Postpartum depression (PPD) is a major depressive episode that occurs after childbirth. There are conflicting data regarding the time of onset. The Diagnostic and Statistical Manual of Mental Disorders (1995) supports the theory that PPD occurs within four weeks of childbirth. Other clinical investigations report its occurrence up to 12 weeks post-delivery; yet others state that PPD occurs from 6–12 months after delivery. It is reported that PPD may last longer than one month.
Description
The beginning of PPD tends to be gradual, and may persist for many months. It might develop into a second episode if there is a subsequent pregnancy. According to several controlled studies, PPD affects approximately 12–16% of childbearing women. In adolescent mothers, the figure can be as high as 26%. Women who have a previous history of depression are predisposed to PPD; and up to 30% of women who have had a major depressive episode before they conceived might develop PPD. This rate can rise as high as 50–62% in women who have a history of depression in previous pregnancies or during the postpartum periods.
Mild cases of PPD are sometimes unrecognized by women themselves. Embarrassment about difficulty coping with their new circumstances is sometimes shared by new mothers—so much that they might conceal it. This is a serious problem that disrupts women's lives and can have negative effects on the baby, other children, the new mother's partner, and other significant relationships. Marital problems, inadequate social networks, ambivalence about the pregnancy, and disturbing life events can add to the risk of depression.
The father's risk of becoming depressed increases significantly during the postpartum period as well.
Postpartum depression is often divided into two types: early onset and late onset. An early-onset depression most often presents as "baby blues," a brief experience during the first days or weeks following birth. During the first week after the birth of their child, up to 80% of mothers may experience the "baby blues." This period of time is characterized by feelings of oversensitivity, uncontrollable teariness, irritability, anxiety, and mood changes. Symptoms tend to peak between three and five days after childbirth, and normally disappear within a few days.
In short, some depression, tiredness, and anxiety often fall within the normal range of reactions after giving birth.
A late-onset PPD appears several weeks after the birth. This may involve a growing feeling of sadness, grief, lack of energy, chronic fatigue, inability to sleep, changes in appetite, significant weight loss or gain, difficulty caring for the baby—and sometimes, thoughts of harming the baby.
Causes and symptoms
As of 2001, experts are not positive about the causes of PPD. It may be caused by factors that vary from person to person. Pregnancy and birth are accompanied by sudden hormonal shifts that can cause a range of emotions. Additionally, the 24-hour responsibilities involved in caring for a newborn present major psychological and lifestyle adjustments for most new mothers. These physical and emotional stresses are usually aggravated by not getting adequate rest until the baby's routine stabilizes.
Experiences of new mothers vary considerably, but may include the following.
worry about harming herself, her partner, or her baby
suicidal ideation
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 at the same time, may signal a problem. If these symptoms persist for a period of at least two weeks, a clinical depression may be occurring, and professional intervention may be required.
There are several important risk factors for PPD, including:
There is no specific diagnostic test for PPD. However, it is important to understand that PPD is a bona fide illness, and that it has specific symptoms, the same as a physical condition. Blood tests to measure thyroid hormone levels can rule out postpartum thyroiditis, which can mimic PPD.
It is important to note that a small percentage of women experience postpartum psychosis, a rare disorder. This is the most severe, but least common, postpartum condition. Occurring in only 1–2 births per 1,000, post-partum psychosis appears between 48–72 hours and several weeks after delivery. Symptoms may include elated mood, mood changeability, disorganized behavior, insomnia, religious preoccupation, agitation, suicide attempts or suicidal ideation, bizarre feelings or behavior, and hallucinations. Postpartum psychosis is a serious condition that requires immediate psychiatric intervention and possible hospitalization.
If PPD is misdiagnosed or remains untreated, a severely depressed woman may attempt or complete suicide. On a lesser but significant level, untreated PPD can lead to severe depression, anxiety, or postpartum psychosis.
Treatment
Several treatment options exist for mild-to-moderate PPD; these are psychiatric therapies that include inter-personal therapy (IPT) and cognitive-behavior therapy (CBT). Under investigation at the time of this writing in 2001, bright-light therapy may be effective in treating PPD. Clinical studies have reported that pregnant depressed women and postpartum depressed women, respectively, experienced antidepressant effects when bright-light therapy was administered. Another effective treatment combines antidepressant medication with counseling. Antidepressants generally become effective several weeks after a patient has begun taking them. Medication must be prescribed carefully if the mother is breastfeeding, as it can pass to the baby in the mother's breast milk. This is why the physician must be aware that the baby is being breast-fed. The results of several short-term studies point to relative safety (i.e., lack of toxicity, minimal exposure to the maternal dose, or few adverse effects) in the use of SSRIs (selective serotonin reuptake inhibitors) by nursing mothers.
Postpartum depression also may be treated with "talk" therapy and participation in a support group. The mother needs to feel cared for, and that her feelings are respected. Nursing staff and allied health professionals can positively affect the treatment course by providing the mother with supportive one-on-one therapy, whereby the therapist listens to the woman's specific concerns and fears.
Such alternative treatment measures as homeopathy may be helpful, since they are meant to address mental, physical, and spiritual states—all of which are affected by PPD. Acupuncture and Chinese and Western herbs may also help by balancing mood and hormone levels. However, caution is strongly advised when taking herbs; as of 2001, they are unregulated. Toxicity studies have not been conducted to evaluate the safety of these substances. Seeking help from a homeopathic practitioner, however, does provide the new mother with an opportunity to discuss specific nutritional needs or mood problems.
Fortunately, there are useful things that a new mother can do for herself, including:
Making each day as simple as possible.
Asking for help from supportive friends and family members whenever possible.
Avoiding extra pressures or unnecessary tasks.
Involving her partner more intensively 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.
Having the babysleep in a separate room so that she can sleep more restfully.
Sharing her feelings with her partner or another good listener.
Talking with other mothers to keep problems in perspective.
Sleeping or resting when the baby is sleeping.
Taking care of her health and well-being.
Not losing her sense of humor or self-esteem.
Prognosis
With appropriate support from friends and family, many mild cases of PPD go away by themselves. If depression becomes severe, a patient should not attempt to care for herself or the baby; in some cases, psychiatric hospitalization may be necessary. However, a three-pronged approach consisting of supervised medication, psychiatric counseling, and support from family, friends, and others, may relieve even severe depression in three to six months.
Health care team roles
Nursing staff and allied health professionals can assist in the diagnosis of postpartum depression by observing the patient for symptoms. Since PPD can present as a mood disorder, anxiety state, or psychotic episode, it is critical that nursing staff and allied health professionals understand the warning signs.
During the treatment phase, nursing staff and allied health professionals can help a new mother by providing her with appropriate patient education materials, and referrals for ongoing supportive therapy or group psychotherapy, if applicable.
Prevention
Exercise can help enhance a new mother's emotional well-being. New mothers should also cultivate good sleeping habits and rest when physically or emotionally tired. It is important for the health professional to teach the patient how to recognize the signs of fatigue and to make time for herself.
"Mood and Anxiety Disorders During Pregnancy and the Postpartum Period," Medscape Inc., <http://www.medscape.com/medscape/psychiatry/TreatmentUpdate/2000/tu02/tu02-04.html>. (May 20, 2001).
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