Because of dramatic hormonal changes, some new mothers experience mild depression or "baby blues." Others fall into a more serious depression or, in rare cases, experience psychotic episodes.
Postpartum disorder describes the range of emotional, physical, and behavioral changes often experienced by new mothers. Symptoms can range from mild to severe. While some new mothers experience a mild, brief bout of "baby blues," others suffer from postpartum depression, a much more serious condition. In some cases, new mothers may have postpartum psychosis, which is rare but severe and incapacitating.
The mildest and most common form of postpartum depression is known as the "baby blues" and occurs in 40 to 85 percent of deliveries. Symptoms arise spontaneously during the first 10 days after childbirth, and tend to peak around 3 to 5 days. Although symptoms are distressing, they subside within 24 to 72 hours. Typical symptoms include anxiety, depression, irritability, confusion, crying spells, sleep and appetite disturbances, and lack of feeling for the baby.
Postpartum depression can occur any time within the first year after childbirth—usually within 4 weeks after delivery but sometimes several months later. Symptoms must be present for at least 2 weeks and must affect the mother's ability to function. Many patients suffer from symptoms 6 months after onset and when untreated up to 25 percent of patients are depressed one year later.
Events that predispose a woman to postpartum depression:
Symptoms reported for postpartum depression:
Postpartum or puerperal psychosis occurs at a rate of 1 to 2 out of every 1,000 deliveries. Symptoms usually occur within the first 4 weeks postpartum but can manifest anytime up to the 90 days after delivery. It is characterized by a rapid and severe onset. Women with this disorder are severely impaired and suffer from delusions and hallucinations and are at risk for suicide and, or, infanticide.
While biological, psychosocial and cultural theories have been investigated the exact causes of postpartum depression are unknown.
Postpartum dysregulation of the thyroid gland is another possible cause of depression. This condition is also linked to fatigue. The thyroid gland regulates several hormones and drops production dramatically after birth, returning to normal functioning in three sequential stages. The first stage, which can last from 3 to 6 months, is hyperthyroidism where the thyroid goes into overdrive, resulting in anxiety and insomnia. The second phase is hypothyroidism where production is slowed, causing lethargy and weight gain. The final stage in recovery is when output reaches prepregnant levels. Investigations into the relationship between thyroid dysregulation and postpartum depression have yielded contradictory results and no firm link has been proven. Therefore, treatment is considered only when symptoms are severe enough to interfere with daily living.
There has been research on specific hormones and postpartum depression. Hormones levels change dramatically throughout pregnancy, delivery, and the postpartum period. Researchers are examining a possible relationship between sudden shifts in hormone levels and postpartum depression.
Causes, though, may be found in social or psychological factors.
Psychosocial and emotional factors seem to be related to this condition, acting as stressors and impacting a woman's self-esteem. New mothers are concerned about levels of support and prolonged postpartum depression is linked to lack of social support.
Sleeplessness and fatigue are common complaints. Giving birth taxes a woman's strength, and it can take several weeks to recover. A cesarean delivery is major surgery and requires even more recovery time. Combined with the energy spent caring for a baby around the clock as well as tending to other responsibilities, it is no surprise new mothers suffer inadequate rest. The resulting fatigue may increase a woman's vulnerability and be an added risk for depression.
A major factor in postpartum depression is lack of support from others. New mothers need comfort and support during pregnancy and after delivery. She also needs help with household chores and childcare. Such support may be lacking for a single mother or for a woman with few family nearby.
The mother's changing role may feed the feeling of "inadequacy." Women with depression sometimes view these changes differently than do non-depressed women.
The mother's attitude toward her pregnancy may be important when evaluating risk. It is common for a woman to feel doubt about pregnancy, particularly when unplanned. A greater incidence of depression is reported among women who were ambivalent about pregnancy.
Weight gain during pregnancy can also affect self-esteem and increase a risk of depression.
Mixed feelings sometimes arise from a woman's past. Early loss of one's own mother or a poor mother-daughter relationship might cause her feel unsure about her new baby. She may fear that caring for the child will lead to pain, disappointment, or loss.
Feelings of loss, such as loss of freedom and control are common and can add to depression.
Breast-feeding problems can also lead to depression. New mothers need not feel guilty if they stop. The baby can be well nourished with formula.
Women who have their babies by cesarean birth are likely to feel more depressed and have lower self-esteem than women who had spontaneous vaginal deliveries.
Mothers with pre-term babies often become depressed. An early birth results in unexpected changes in routines and is an added stressor.
A baby with a birth defect makes adjustment even more difficult for parents.
The length of time the mother spends in the hospital may be related to her emotional well-being. There is evidence that early discharge increases the risk of developing depression.
The birth of a first child is a particularly stressful event for new mothers and seems to have a greater relationship to depression than do the birth of a second or third child.
Cross-cultural studies indicate that the incidence of postpartum depression but not psychosis is much lower in non-western cultures. These cultures seem to provide the new mother with a level of emotional and physical support that is largely absent in western society. In more traditional cultures there is greater recognition of the demands of motherhood. Thus, the new mother receives assurance that the discomfort she is experiencing will pass and that she will not have to face those feelings alone. In contrast, the absence of such support has been reported in the U.S. Only 18 percent of new mothers receive more than two weeks assistance with housework and 20 percent reported help with child care beyond the first week.
Postpartum depression is treated much like other types of depression. The most common treatments for depression are antidepressant medication, psychotherapy, and participation in a support group, or a combination of treatments.
There are several types of antidepressants. These include newer medications—chiefly the selective serotonin reuptake inhibitors (SSRIs), the tricyclics, and the monoamine oxidase inhibitors (MAOIs). The MAOIs are generally not prescribed for postpartum depression. The SSRIs, and other newer medications that affect neurotransmitters such as dopamine or norepinephrine, generally have fewer side effects than tricyclics. Sometimes the doctor will try a variety of antidepressants, or increase the dosage of one, before finding the most effective medication or combination of medications. Although some improvements may be seen in the first few weeks, antidepressant medications must be taken regularly for 3 to 4 weeks (in some cases, as many as 8 weeks) before therapeutic effect occurs.
Patients are often tempted to stop medication too soon. They may think it isn't working, or they may feel better and think they no longer need it. It is important to keep taking medication until it has a chance to work, though side effects may appear before antidepressant activity does. Once the individual is feeling better, it is important to continue the medication for 4 to 9 months to prevent recurrence. Some medications must be stopped gradually to give the body time to adjust, and many can produce withdrawal symptoms if discontinued abruptly. For individuals with bipolar disorder and those with chronic or recurrent major depression, medication may have to be maintained indefinitely.
Antidepressant drugs are not habit-forming. However, as is the case with any type of medication prescribed for more than a few days, antidepressants have to be carefully monitored to see if the correct dosage is being given. The doctor will check the dosage and its effectiveness regularly.
Some antidepressants can contaminate breast milk. Women who breast-feed should talk to their doctors to determine the most suitable treatment.
Antidepressants may cause mild and, usually, temporary side effects in some people. Typically these are annoying, but not serious. However, any unusual reaction or those that interfere with functioning should be reported immediately.
The most common side effects of tricyclic antidepressants, and ways to deal with them, are:
The newer antidepressants have different types of side effects:
Many forms of psychotherapy, including some short-term (10 to 20 week) therapies, can help depressed individuals. "Talking" therapies help patients gain insight into and resolve their problems through verbal exchange with the therapist, sometimes combined with "homework" assignments between sessions. "Behavioral" therapists help patients learn how to obtain more satisfaction and rewards through their own actions and how to unlearn the behavioral patterns that contribute to or result from their depression.
Two effective short-term psychotherapies are interpersonal and cognitive-behavioral therapies. Interpersonal therapists focus on the patient's disturbed personal relationships that both cause and exacerbate the depression. Cognitive-behavioral therapists help patients change negative thinking and behavior often associated with depression.
Psychodynamic therapies, which are sometimes used to treat depressed persons, focus on resolving the patient's conflicted feelings. These therapies are often reserved until the depressive symptoms are significantly improved. In general, severe depressive illnesses, particularly those that are recurrent, will require medication (or ECT under special conditions) along with, or preceding, psychotherapy for the best outcome.
Electroconvulsive therapy (ECT) is useful, particularly for individuals whose depression is severe or life threatening or who cannot take antidepressant medication. ECT often is effective in cases where antidepressants do not provide sufficient relief. In recent years, ECT has been improved. A muscle relaxant is given before treatment, which is done under brief anesthesia. Electrodes are placed at precise locations on the head to deliver electrical impulses. The stimulation causes a brief (around 30 seconds) seizure within the brain. The person receiving ECT does not consciously experience the electrical stimulus. For full therapeutic benefit, at least several sessions, typically at the rate of three per week, are required.