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Dr:Eman Elsheshtawy
Ass. Prof. Psychiatry
Heightened emotional reactivity
50-85% women experience baby blues
Peaks 3-5 days after delivery
Lasts up to 10-14 days
Considered normal experience of childbirth
Symptoms can be distressing
Usually don’t affect mother’s ability to function
and care for child
Mild mood swings
Decreased concentration
Crying spells
Two leading hypothesis:
Abrupt hormone withdrawal
Ovarian steroid receptors in CNS are heavily
concentrated in the limbic system
The magnitude of the postpartum drop in
estrogens and progesterone correlates with
presence of “blues”; absolute levels don’t
Neuroactive steroids (pregnanolone,
allopregnanolone) decrease postpartum,
affecting GABA
 Neurobiological
systems foster attachment
between mammalian mothers & infants
 Oxytocin
activates limbic structures (e.g. the
ACG) that mediate the interface between
attention & emotion
 Postpartum
 With
reactivity may stem from this
stressors, depression may result
About 10% of women after delivery
Average duration 7 months
¼ still affected at child’s first birthday
Overlooked and under diagnosed
Female is a 27 year old mother brought into my office as
an urgent care appointment. She just had a baby 4
weeks ago after much anticipation. Her husband is an
only child and her in-laws filled the nursery with toys and
clothes for the baby and are very excited.
She is unable to sleep and eat, extremely doubtful of her
ability to do anything.
She is preoccupied with the fear that she will harm the
baby and intense guilt of her inability to meet the
expectations of the family.
She has been thinking that how easy it is kill herself than
to be this worthless
Depression negatively effects:
 Mother’s
ability to mother
 Mother—infant
 Emotional
and cognitive development
of the child
Infants perceived to be more bothersome
Make harsh judgments of their infants
Feelings of guilt, resentment, and ambivalence
toward child
Loss of affection toward child
 Gaze
less at their infants
 Take
longer to respond to infant’s utterances
 Show
 Lack
fewer positive facial expressions
awareness of their infants
Negative interactive patterns with infant
Children exposed to maternal psychiatric
illness have:
 Higher
incidence of conduct disorders
 Inappropriate
 Cognitive
and attention deficits
 London
study 2001 demonstrated lower
IQ’s in 11 year olds whose mothers
were depressed at 3 months age
 Increased
behavior concerns and ADHD
(sp. in boys)
 Shorter duration of breastfeeding in
 Continued
breastfeeding in PPD was
 Patient,
society, and physicians dismiss or
minimize patients experiences as “normal”
 Patient
without a primary care physician
don’t know who to turn to
 Women’s
fear and shame about not being a
“good mother”
 Patients
don’t present with CC of depression
 Noted
in medical history since Hippo
crates Recognized in DSM-IV in 1994
 Major
depression that occurs within 4
weeks of delivery
 Definition
used by researchers usually
allows up to 6 months
symptoms, every day, at least 2
AND functional impairment
Depressed mood
Lack of pleasure or interest
Appetite disturbance or weight loss*
Sleep disturbance*
Physical agitation or psychomotor slowing
Fatigue, loss of energy*
Feelings of worthlessness or excessive guilt
Diminished concentration, or indecisiveness*
Thoughts of death or suicidal ideation ,Thoughts of
harming infant
Severe Symptoms:
 Thoughts
of dying
 Thoughts of suicide
 Wanting
to flee or get away
 Being
unable to feel love for the baby
 Thoughts of harming the baby
 Thoughts
of not being able to protect the
 Hopelessnes
decline in reproductive
factors increase risk
 Prior
episodes depression, anxiety,
OCD, bipolar d/o, eating d/o
 Prior
depression = 25% risk PPD
 Prior
PPD = 50% risk recurrent PPD
 Stressful
 FHx
 Hx
life events
mood disorders
 Inadequate
social support
 Education
 Sex
of infant
 Breastfeeding
 Mode
of delivery
 Planned
or unplanned pregnancy
During Pregnancy
A young and single
H/O Mental illness or
substance abuse
Financial or
Previous Pregnancy
or postpartum
After Birth
Low confidence as a
Problems with Baby’s
Lack of supports
Major Life change at
the same time as
birth of the baby
2:1,000 births
Psychiatric emergency
Usually within 3 weeks
Usually manifestation of bipolar d/o
70% women experience recurrence in PPP
 Severe
 Rapidly
evolving manic episodes
 Dramatic
 Initial
signs are restlessness,
irritability, insomnia
 Infanticide:
 Suicide:
4% of untreated PPP
5% of untreated PPP
Extreme disorganization
of thought
Bizarre behavior
Unusual hallucinations
Visual, olfactory, or
Delusions (often
centered on the
Not feeling need to
Rapid speech
Loss of touch with
Inform the public
Depression screening in public health settings
Provide appropriate referrals
Partnership with mental health, social service
Follow up care (home visits, support services
“Behind the Smile: My Journey Out of
Postpartum Depression”, Marie Osmond
“Down Came the Rain”, Brooke Shields
Anne Lamott, “Operating Instructions: A
Journal of My Son’s First Year”
Depression After Delivery 1-800-944-4PPD
National Women’s Health Information
Center (
Postpartum Support International 1-805967-7636