Postpartum Depression

Some individuals with depression experience an increase or decrease in appetite, which may lead to substantial loss or gain in weight.

Postpartum depression (PPD) is a common problem associated with childbirth. Peripartum depression is depression that a woman experiences during pregnancy or within four weeks of giving birth. Postpartum depression is medically considered a subset of peripartum depression. Biological, psychological, and social factors play roles in predisposing women to develop postpartum depression. There is no one test that definitively indicates that someone has PPD. New moms who have suffered from peripartum depression are much more likely to have a depression again sometime in the future. Intensive nursing intervention can help prevent the development of peripartum depression. Symptoms of postpartum depression begin either during pregnancy or within four weeks after having a baby. Several treatments include educational programs, support groups, psychotherapies, and medications.

The first six weeks after giving birth is called the postpartum period. During the postpartum period, the mother experiences several changes including physical and emotional changes.

This can be a difficult time for the woman, especially if it is her first child. There can be additional stress for the mother, such as tackling breastfeeding, lack of sleep because of the baby's nighttime waking, as well as the demands of caring for her new baby.

At this time, the mother needs support from her partner, family, and friends. The mother's physical and mental health will need attention, and her doctor can help ease some of the pain, discomfort, and other physical and mental changes during the postpartum period.

The time taken to recover after childbirth can vary with each woman. It can take longer for a first-time mother to recover. A woman may usually take longer to recover after Cesarean delivery compared to vaginal delivery. Complete recovery after childbirth can take six months to a year, sometimes even longer.

Postpartum depression, now included in the description of depression with peripartum onset (during pregnancy or within a month after giving birth), may be the most common problem associated with childbirth. This illness is characterized by depression that a woman experiences either during pregnancy or within four weeks of giving birth, affecting about 3%-6% of women who give birth, up to 20% when only women with postpartum depression, rather than including those who are depressed during the pregnancy are counted. Peripartum depression, as well as postpartum anxiety, occurs after one out of every eight deliveries in the United States, affecting about half a million women every year. Peripartum depression is also called major depression with peripartum onset. Delusional thinking after childbirth, called postpartum psychosis, affects about one in every 500 to 1,000 women.

Notably, postpartum depression is not an illness that is exclusive to mothers. Fathers can experience it, as well. As with women, symptoms in men can result in fathers having difficulty caring for themselves and for their children when suffering from postpartum depression.

Unfortunately, up to 50% of individuals with postpartum depression or postpartum psychosis are never detected. That can result in devastating outcomes for the patient and family. For example, postpartum psychosis is thought to have been a potential factor in Andrea Yates drowning her five children in 2001 and was explored as a factor in Susan Smith drowning her two sons in 1994.

Similar to many other mental health conditions, there is thought to be a genetic vulnerability to developing postpartum depression, in that people who have family members who have had this or any other mental illness have a higher risk of developing postpartum depression compared with people who have no such family history.

Rapid changes in reproductive hormone levels (like estrogen and progesterone) that occur during pregnancy and after delivery are thought to be biological factors in the development of this condition. People with any history of depression, anxiety, alcohol, or other substance use disorders prior to the pregnancy are at risk for developing depression during the pregnancy or within a few weeks after delivery. Examples of specific illnesses that have been associated with being associated with the potential to develop postpartum depression include any form of major depression, such as premenstrual dysphoric disorder, bipolar disorder, and generalized anxiety disorder.

Interestingly, men are also known to experience changes in a number of hormonal changes during the peripartum period that can contribute to the development of PPD. Also, the stress of any medical complications as a result of the pregnancy or delivery, as well as the stress that is inherent in caring for a newborn are considerable factors.

Further risk factors for developing postpartum depression include age younger than 20 years, low self-esteem, or life stressors like low socioeconomic status, a lack of social support before and after the birth of the baby, and marital problems, including any history of intimate partner violence.

Symptoms of postpartum depression begin either during pregnancy or within four weeks after having a baby and include the following:

• Feelings of profound sadness, emptiness, emotional numbness, irritability, or anger
• A tendency to withdraw from relationships with family, and friends, or from activities that are usually pleasurable for the PPD sufferer
• Constant fatigue or tiredness, difficulty sleeping, overeating, or loss of appetite
• A strong sense of failure or inadequacy
• Intense concern and anxiety about the baby or a lack of interest in the baby
• Thoughts about suicide or fears of harming the baby

Postpartum psychosis occurs much more rarely and is thought to be a severe form of postpartum depression. Symptoms of that disorder include the following:

• Delusions (false beliefs)
• Hallucinations (for example, hearing voices or seeing things that are not real)
• Suicidal thoughts
• Thoughts of harming the baby
• Severe depressive symptoms

There is no one test that definitively indicates that someone has PPD. Therefore, healthcare providers diagnose this disorder by gathering comprehensive medical, family, and mental health history. Patients tend to benefit when the health care provider takes into account their client's entire life and background. This includes, but is not limited to, the person's gender, sexual orientation, cultural, religious, ethnic background, and socioeconomic status. The health care professional will also either perform a physical examination or request that the individual's primary care doctor perform one. The medical examination will usually include lab tests to evaluate the person's general health and as part of screening the individual for medical conditions that might contribute to mental health symptoms.

Postpartum depression must be distinguished from what is commonly called the postpartum blues or "baby blues," which tend to occur in most new mothers. In the brief mood problem of baby blues, symptoms like crying, sadness, irritability, anxiety, and confusion can occur. In contrast to the symptoms of PPD, the symptoms of the baby blues tend to occur within a few days postpartum, peaking around the fourth day after delivery, resolving by the tenth day, and do not tend to affect the individual's ability to function.

Postpartum psychosis is a psychiatric emergency that requires immediate intervention because of the danger that the sufferer might kill their baby or themselves. Postpartum psychosis usually begins within the first two weeks after delivery. Symptoms of this disorder tend to involve extremely disorganized thinking, bizarre behavior, unusual hallucinations, and delusions. Postpartum psychosis is often a symptom of bipolar disorder, previously called manic depression.

Educational programs and support groups

Treatment of postpartum depression in men and women is similar. Both mothers and fathers with this condition have been found to greatly benefit from being educated about the illness, as well as from the support of other parents who have been in this position.

Psychotherapies

Psychotherapy ("talk therapy") involves working with a trained therapist to determine methods to solve problems and cope with all forms of depression, including postpartum depression. It can be a powerful intervention and may produce positive biochemical changes in the brain. This is a particularly important alternative to treatment with medication in women who are breastfeeding. In general, these therapies take weeks to months to complete. More intense counseling may be needed for longer when treating very severe depression or other psychiatric symptoms.

Interpersonal therapy (IPT): This helps to alleviate depressive symptoms and helps the person with PPD develop more effective skills for coping with social and interpersonal relationships. IPT employs two strategies to achieve these goals.

• The first is education about the nature of depression. The therapist will emphasize that depression is a common illness and that most people can expect to get better with treatment.
• The second is defining specific problems (such as childcare pressures or interpersonal conflicts). After the problems are defined, the therapist can help set realistic goals for solving these problems. Together, the individual with PPD and his or her therapist will use various treatment techniques to reach these goals.

Cognitive behavioral therapy (CBT): This helps to alleviate depression and reduce the likelihood it will return by helping the PPD sufferer change his or her way of thinking. In CBT, the therapist uses three techniques to accomplish these goals.

• Didactic component: This phase helps to set up positive expectations for therapy and promote cooperation.
• Cognitive component: This helps to identify the thoughts and assumptions that influence behaviors, particularly those that may predispose the person with PPD to be depressed.
• Behavioral component: This employs behavior-modification techniques to teach the individual with PPD more effective strategies for dealing with problems.

Medications

Medication therapy for postpartum depression usually involves the use of antidepressant medication. The major types of antidepressant medication are

• selective serotonin reuptake inhibitors (SSRIs),
• serotonin/norepinephrine/dopamine reuptake inhibitors (SNRIs),
• tricyclic antidepressants (TCAs), and
• monoamine oxidase inhibitors (MAOIs).

SSRI medications affect levels of serotonin in the brain. For many prescribing doctors, these medications are the first choice because of the high level of effectiveness and general safety of this group. People with depression or anxiety during pregnancy or postpartum (the two together are known as the perinatal period) should consult with their doctor about safety issues for the developing fetus than the new baby. That issue should also be addressed with the baby's pediatrician for babies who receive breast milk. Examples of antidepressants are listed here.

SSRIs

• Fluoxetine (Prozac)
• Sertraline (Zoloft)
• Paroxetine (Paxil)
• Fluvoxamine (Luvox)
• Citalopram (Celexa)
• Escitalopram (Lexapro)
• Vilazodone (Viibryd)
• Vortioxetine (Trintellix)

SNRIs and NDRs

• Bupropion (Wellbutrin)
• Mirtazapine (Remeron)
• Venlafaxine (Effexor)
• Duloxetine (Cymbalta)
• Desvenlafaxine (Pristiq)
• Levomilnacipran (Fetzima)

TCAs are sometimes prescribed in severe cases of depression or when SSRIs or SNRIs are ineffective. These medications affect a number of brain chemicals (neurotransmitters), especially epinephrine and norepinephrine (also called adrenaline and noradrenaline, respectively). Examples include

• amitriptyline (Elavil),
• clomipramine (Anafranil),
• desipramine (Norpramin),
• doxepin (Adapin),
• imipramine (Tofranil), and
• nortriptyline (Pamelor).

About two-thirds of people who take antidepressant medications improve. It may take anywhere from one to six weeks of taking medication at its effective dose to notice mood improvement. It is, therefore, important not to stop taking the medication because benefits may not be seen immediately. Atypical neuroleptic medications are often prescribed in addition to a mood-stabilizer medication in people with severe postpartum depression or who have postpartum psychosis. Examples of atypical neuroleptics include

• aripiprazole (Abilify),
• olanzapine (Zyprexa),
• paliperidone (Invega),
• quetiapine (Seroquel),
• risperidone (Risperdal),
• ziprasidone (Geodon),
• asenapine (Saphris),
• iloperidone (Fanapt),
• paliperidone (Invega),
• lurasidone (Latuda), and
• brexpiprazole (Rexulti).

Non-neuroleptic mood-stabilizer medications are also sometimes used with neuroleptic medication to treat people with postpartum psychosis because the bipolar disorder may also be present in some patients. Examples of non-neuroleptic mood stabilizers include

• lithium (Lithium Carbonate, Lithium Citrate),
• divalproex sodium (Depakote),
• carbamazepine (Tegretol), and
• lamotrigine (Lamictal).

Electroconvulsive therapy

Electroconvulsive therapy (ECT), previously called electroshock therapy or shock treatment, is a therapy that addresses severe psychiatric symptoms. It involves inducing seizures in people by placing electrodes on the person's head, usually on what corresponds to one side of the brain. The treatment occurs while the person is fully sedated to avoid any distress associated with having seizures. Healthcare professionals administer treatments up to three times per week for at least one week, continuing until symptoms have significantly improved. Side effects usually include confusion and memory loss immediately after the procedure, the latter of which may take weeks to resolve.

Also effective in treating many people with severe depression, psychosis, and the mood swings associated with manic depressive (bipolar disorder) episodes in general, ECT is effective in treating postpartum psychosis and severe forms of postpartum depression. There is research that indicates a higher response of people with depression or psychosis during the postpartum period compared with those symptoms outside of the postpartum period.

Women who have suffered from postpartum depression are much more likely to have a depression again sometime in the future. They are also at risk for poor diet and low compliance with medical recommendations, as well as having more financial problems, being the victim of emotional, physical, or sexual abuse, as well as for developing tobacco or other substance abuse. Children of mothers with PPD are at risk for medical and emotional challenges as a result of problematic relationships with their mothers and of receiving compromised care from their mothers.

Intensive nursing intervention in the form of visits to new mothers by a nurse can help prevent the development of postpartum depression, but there is no definitive way to prevent its development. Screening women before they become pregnant (pre-pregnancy), screening parents for the early signs and gathering history about any family members who have suffered from depression, anxiety, or any other mental health problem are other important tools that may help prevent the progression of minor symptoms to a full-blown illness.

Baby Blues Connection
http://www.babybluesconnection.org
Toll free: 866-616-3752

Online Postpartum Depression Support Group
http://www.ppdsupportpage.com

Postpartum Dads
Email: [email protected]

Postpartum Education for Parents
PO Box 261
Santa Barbara, CA 93116
Email: [email protected]
PEP Warmline: 805-564-3888
Our free 24-hour service provides confidential one-on-one support from trained volunteers who are parents just like you.

Postpartum Stress Center
http://www.postpartumstress.com

Postpartum Support International
Email: [email protected]
800-944-4773
503-894-9453

Jennifer Mudd Houghtaling Postpartum Depression Foundation

200 E. Delaware Apt. 3D
Chicago, IL 60611
Phone: 312-867-7239
Email: [email protected]

Kids Health -- Postpartum Depression and Caring for Your Baby
http://kidshealth.org/parent/emotions/feelings/ppd.html

Postpartum Education for Parents
http://www.sbpep.org

Postpartum Progress
http://postpartumprogress.com

Womenshealth.gov helpline (English and Spanish)
Phone: 800-994-9662
TDD: 888-220-5446
Hours: Monday through Friday, 9 a.m. to 6 p.m., EST. (closed on federal holidays)