Because of dramatic hormonal changes associated with pregnancy and childbirth, some new mothers experience the onset of a depressive episode. While mild depression, or the "baby blues," are common, and may also reflect the lifestyle changes accompanying new motherhood, approximately 3 to 6 percent of women experience the onset of a major depressive episode in the weeks or months following delivery. The episode is often accompanied by severe anxiety and even panic attacks. In rare cases, the depression may be accompanied by such psychotic features as delusions and hallucinations. Experts find that fully 50 percent of depressive episodes considered postpartum actually have their onset prior to delivery—referred to as depression with peripartum onset. Studies show that women who experience mood and anxiety symptoms during pregnancy are at increased risk for developing a postpartum major depressive episode.
The mildest and most common form of postpartum depression is known as the baby blues. 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.
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
- Panic attacks
- Agitation or lethargy
Postpartum psychosis occurs at a rate of one to two 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—sometimes with command hallucinations to kill the infant or delusions that the infant is possessed—and are at risk for suicide and/or infanticide.
While biological, psychosocial, and cultural factors influence the condition, the exact causes of postpartum depression are unknown.
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.
Postpartum dysregulation of the thyroid gland may play a role. The thyroid gland regulates several hormones and production drops dramatically after birth, returning to normal functioning over a period of months. Thyroid changes may contribute to the feelings of fatigue that newmothers commonly experience.
Social and psychological factors can also contribute to the onset of a postpartum disorder.
New mothers require high levels of support in their new role, and prolonged postpartum depression is linked to lack of social support. New mothers need not only emotional support but household support, including 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, new mothers almost invariably experience inadequate rest. The resulting fatigue may increase a woman's vulnerability and serve as an added risk for depression.
The mother's changing role may feed feelings of inadequacy.
A woman's attitude toward her pregnancy may influence risk for peripartum or postpartum depression. 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. 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.
Weight gain during pregnancy can also affect self-esteem and increase the risk of depression, as can breatfeeding problems. .
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.
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.
Postpartum depression is treated much like other types of depression. The most common treatments for depression are psychotherapy, and participation in a support group, antidepressant medication, or a combination of those treatments.
The most commonly used medications to treat depression are selective serotonin reuptake inhibitors, or SSRIs.
As is the case with other medications, antidepressants can find their way into breast milk. Women who breast-feed should talk to their doctors to determine the most suitable treatment.
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.