Focus on Women's Health Article

Postpartum Depression

Postpartum depression can have tragic consequences to the mother and her relationship with her infant and family. It is a problem that has received far too little attention despite its prevalence. Each year in the United States, approximately half a million new mothers suffer from postpartum depression; unfortunately, the majority of these women do not seek help. New mothers often feel embarrassed or ashamed that they are not feeling the joy and fulfillment which "society" says should come with motherhood. Some depressed mothers even assume that the way they feel is not abnormal and never seek support. Untreated, postpartum depression has adverse consequences for both the mother and child.

Postpartum mood disorders include the postpartum blues, postpartum depression, and postpartum psychosis. Although these three disorders are distinct, there is some overlap between them.

Baby Blues

The blues affect from 50 to 80% of postpartum women¹. Symptoms include tearfulness, fatigue, insomnia, irritability, poor concentration, sadness and mood changes. These symptoms are generally mild and short-lived. They usually start within 3-4 days after delivery and disappear by 10 days after delivery. Symptoms typically last for just a few minutes or hours each day for only a few days. The transient, sporadic, and limited nature of the blues, which usually comes and goes for short time periods, requires no treatment except for reassurance and support.

Postpartum Psychosis

In sharp contrast, postpartum psychosis is a rare condition, affecting one to two mothers out of every 1,000 births². Symptoms include thought disorders, hallucinations and delusions. Although some psychotic episodes during the postpartum period may be due to schizophrenia, the majority of postpartum psychoses are due to affective disorders, such as bipolar disorder or major depression, that are triggered by the stress of the perinatal period³. Seventy-five percent of postpartum psychosis begins within the first month after delivery and can occur as early as three to four days postpartum. Symptoms usually evolve rapidly. The presentation is often dramatic with intense restlessness, irritability, sleep disturbances, confusion, and disorganized behavior. Postpartum psychosis is a medical emergency. The risk for suicide is 5% and the risk for infanticide is 4%⁴. Women with a history of bipolar disorder or postpartum psychosis in a previous pregnancy have a 70% chance of developing postpartum psychosis again⁵. Hospitalization is usually necessary since the mother is unable to take care of herself or is a danger to herself and others. Treatment with psychotropic medication and electroconvulsive therapy (ECT) is usually necessary.

Postpartum Depression

Symptoms

Most studies place the prevalence of postpartum depression to be between 10-15% of new mothers^1,5,6,7. Studies have indicated that the hospitalization rates for depression are significantly higher during the first 90 days after delivery than for any other time within two years of pregnancy or delivery⁸, making this an especially vulnerable time for new mothers. Symptoms associated with postpartum depression are the same as those for major depression as defined by the American Psychiatric Association (see Table 1)⁹. The key critieria is that symptoms last most of the day, everyday, for at least two weeks. Although the DSM limits the definition of postpartum depression to symptoms occurring within 28 days of delivery, most experts agree that symptoms may develop later after delivery¹⁰. Two-thirds of these women experience the onset of these symptoms by 6 weeks postpartum; however, the definition for onset of postpartum depression varies widely (onset by 4 weeks to up to 12 months after delivery). In addition to the DSM-IV criteria, postpartum depression may be associated with unique feelings toward the new baby such as overly intense worries, lack of interest or fear of harming the baby. Feelings of anxiety and obsession also tend to be rather common and dominant¹¹.

The following symptoms may be more diagnostic during the postpartum period. New mothers should seek help if they experience any of the following signs. Family or friends should also encourage new mothers to seek help if they notice:

• strong feelings of sadness, anxiety, or irritability
• emotional stress which interferes with taking care of self or family
• tearfulness
• trouble motivating oneself to do normal everyday tasks
• diminished interest in food (or compulsive overeating)
• diminished interest in self-grooming (dressing, bathing, fixing hair)
• inability to sleep when tired or sleeping too much
• trouble concentrating, making decisions, remembering things
• loss of pleasure or interest in things which used to be fun or interesting
• overly intense worries about the baby
• lack of interest in the new baby
• fear of harming the baby
• thoughts of self-harm or suicide

Risk Factors

The risk for postpartum depression is higher in women with a personal or family history of mood disorders or depression during pregnancy¹. These include:

• history of prior postpartum depression
• history of depression or bipolar disorder during or before pregnancy
• history of severe PMS (premenstrual syndrome)
• family history of depression or bipolar disorder

In addition, recent stressful events such as marital or partner discord, loss of loved one, and family illness also increase the likelihood of depressive illness¹⁰. Both biological and psychosocial factors contribute to the causes of postpartum depression. Some women may be sensitive to the tremendous change in hormones after childbirth¹². Fluctuations in the concentration of estrogen, progesterone, gonadal hormones, prolactin, oxytocin, corticotropin releasing hormone, cortisol, norepinephrine, calcium, and beta endorphins have not been consistently found to be a direct cause for mood disturrbances in all women¹³. Some women may be sensitive to the changes in their environment. Often no single cause can be identified.

Screening

Postpartum depression commonly occurs in women without any risk factors. Many of the symptoms of major depression are relatively common during the postpartum time period. For example, most new mothers routinely deal with weight changes, sleep disturbances, fatigue, and loss of energy. This overlap of symptoms makes the diagnosis of clinical depression difficult. The Edinburgh Postnatal Depression Scale (EPDS) was created specifically for postpartum women¹⁴. It consists of ten questions designed for self-administration which can be completed in five minutes. According to Cox, et al, mothers who score above 12/13 on the test are likely to be suffering from depression and should be further assessed¹⁴. Routine screening at the 6-week postpartum visit has resulted in more than double the rate of diagnosis of depression¹⁵. In addition to the EPDS, the Postpartum Depression Screening Scale (PDSS), a 35-question self-report test, was also created specifically for new mothers. Other general depression screening tools such as the Zung Scale, General Health Questionnaire, and Center for Epidemiologic Studies Depression Scale (CES-D) can be used as well¹⁶. The United States Preventive Services Task Force (USPSTF) has recently recommended: "Adults should be screened for depression when accurate diagnosis, effective treatment, and careful followup can be assured"¹⁷. The USPSTF recommendation suggests a two question screen:

1. Over the past 2 weeks, have you ever felt down, depressed, or hopeless?
2. Over the past 2 weeks, have you felt little interest or pleasure in doing things?

Many clinicians have their own method of assessing for depression and should use whatever method fits their style and patient population.

Getting Screened for Hypothyroidism

Thyroid hormone may be very low in 6% of women after birth due to a postpartum autoimmune thyroiditis. Women with low thyroid levels suffer from many of the identical symptoms as depression such as fatigue, mood swings, appetite/weight changes, sleep changes and feeling sad. It is advisable to get a thyroid hormone level test for any of these symptoms and prior to commencement of depression treatment¹⁸. If a woman is hypothyroid, the symptoms resolve readily with thyroid replacement therapy. However, the co-existence of both thyroiditis and depression should also be entertained if there is not a prompt improvement of symptoms.

Untreated Maternal Depression

Untreated, postpartum depression tends to last longer and recur more often. Mothers suffering from postpartum depression often have difficulties relating to their infants. This could have an impact on the child's psychological adjustment and behavioral development later on¹⁹. Many authors have described decreased cognitive skills, delay in language development and poor attention span in the offspring of depressed mothers.^20,21,22,23

Treatment

Antidepressants are very effective in the treatment for postpartum depression. If the new mother has used antidepressants in the past successfully, then that same antidepressant should be prescribed in the postpartum period. The selective serotonin-reuptake inhibitors (SSRIs) are most commonly used because of their ease of administration, few serious side effects and low risk of fatality in case of overdose. Treatment is usually continued for six to twelve months after full remission of symptoms. All psychotropic medications are secreted into breast milk. Serum levels in infants who were exposed to fluoxetine, sertraline and paroxetine while breast-feeding revealed only trace or negligible amounts of the parent compounds or their metabolites.^24,25,26 Paroxetine was not found in the plasma of exposed infants that were breastfed²⁶. More importantly, there were no treatment side effects observed in the infants. As expected, recent studies show that venlafaxine also appears to have a similar safety profile and be equally effective as earlier studies SSRIs in the treatment of postpartum depression²⁷. Although more studies are needed, the probability of adverse effects appears small. For moderate to severe depression, antidepressants are usually necessary. However, for mild depression, professional counseling such as interpersonal psychotherapy or cognitive-behavioral therapy may be all that is necessary in the treatment of postpartum depression^28,29. Including the spouse in treatment decisions as well as securing household help for the new mother are also seen as important components in therapy by most providers.

Conclusion

The successful of treatment for postpartum depression is dependent on an awareness of the commonality of the disorder, getting women screened, and prompt initiation of therapy. Since depression occurs across all age, race, ethnic and economic groups, every new mother should be screened and educated about postpartum depression. The postpartum checkup and routine well-baby visits are an opportune time for obstetricians and pediatricians to discuss and screen for depression. Other individuals or organizations in the community who have contact with new mothers such as daycare providers and lactation consultants, can also help in the screening effort. Treatment for this disorder usually requires medication (most commonly antidepressants) but counseling alone may benefit some women who have only mild symptoms. Increased recognition, diagnosis and treatment of postpartum depression will improve the health and well being of new mothers and their families.

Bibliography

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