth . There are conflicting data regarding the time of onset. The Diagnostic and Statistical Manual of Mental Disorders (1995) supports the theory that PPD occurs within four weeks of childbirth. Other clinical investigations report its occurrence up to 12 weeks post-delivery; yet others state that PPD occurs from 6–12 months after delivery. It is reported that PPD may last longer than one month.

Description

The beginning of PPD tends to be gradual, and may persist for many months. It might develop into a second episode if there is a subsequent pregnancy . According to several controlled studies, PPD affects approximately 12–16% of childbearing women. In adolescent mothers, the figure can be as high as 26%. Women who have a previous history of depression are predisposed to PPD; and up to 30% of women who have had a major depressive episode before they conceived might develop PPD. This rate can rise as high as 50–62% in women who have a history of depression in previous pregnancies or during the postpartum periods.

Mild cases of PPD are sometimes unrecognized by women themselves. Embarrassment about difficulty coping with their new circumstances is sometimes shared by new mothers—so much that they might conceal it. This is a serious problem that disrupts women's lives and can have negative effects on the baby, other children, the new mother's partner, and other significant relationships. Marital problems, inadequate social networks, ambivalence about the pregnancy, and disturbing life events can add to the risk of depression.

The father's risk of becoming depressed increases significantly during the postpartum period as well.

Postpartum depression is often divided into two types: early onset and late onset. An early-onset depression most often presents as "baby blues," a brief experience during the first days or weeks following birth. During the first week after the birth of their child, up to 80% of mothers may experience the "baby blues." This period of time is characterized by feelings of oversensitivity, uncontrollable teariness, irritability, anxiety , and mood changes. Symptoms tend to peak between three and five days after childbirth, and normally disappear within a few days.

In short, some depression, tiredness, and anxiety often fall within the normal range of reactions after giving birth.

A late-onset PPD appears several weeks after the birth. This may involve a growing feeling of sadness, grief, lack of energy, chronic fatigue, inability to sleep, changes in appetite, significant weight loss or gain, difficulty caring for the baby—and sometimes, thoughts of harming the baby.

Causes and symptoms

As of 2001, experts are not positive about the causes of PPD. It may be caused by factors that vary from person to person. Pregnancy and birth are accompanied by sudden hormonal shifts that can cause a range of emotions. Additionally, the 24-hour responsibilities involved in caring for a newborn present major psychological and lifestyle adjustments for most new mothers. These physical and emotional stresses are usually aggravated by not getting adequate rest until the baby's routine stabilizes.

Experiences of new mothers vary considerably, but may include the following.

Feelings:

• persistent low mood
• inadequacy, failure, hopelessness, helplessness
• exhaustion, emptiness, sadness, teariness
• guilt, shame, worthlessness
• confusion, anxiety, and panic
• fear for the baby and of the baby
• fear of being alone or going out

Behaviors:

• lack of interest or pleasure in usual activities
• insomnia or excessive sleep; nightmares
• changes in appetite
• decreased energy and motivation
• withdrawal from social contact
• poor self-care
• inability to cope with routine tasks

Thoughts:

• inability to think clearly and make decisions
• lack of concentration and poor memory
• inability to deal with stressful situations
• fear of being rejected by partner
• worry about harming herself, her partner, or her baby
• suicidal ideation

Some symptoms may not indicate a severe problem. However, persistent low mood or loss of interest or pleasure in activities, along with four other symptoms occurring at the same time, may signal a problem. If these symptoms persist for a period of at least two weeks, a clinical depression may be occurring, and professional intervention may be required.

There are several important risk factors for PPD, including:

• stress
• loss of pleasure or interest in living
• lack of sleep (sleep deprivation)
• poor nutrition
• lack of support from one's partner, family, or friends
• family history of clinical depression
• complications for mother or baby during labor and delivery
• premature or postmature delivery
• poor newborn health
• separation of mother and baby
• a difficult baby (i.e., problems with temperament, feeding, sleeping, or settling)
• preexisting neurosis or psychosis

Diagnosis

There is no specific diagnostic test for PPD. However, it is important to understand that PPD is a bona fide illness, and that it has specific symptoms, the same as a physical condition. Blood tests to measure thyroid hormone levels can rule out postpartum thyroiditis, which can mimic PPD.

It is important to note that a small percentage of women experience postpartum psychosis, a rare disorder. This is the most severe, but least common, postpartum condition. Occurring in only 1–2 births per 1,000, post-partum psychosis appears between 48–72 hours and several weeks after delivery. Symptoms may include elated mood, mood changeability, disorganized behavior, insomnia, religious preoccupation, agitation, suicide attempts or suicidal ideation, bizarre feelings or behavior, and hallucinations. Postpartum psychosis is a serious condition that requires immediate psychiatric intervention and possible hospitalization.

Other psychiatric conditions, such as panic disorder and obsessive-compulsive disorder (OCD), are possible manifestations of PPD.

Complications

If PPD is misdiagnosed or remains untreated, a severely depressed woman may attempt or complete suicide. On a lesser but significant level, untreated PPD can lead to severe depression, anxiety, or postpartum psychosis.

Treatment

Several treatment options exist for mild-to-moderate PPD; these are psychiatric therapies that include inter-personal therapy (IPT) and cognitive-behavior therapy (CBT). Under investigation at the time of this writing in 2001, bright-light therapy may be effective in treating PPD. Clinical studies have reported that pregnant depressed women and postpartum depressed women, respectively, experienced antidepressant effects when bright-light therapy was administered. Another effective treatment combines antidepressant medication with counseling. Antidepressants generally become effective several weeks after a patient has begun taking them. Medication must be prescribed carefully if the mother is breastfeeding, as it can pass to the baby in the mother's breast milk. This is why the physician must be aware that the baby is being breast-fed. The results of several short-term studies point to relative safety (i.e., lack of toxicity, minimal exposure to the maternal dose, or few adverse effects) in the use of SSRIs (selective serotonin reuptake inhibitors) by nursing mothers.

Postpartum depression also may be treated with "talk" therapy and participation in a support group. The mother needs to feel cared for, and that her feelings are respected. Nursing staff and allied health professionals can positively affect the treatment course by providing the mother with supportive one-on-one therapy, whereby the therapist listens to the woman's specific concerns and fears.

Such alternative treatment measures as homeopathy may be helpful, since they are meant to address mental, physical, and spiritual states—all of which are affected by PPD. Acupuncture and Chinese and Western herbs may also help by balancing mood and hormone levels. However, caution is strongly advised when taking herbs; as of 2001, they are unregulated. Toxicity studies have not been conducted to evaluate the safety of these substances. Seeking help from a homeopathic practitioner, however, does provide the new mother with an opportunity to discuss specific nutritional needs or mood problems.

Fortunately, there are useful things that a new mother can do for herself, including:

• Making each day as simple as possible.
• Asking for help from supportive friends and family members whenever possible.
• Avoiding extra pressures or unnecessary tasks.
• Involving her partner more intensively in the care of the baby from the beginning.
• Discussing with her partner how both can share the household chores and responsibilities.
• Scheduling frequent outings, such as walks and short visits with friends.
• Having the baby sleep in a separate room so that she can sleep more restfully.
• Sharing her feelings with her partner or another good listener.
• Talking with other mothers to keep problems in perspective.
• Sleeping or resting when the baby is sleeping.
• Taking care of her health and well-being.
• Not losing her sense of humor or self-esteem.

Prognosis

With appropriate support from friends and family, many mild cases of PPD go away by themselves. If depression becomes severe, a patient should not attempt to care for herself or the baby; in some cases, psychiatric hospitalization may be necessary. However, a three-pronged approach consisting of supervised medication, psychiatric counseling, and support from family, friends, and others, may relieve even severe depression in three to six months.

Health care team roles

Nursing staff and allied health professionals can assist in the diagnosis of postpartum depression by observing the patient for symptoms. Since PPD can present as a mood disorder, anxiety state, or psychotic episode, it is critical that nursing staff and allied health professionals understand the warning signs.

During the treatment phase, nursing staff and allied health professionals can help a new mother by providing her with appropriate patient education materials, and referrals for ongoing supportive therapy or group psychotherapy , if applicable.

Prevention

Exercise can help enhance a new mother's emotional well-being. New mothers should also cultivate good sleeping habits and rest when physically or emotionally tired. It is important for the health professional to teach the patient how to recognize the signs of fatigue and to make time for herself.

Psychotherapy or the use of antidepressant medication can also help to prevent future episodes of postpartum or ongoing clinical depression.

Resources

BOOKS

Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Press, 1995.

PERIODICALS

"Postpartum depressions." Clinical Reference Systems 1 (Annual 2000): 952.

ORGANIZATIONS

Depression After Delivery (D.A.D.). P.O. Box 1282, Morrisville, PA 19067. (800) 944-4773.

Postpartum Support International. 927 North Kellog Avenue, Santa Barbara, CA 93111. (805) 967-7636.

OTHER

"Postpartum Depression and the 'Baby Blues,'" Information from Your Family Doctor. <http://familydoctor.org/handouts/379.html>. (April 5, 2001).

"Mood and Anxiety Disorders During Pregnancy and the Postpartum Period," Medscape Inc., <http://www.medscape.com/medscape/psychiatry/TreatmentUpdate/2000/tu02/tu02-04.html>. (May 20, 2001).

Bethanne Black

Postpartum Depression

Definition

Postpartum depression (PPD) is a major depressive episode that occurs after childbirth. There are conflicting data regarding the time of onset. The Diagnostic and Statistical Manual of Mental Disorders IV supports the theory that PPD occurs within four weeks of childbirth. Other clinical investigations report its occurrence up to 12 weeks post-delivery; yet others state that PPD occurs from six to 12 months after delivery. It is reported that PPD may last longer than one month.

Description

The beginning of PPD tends to be gradual, and may persist for many months. It might develop into a second episode if there is a subsequent pregnancy. According to several controlled studies, PPD affects approximately 12-16% of childbearing women. In adolescent mothers, the figure can be as high as 26%. Women who have a previous history of depression are predisposed to PPD; and up to 30% of women who have had a major depressive episode before they conceived might develop PPD. This rate can rise as high as 50-62% in women who have a history of depression in previous pregnancies during the postpartum periods.

Mild cases of PPD are sometimes unrecognized by women themselves. Embarrassment about difficulty coping with their new circumstances is sometimes shared by new mothers—so much that they might conceal it. This is a serious problem that disrupts women's lives and can have negative effects on the baby, other children, the new mother's partner, and other significant relationships. Marital problems, inadequate social networks, ambivalence about the pregnancy, and disturbing life events can add to the risk of depression.

The father's risk of becoming depressed increases significantly during the postpartum period as well.

Postpartum depression is often divided into two types: early onset and late onset. An early-onset depression most often presents as "baby blues," a brief experience during the first days or weeks following birth. During the first week after the birth of their child, up to 80% of mothers may experience the "baby blues." This period of time is characterized by feelings of oversensitivity, uncontrollable teariness, irritability, anxiety, and mood changes. Symptoms tend to peak between three and five days after childbirth, and normally disappear within a few days.

In short, some depression, tiredness, and anxiety often fall within the normal range of reactions after giving birth.

A late-onset PPD appears several weeks after the birth. This may involve a growing feeling of sadness, grief, lack of energy, chronic fatigue, inability to sleep, changes in appetite, significant weight loss or gain, difficulty caring for the baby—and sometimes, thoughts of harming the baby.

Causes and symptoms

Experts are not positive about the causes of PPD. It may be caused by factors that vary from person to person. Pregnancy and birth are accompanied by sudden hormonal shifts that can cause a range of emotions. Additionally, the 24-hour responsibilities involved in caring for a newborn present major psychological and lifestyle adjustments for most new mothers. These physical and emotional stresses are usually aggravated by not getting adequate rest until the baby's routine stabilizes.

Experiences of new mothers vary considerably, but may include the following.

Feelings:

• persistent low mood
• inadequacy, failure, hopelessness, helplessness
• exhaustion, emptiness, sadness, teariness
• guilt, shame, worthlessness
• confusion, anxiety, and panic
• fear for the baby and of the baby
• fear of being alone or going out

Behaviors:

• lack of interest or pleasure in usual activities
• insomnia or excessive sleep; nightmares
• changes in appetite
• decreased energy and motivation
• withdrawal from social contact
• poor self-care
• inability to cope with routine tasks

Thoughts:

• inability to think clearly and make decisions
• lack of concentration and poor memory
• inability to deal with stressful situations
• fear of being rejected by partner
• worry about harming herself, her partner, or her baby
• suicidal ideation

Some symptoms may not indicate a severe problem. However, persistent low mood or loss of interest or pleasure in activities, along with four other symptoms occurring at the same time, may signal a problem. If these symptoms persist for a period of at least two weeks, a clinical depression may be occurring, and professional intervention may be required.

There are several important risk factors for PPD, including:

• stress
• loss of pleasure or interest in living
• lack of sleep (sleep deprivation)
• poor nutrition
• lack of support from one's partner, family, or friends
• family history of clinical depression
• complications for mother or baby during labor and delivery
• premature or post mature delivery
• poor newborn health
• separation of mother and baby
• a difficult baby (i.e., problems with temperament, feeding, sleeping, or settling)
• preexisting neurosis or psychosis

Diagnosis

There is no specific diagnostic test for PPD. However, it is important to understand that PPD is a bona fide illness, and that it has specific symptoms, the same as a physical condition. Blood tests to measure thyroid hormone levels can rule out postpartum thyroiditis, which can mimic PPD.

It is important to note that a small percentage of women experience postpartum psychosis, a rare disorder. This is the most severe, but least common, postpartum condition. Occurring in only 1-2 births per 1,000, postpartum psychosis appears between 48-72 hours and several weeks after delivery. Symptoms may include elated mood, mood change ability, disorganized behavior, insomnia, religious preoccupation, agitation, suicide attempts or suicidal ideation, bizarre feelings or behavior, and hallucinations. Postpartum psychosis is a serious condition that requires immediate psychiatric intervention and possible hospitalization. Other psychiatric conditions, such as panic disorder and obsessive-compulsive disorder (OCD), are possible manifestations of PPD.

Complications

If PPD is misdiagnosed or remains untreated, a severely depressed woman may attempt or complete suicide. On a lesser but significant level, untreated PPD can lead to severe depression, anxiety, or post partum psychosis.

Treatment

Several treatment options exist for mild-to-moderate PPD; these are psychiatric therapies that include interpersonal therapy (IPT) and cognitive-behavior therapy (CBT). At the time of this writing in 2001, bright-light therapy was under investigation for treating PPD. Clinical studies have reported that pregnant, depressed women and postpartum, depressed women, respectively, experienced antidepressant effects when bright-light therapy was administered. Another effective treatment combines antidepressant medication with counseling. Antidepressants generally become effective several weeks after a patient has begun taking them. Medication must be prescribed carefully if the mother is breast-feeding, as it can pass to the baby in the mother's breast milk. This is why the physician must be aware that the baby is being breast-fed. The results of several short-term studies point to relative safety (i.e., lack of toxicity, minimal exposure to the maternal dose, or few adverse effects) in the use of SSRIs (selective serotonin reuptake inhibitors) by nursing mothers.

Postpartum depression also may be treated with "talk" therapy and participation in a support group. The mother needs to feel cared for, and that her feelings are respected. Nursing staff and allied health professionals can positively affect the treatment course by providing the mother with supportive one-on-one therapy, whereby the therapist listens to the woman's specific concerns and fears.

Alternative treatment measures, such as homeopathy, may be helpful, since they are meant to address mental, physical, and spiritual states—all of which are affected by PPD. Acupuncture and Chinese and Western herbs may also help by balancing mood and hormone levels. However, caution is strongly advised when taking herbs because they are unregulated. Toxicity studies have not been conducted to evaluate the safety of these substances. Seeking help from a homeopathic practitioner, however, does provide the new mother with an opportunity to discuss specific nutritional needs or mood problems.

Fortunately, there are useful things that a new mother can do for herself, including:

• making each day as simple as possible
• asking for help from supportive friends and family members whenever possible
• avoiding extra pressures or unnecessary tasks
• involving her partner more intensively in the care of the baby from the beginning
• discussing with her partner how both can share the household chores and responsibilities
• scheduling frequent outings, such as walks and short visits with friends
• having the baby sleep in a separate room so that she can sleep more restfully
• sharing her feelings with her partner or another good listener
• talking with other mothers to keep problems in perspective
• sleeping or resting when the baby is sleeping
• taking care of her health and well-being
• not losing her sense of humor or self-esteem

Prognosis

With appropriate support from friends and family, many mild cases of PPD go away by themselves. If depression becomes severe, a patient should not attempt to care for herself or the baby; in some cases, psychiatric hospitalization may be necessary. However, a three-pronged approach, consisting of supervised medication, psychiatric counseling, and support from family and friends, may relieve even severe depression in three to six months.

Health care team roles

Nursing staff and allied health professionals can assist in the diagnosis of postpartum depression by observing the patient for symptoms. Since PPD can present as a mood disorder, anxiety state, or psychotic episode, it is critical that nursing staff and allied health professionals understand the warning signs.

During the treatment phase, nursing staff and allied health professionals can help a new mother by providing her with appropriate patient education materials, and referrals for ongoing supportive therapy or group psychotherapy, if applicable.

Prevention

Exercise can help enhance a new mother's emotional well-being. New mothers should also cultivate good sleeping habits and rest when physically or emotionally tired. It is important for the health professional to teach the patient how to recognize the signs of fatigue and to make time for herself.

Psychotherapy or the use of antidepressant medication can also help to prevent future episodes of postpartum or ongoing clinical depression.

Resources

BOOKS

Diagnostic and Statistical Manual of Mental Disorders IV. Washington, DC: American Psychiatric Press, 1995.

PERIODICALS

"Postpartum depressions." Clinical Reference Systems 1 (Annual 2000): 952.

ORGANIZATIONS

Depression After Delivery (D.A.D.). P.O. Box 1282, Morrisville, PA 19067. (800) 944-4773.

Postpartum Support International. 927 North Kellog Avenue, Santa Barbara, CA 93111. (805) 967-7636.

OTHER

"Postpartum Depression and the 'Baby Blues,'" Information from Your Family Doctor. 〈http://familydoctor.org/handouts/379.html〉. (April 5, 2001).

"Mood and Anxiety Disorders During Pregnancy and the Postpartum Period," Medscape Inc., 〈http://www.medscape.com/medscape/psychiatry/TreatmentUpdate/2000/tu02/tu02-04.html〉. (May 20, 2001).