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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:
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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:
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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
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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:
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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.
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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.
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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.
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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
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