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Postpartum depression that controls the release of cortisol. Updated08/29/2012 Definition Research seems to indicate that postpartum depression is unlikely to occur in a patient with an otherwise psychologically uncomplicated pregnancy and past history. There is no association of postpartum depression with marital status, social class, or the number of live children born to the mother. However, there seems to be an increased chance to develop this disorder after pregnancy loss. 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, partners, 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 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 and symptoms The cause of postpartum depression has been extensively studied. Alterations of hormone levels of prolactin, progesterone, estrogen, and cortisol are not significantly different from those of patients who do not suffer from postpartum depression. However, some research indicates a change in a brain chemical Certain characteristics have been associated with increased risk of developing postpartum depression. These risk factors include: medical indigence—being in need of health care and not being able to receive it, possibly due to lack of medical insurance being younger than 20 years old at time of delivery being unmarried having been separated from one or both parents in childhood or adolescence receiving poor parental support and attention in childhood having had limited parental support in adulthood poor relationship with husband or boyfriend economic problem with housing or income dissatisfaction with amount of education low self-esteem past or current emotional problem(s) family history of depression 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 (such as Communist China) 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 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 Physical and emotional stress during delivery in conjunction with great demands for infant care may cause the patient to neglect other family members, increasing the woman's feelings of self-worthlessness, isolation, and being trapped. Patients may also feel as if they are inadequate mothers, causing them guilt and embarrassment. 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 There is a 20% to 30% risk of postpartum depression for women who had a previous depressive episode that was not associated with pregnancy. Additionally, there is an increased risk of recurrence in subsequent pregnancies since more than half of patients will have more than one episode. Thoughts: Diagnosis inability to think clearly and make decisions lack of concentration and poor memory running away from everything fear of being rejected by the partner worry about harm or death to partner or baby ideas about suicide Diagnosis of postpartum depression entails a clinical interview with the patient to assess symptoms. A doctor or other professional healthcare provider may ask the mother about thoughts and feelings, and take a detailed personal history. Clinical assessment may be conducted by a psychologist or psychiatrist, who can determine the risk factors and diagnose the condition. A comprehensive psychological assessment interview could reveal a previous depressive cycle or a family history of depression—important risk factors. The most widely used standard for diagnosis is the Edinburgh Postnatal Depression Scale (EPDS). This is a simple and short 10-question scale. A score of 12 or greater on the EPDS is considered high risk for postpartum depression. 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. Demographics There are several important risk factors for postpartum depression, including the following: Treatment stress Several treatment options exist, including medication, psychotherapy, counseling, and group treatment and support strategies. Treatment should begin as soon as the diagnosis is established. 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. There are many classes of antidepression medications. Two of the most commonly prescribed for PPD are selective serotonin reuptake inhibitors (SSRIs) such as citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), paroxetine (Paxil, Pexeva), and sertraline (Zoloft), and tricyclids, such as amitriptyline (Elavil), desipramine (Norpramin), imipramine (Tofranil), and nortriptyline (Aventyl, Pamelor). Nevertheless, medication alone is never sufficient and should always be accompanied by counseling or other support services. Also, many women with postpartum depression feel isolated. It is important for these women to know that they are not alone in their feelings. There are various postpartum depression support groups available in local communities, often sponsored by non-profit organizations or hospitals. For women who have thoughts of suicide, it is imperative to seek help immediately. Expected results When a woman has supportive friends and family, mild postpartum depression usually disappears quickly. If depression becomes severe and a mother cannot care for herself and the baby, hospitalization may be necessary. Medication, counseling, and support from others usually resolve even severe depression in three to six months. The prognosis for postpartum depression is better if it is detected early during its clinical course and a combination of SSRIs and psychotherapy is available and initiated. Prevention Adjunct therapies such as Acupuncture, traditional Chinese medicine, yoga, meditation, and herbs may be considered to help the mother suffering from postpartum depression. Mothers should be advised prior to hospital discharge that if the "maternity blues" last longer than two weeks or pose tough difficulties with family interactions, they should call the hospital where their baby was delivered and pursue a referral for a psychological evaluation. Education concerning risk factors and reduction of these is important. Prophylactic (preventive) use of SSRIs is indicated two to three weeks before delivery to prevent the disorder in a patient with a past history of depression, since recurrence rates are high if the mother had a previous depressive episode. Some strategies that may help new mothers cope with the stress of becoming a parent include: Source Citation: Gulli, Laith Farid, MD; , , Nicole Mallory, M.S., PA-C, and Laura When medications are combined with psychological therapy, the rates for successful treatment are increased. Interpersonal therapy and cognitivebehavioral therapy have been found to be effective. learn to recognize her own warning signs of fatigue and respond to them by taking a break. 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. Exercise, including yoga, can help enhance a new mother's emotional wellbeing. 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 Jean Cataldo, RN, Ed.D. "Postpartum depression." Gale Encyclopedia of Medicine. Laurie J. Fundukian. 5.4th Detroit: Gale, 2011. Nursing Resource Center. Gale. DISCUS. 8 Jan. 2013 <http://find.galegroup.com/nrcx/infomark.do?&source=gale&srcprod=NRCX&prod Id=NRC&userGroupName=scschools&tabID=T001&docId=DB2979101357&type=r etrieve&contentSet=GREF&version=1.0>.