Postpartum Disorder

Because of dramatic hormonal changes, some new mothers experience mild depression or the "baby blues." Others fall into a more serious depression or, in rare cases, experience psychotic episodes.

Definition

Postpartum disorder describes the range of emotional, physical, and behavioral challenges often experienced by new mothers. Symptoms can range from mild to severe. While many 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.

Symptoms

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 three to five days. Although symptoms are distressing, they typically subside within 24 to 72 hours. Common 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 four weeks after delivery but sometimes several months later. Symptoms must be present for at least two weeks and must affect the mother's ability to function. Many patients suffer from symptoms six 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 include:

  • Previous postpartum depression; one incidence may increase the risk of re-occurrence by up to 70 percent
  • Depression unrelated to pregnancy; a prior episode may increase the risk by 30 percent
  • Severe premenstrual syndrome
  • Stressful marital, family, vocational, or financial conditions
  • Unwanted pregnancy or ambivalence about the pregnancy

Symptoms reported for postpartum depression include:

  • Depressed mood for most of the day and nearly every day
  • Loss of interest in activities previously considered pleasurable
  • Hopelessness and despair
  • Thoughts of suicide and/or infanticide
  • Fear of harming the baby
  • Lack of concern or over-concern for the baby
  • Feelings of guilt, inadequacy, and worthlessness
  • Poor focus and impaired memory
  • Bizarre thoughts
  • Hallucinations
  • Nightmares
  • Panic attacks
  • Agitation or lethargy

Postpartum psychosis occurs at a rate of 1 to 2 out of every 1,000 deliveries. Symptoms usually occur within the first four weeks following delivery but can manifest anytime up to 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.

Causes

While biological, psychosocial and cultural theories have been investigated, the exact causes of postpartum depression are unknown.

Biological

Postpartum dysregulation of the thyroid gland is a 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, sometimes resulting in anxiety and insomnia. The second phase is hypothyroidism where production is slowed, often causing lethargy and weight gain. The final stage in recovery is when output reaches pre-pregnancy 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. Hormone 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.

Social and psychological factors can also contribute to the onset of a postpartum disorder.

Psychosocial

Psychosocial and emotional factors can act as stressors and impact a woman's self-esteem. New mothers require high levels of support, and prolonged postpartum depression is linked to lack of social support. New mothers need comfort and support during pregnancy and after delivery. They also need help with household chores and childcare. Such support may be lacking for a single mother or for a woman with few family members nearby.

Sleeplessness and fatigue are common complaints following childbirth. 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 experience inadequate rest. The resulting fatigue may increase a woman's vulnerability and be an added risk for depression.

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 the 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 a woman to 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 opt out of or stop breastfeeding. 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 routine 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.

Cultural Aspects

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 report help with child care beyond the first week.

Treatments

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.

Medications

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 three to four weeks (in some cases, as many as eight weeks) before a 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 four to nine months to prevent recurrence of symptoms. 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.

Side Effects

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:

  • Dry mouth: Sip water, chew sugarless gum, and clean teeth daily.
  • Constipation: Bran cereals, prunes, fruit, and vegetables should be consumed.
  • Bladder problems: Emptying the bladder may be difficult, and the urine stream may not be as strong as usual. The doctor should be notified if there is marked difficulty or pain.
  • Sexual problems: Sexual functioning may change. If troublesome, a patient should discuss this with their doctor.
  • Blurred vision: This will pass and usually will not necessitate new glasses.
  • Dizziness: Rise from the bed or chair slowly.
  • Drowsiness as a daytime problem:This usually passes. A person feeling drowsy should not drive or operate heavy equipment. Sedating antidepressants are generally taken at bedtime to help sleep and minimize daytime drowsiness.

The newer antidepressants have different types of side effects:

  • Headache: This will usually subside with time.
  • Nausea: This is also temporary, and is typically transient after each dose.
  • Nervousness and insomnia, trouble falling asleep or waking often during the night. These may occur during the first few weeks. Dosage reductions or time will usually resolve these issues.
  • Agitation, feeling jittery: If this happens for the first time after taking the drug and is more than transient, the doctor should be notified.

Psychotherapy

Many forms of psychotherapy, including some short-term (10 to 20 week) therapies, can help depressed individuals. Talk therapies can 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. Additionally, therapy can help a person understand what triggers their symptoms, and how best to cope with their distress.

Two effective short-term psychotherapies are interpersonal and cognitive-behavioral therapies. Interpersonal therapists focus on the patient's 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 often used to treat depression, 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 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.

References

  • Journal of Abnormal Psychology
  • Nursing Research
  • Journal of Consulting and Clinical Psychology
  • National Institute of Mental Health
  • US Department of Health and Human Services
  • National Mental Health Association
  • National Women's Health Information Center
  • Office of Women's Health, US Department of Health and Human Services
  • Depressive Symptoms in the Late Postpartum Among Low Socioeconomic Status Women

Last reviewed 02/09/2017