Postpartum depression: causes, symptoms, and treatment

Postpartum Depression

According to the article by Dean Seehusen in the February 01, 2004 issue of Southern Medical Journal, postpartum depression, PPD, is present in 10 -20% of women in the United States within the first six months of delivery, and may be 25% or higher in women with a history of postpartum depression after a previous delivery. Moreover, more than 50% of all women who develop postpartum depression still suffer symptoms a year later (Seehusen pp). This condition causes tremendous morbidity in terms of suffering and decreased quality of life, and as with other psychiatric disorders, patients with PPD are more likely to seek help from their primary care physicians than from mental health professionals, thus providers need to be prepared with the necessary tools and knowledge to properly care for women with PPD (Seehusen pp).

Postpartum Depression is a clinical term that refers to a major depressive episode that is temporally associated with childbirth, and although some women report the acute onset of symptoms shortly after delivery, it generally begins within three to six months after delivery (Seehusen pp). The American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision "uses the term 'postpartum' in reference to symptoms of major depressive disorder, bipolar disorder, or brief psychotic disorder beginning within 4 weeks of delivery" (Seehusen pp). However, depressive episodes at any time during the first year postpartum can be considered as being postpartum in onset (Seehusen pp). The psychiatric postpartum experiences are generally divided into three categories, maternal blues, PPD, and postpartum psychosis (Seehusen pp). Although the DSM IV does not apply the postpartum modifier to all other psychiatric illnesses, anxiety disorders, such as panic disorder, obsessive-compulsive disorder, and phobias, may occur initially or worsen during the postpartum period (Seehusen pp). Diagnosing PPD can be complicated by the similarity of signs and symptoms of depression and the sequelae of normal childbirth, and since subclinical mood fluctuations that frequently occur during the first two-week after delivery are considered part of the normal postpartum experience, determining the time of symptom onset may help to distinguish PPD from normal childbirth mood changes (Seehusen pp).

The majority of women, some 50-85%, experience the 'maternal blues,' which is also known as the 'baby blues,' and is characterized by "mild depressive symptoms, anxiety, irritability, mood swings, tearfulness, increased sensitivity, and fatigue," that generally peaks on postpartum Days 4 and 5, and my last for hours or up to days, and typically resolves by postnatal Day 10 (Seehusen pp). As distressing as these symptoms may be, they do not reflect psychopathology and do not affect the mother's ability to function and care for her child (Seehusen pp). It is important to distinguish PPD from postpartum psychosis, which occurs in 0.2% of childbearing women and generally with onset during the first four weeks of delivery (Seehusen pp). The psychosis is typically manic in nature and in the majority of cases may be considered a manifestation of bipolar disorder, which affects 1 to 2% of the population and commonly occurs in women of childbearing years (Seehusen pp). Early warning signs for postpartum psychosis include "insomnia for several nights, agitation, an expansive or irritable mood, and infant avoidance, and when delusions or hallucinations are present, they often involve the infant (Seehusen pp). In fact, rates of infanticide associated with untreated postpartum psychosis have been estimated to be nearly 4%, and because the mother is at risk for harming herself or the baby, postpartum psychosis is considered a medical emergency, with most patients treated in an inpatient setting with neuroleptic agents and mood stabilizers (Seehusen pp).

In the April 01, 2005 issue of Perspectives in Psychiatric Care, Kathie Records revealed the findings of her study, using a psychophenomenological design, in which investigators examined reports from seven clients with a psychiatric diagnosis of postpartum depression and the role life experiences played in their labor, delivery, and postpartum periods (Records pp). According to Records' study, "phenomenological analysis indicated that the psychological and physiological effects of abuse interact to create a cognitive frame of reference similar to the experience of abuse" (Records pp).

Records concluded that the normal developmental event of childbearing contributes to the recall of abuse and thus sets the stage for postpartum depression (Records pp).

Western culture expects new mothers to adjust to motherhood through a series of developmental steps, such as interdependence to independence, yet, not all mothers can manage these steps on their own (Records pp). The issue that is most often associated with the diagnosis of PPD is the time frame, however Records notes that there are major discrepancies between the maternity and psychiatric literature making a 2-12-month diagnosis difficult (Records pp). The subjects in Records's study described how their past abuse experiences affected their thoughts and view of their labor, delivery, and postpartum experiences (Records pp). Records revealed that "all of the subjects felt that the combined recall of trauma events and the labor and delivery experience provided the foundation for the PPD...perceived negative labor and delivery experience as the basis for their PPD" (Records pp).

In the May 01, 2002 issue of OB GYN News, Erik L. Goldman cites Dr. Diana Dell's press briefing sponsored by the American College of Obstetricians and Gynecologists. According to Dell, women are under tremendous pressure to "make perfect babies and to be perfect mothers and perfect wives...and she's got huge expectations about what it will be like," and reality is less like a Gerber baby food commercial and more like Marine boot camp than most new mothers expect (Goldman pp). Being a new mother means that there is an incessant demand, the woman must obey every order, and there is "no rest, no mercy and no concern" for her feelings (Goldman pp). Yet this does not mean that false expectations cause postpartum depression, however in a woman with a history of depression or other risk factors, the "discord between longstanding expectations and the realities of early parenthood can trigger episodes of depression which can sometimes tailspin very quickly" (Goldman pp). Dell estimates that up to 70% of all pregnant women experience some symptoms of depression during their pregnancy or in the postpartum periods, but only 10-16% of them meet the criteria for major depression (Goldman pp). Up to 20% will have an episode of major depression before the end of the first year, and the numbers are even higher, up to 25%, for first time adolescent mothers (Goldman pp). Dell advised being especially concerned about women with bipolar disorder or schizophrenia, and although psychosis is very rare among the general female population, it has a prevalence of 25-35% among women with these conditions (Goldman pp).