Postpartum Depression

While postpartum psychosis is rare and extremely dangerous (see box about Andrea Yates), postpartum depression – or PPD – is actually very common. It’s estimated that up to 70% of all new mothers experience the “baby blues.” These “blues” typically peak four to five days after delivery and fade away within a week or two. However, sometimes these “blues” don’t go away. Instead the new mother becomes increasingly distraught. She may become weepy, lethargic, agitated, or even have thoughts of suicide. She may start to worry excessively about her new baby or have unwanted thoughts of harming the child. These are all symptoms of PPD. About one in ten new mothers experience some degree of postpartum depression.

Historically, the connection between childbirth and psychiatric illness has been well-recognized. In 460 BC, Hippocrates described postpartum “fever,” which produced “agitation, delirium and attacks of mania.” The 11th century writings of the gynecologist Trotula of Salerno note that “if the womb is too moist, the brain is filled with water, and the moisture running over to the eyes, compels them to involuntarily shed tears.”

Although PPD is more common than many typical pregnancy ailments, such as preeclampsia, gestational diabetes, and preterm delivery, this condition is typically under-diagnosed. Despite its common occurrence and devastating consequences, PPD receives little attention in modern clinical literature, training, and practice.

Symptoms of Postpartum Depression
Signs that you may be suffering from PPD include:

  • Depressed (sad) mood
  • Lack of pleasure or interest in activities
  • Sleep disturbance (sleeping too much or too little)
  • Weight loss
  • Loss of energy
  • Agitation or psychomotor retardation (moving very slowly)
  • Feelings of worthlessness or inappropriate guilt
  • Diminished concentration, or indecisiveness
  • Frequent thoughts of death or suicide
  • Having thoughts about hurting self
  • Worrying about hurting baby

PPD may be hard to diagnose because of the new mothers’ own feelings of shame and secrecy. Women are expected to have a love affair with their new babies, so if they start having even mild symptoms of PPD, they may feel ashamed and guilty, thus new moms may be reluctant to get help. They fear will be “locked up” or someone will take their baby away from them. PPD can also be hard to diagnose because so many of the symptoms – like sleep disturbance, weight loss, and lack of energy – are a typical of new mothers. Therefore careful assessment by a qualified professional is essential.

Women Vulnerable to Depression
Postpartum depression is not much different than major depression, except that it strikes shortly after childbirth. Major depression is a serious medical illness affecting about five percent of the adult population in a given year. Unlike normal emotional experiences of sadness, loss, or passing moods, major depression is persistent and can significantly interfere with a person’s thoughts, behavior, mood, and physical health. Among all medical illnesses, major depression is the leading cause of disability in the U.S. and many other developed countries.

More than twice as many women (6.7 million) as men (3.2 million) suffer from major depressive disorders each year. All ethnic, racial, socioeconomic, and age groups suffer from depression. About three-fourths of those who experience a first episode of depression will have at least one other episode in their lives. Some individuals may have several episodes in the course of a year.

Why are women so much more vulnerable to depression than men? Differences in social status, expectations, and opportunities no doubt play a role. Studies show that women with poor social support, relationship difficulties, and child care stress are more likely to affected by PPD. But there is also evidence to suggest that rapid changes in women’s hormones – such as following pregnancy, during certain times of the menstrual cycle, or with the use of hormonal contraceptives – can induce depression as well.

Postpartum Psychosis
Postpartum psychosis is a form of depression so severe that the patient loses touch with reality. Although only about 1 in 500 women will get postpartum psychosis, there is a sevenfold increase in the risk of psychiatric hospitalization within the first three months after delivery, and the risk of psychosis is 20 times higher than the pre-pregnancy rate.

When delusions or hallucinations are present, they often involve the infant. A woman may have thoughts that the baby is possessed by a demon and should die. She may even hear voices (auditory hallucinations) telling her to kill her infant. This is an emergency situation, and in such cases a new mother should be taken to the hospital immediately.

Postpartum depression is successfully treated with medications, psychotherapy, or a combination of both. There are several types of psychotherapy that have been shown to be effective for depression including cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT). Research has shown that mild to moderate depression can often be treated successfully with either of these therapies used alone.

Severe depression may be best treated with a combination of psychotherapy and medication. Medication is especially appropriate in patients with more severe or chronic symptoms, prior episodes or family histories, or who have done well with medication in the past. Selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants are most commonly used to treat depression. SSRIs, such as Prozac, Zoloft, and Paxil, are known to be safe, effective, and produce few side effects. However, if breastfeeding, the use of psychiatric medication must be carefully monitored. Electroconvulsive therapy may also be an option for women who do not respond to medications or psychotherapy.

The Main Message
Postpartum depression is a common disorder that is frequently unrecognized. Early identification and intervention are important, especially if psychosis is suspected. The good news is that there are many proven treatments, including psychotherapy and medication. With treatment, women suffering with PPD will be able to effectively manage difficulties of motherhood and also experience its joys.

© M. Williams 2005 for Epigee Pregnancy Resource

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