Postpartum Depression: Epidemiology, Symptoms, and Treatment

Introduction to Postpartum Depression

Postpartum depression is a serious problem among women. Once thought of as a relatively minor phase within the postpartum cycle, it is now known that it can seriously impair an individual woman's ability to function under the stress of new parenthood and can seriously erode the family unit at a point of foundational transition. Over the last twenty years, doctors and the general public have demonstrated greater awareness and knowledge of postpartum depression, largely driven by ongoing research.

Within such research are clues to the epidemiology, outward symptoms, and possible interventions for the problem. This paper analyzes those three factors as they relate to the individual and the family, and as they apply to the healthcare professional. Social support has been found, across much of the research literature, to be a major contributing factor in maladaptive parenting behavior and many difficulties faced by new parents, especially new mothers. As one source notes, "Endocrine changes, fatigue, and the responsibilities of motherhood are the probable causes of postpartum depression. The mother, unconsciously, resents the baby. Consciously, she is depressed" (Miletich, 1995, p. 50).

Prevalence and Risk Factors

According to the British Columbia Reproductive Mental Health Program, the prevalence of postpartum depression is relatively high and carries risk factors associated with age, level of social support, and prior history of either postpartum depression or other forms of clinical depression. The most vulnerable time for a woman to develop the onset of a mood disorder is during the postpartum period. Approximately 12–16% of women experience depression during the postpartum period, with adolescent mothers experiencing depression more frequently.

A diagnosis of depression may be missed during the postpartum period because of the demands of caring for a new infant. Changes in sleep, appetite, fatigue, and energy are common to both the normal postpartum period and postpartum depression, making differentiation difficult. Approximately 30% of women with a history of depression prior to conceiving will develop postpartum depression, and approximately 50% of women with a history of postpartum depression will develop it again in a subsequent pregnancy. Emotional disorders during the postpartum period can occur during labor and delivery, within a few days or weeks of delivery — most frequently starting within six weeks — or at any point up to one year following the birth (BC Reproductive Mental Health Program, 2000).

The Canadian Mental Health Association similarly reports that 15–20% of women in the general population will experience postpartum depression, that 30% of women with a history of depression will develop it postpartum, and that 50% of women with a prior episode will develop it again in a subsequent pregnancy (Canadian Mental Health Association, 2004).

Pharmacological Limitations and the Case for Non-Drug Interventions

It has been established over twenty years of research that postpartum depression has clinical causes; however, clinical solutions such as medication are limited during the pregnancy and nursing phases. Pharmacotherapy during pregnancy carries potential teratogenic risk (American Academy of Pediatrics, 1994), as most antidepressant medications cross the placenta. The few studies examining their fetal effects have been inconclusive (Chambers et al., 1996; Pastuszak et al., 1993; Koren, 1994; Nulman et al., 1997). Moreover, medication may carry the risk of behavioral morbidity for the fetus. The fetus develops behavioral responses quite early in gestation — responding to external sounds from at least twenty weeks and producing its own hormonal and other stress responses from mid-gestation (Glover, 1997) — making the stakes of pharmacological intervention particularly high (Weissman, Markowitz, & Klerman, 2000, p. 300).

Though pharmacological solutions have been available for the general treatment of depression for some time, their use during pregnancy and nursing is, as it should be, met with considerable skepticism and applied only with great care. Most modern medications, owing to an inability to test them on pregnant subjects, have unknown effects on fetal and infant development. For this reason, most clinicians and patients elect to eliminate the use of medications during pregnancy and the immediate postpartum period. That period — from day one postpartum to approximately two years — appears to represent the time of greatest risk for complications associated with postpartum depression, with risk and severity declining over time.

The combined reasons above give cause for interventions for postpartum depression to be largely drug-free, relying instead on counseling and social support solutions. Furthermore, research has shown that counseling the individual alone is not the most effective solution in most cases, and that these counseling solutions must be family-based interventions for the greatest effect to be achieved.

Conclusion

The challenges faced by those who experience postpartum depression are intense but can be addressed through treatment. Educating the public is the first intervention needed in society at large, but non-pharmacological treatments are available to individual women who are experiencing difficulties beyond normal transitional adjustment. Family-based counseling approaches and structured therapies such as IPT offer effective, safe pathways to recovery, and community awareness remains essential for ensuring that women at risk are identified and supported in a timely manner.