Postpartum depression

Definition

Postpartum depression is a depression that can range from mild to suicidal and can occur anytime after delivery up to one year later.

Description

Postpartum depression is an affective disorder (any mental disorder characterized by a consistent change in mood that affects thoughts and behaviors) that can occur after pregnancies of all duration, from spontaneous (not induced) abortions, also called miscarriages, to full-term deliveries. The depression can take a mild clinical course or it can range to suicidal ideations (thoughts). The depression can occur anytime post-delivery to one year after delivery. Symptoms commonly start within four to six weeks after delivery. Differentiating postpartum depression from "maternity blues" or the stress from the pregnancy and delivery can be difficult. Postpartum depression can be differentiated from other types of depression if the mother exhibits signs of ambivalence to the infant and neglect of other family members.

Causes and symptoms

Causes

The cause of postpartum depression has been extensively studied. Alterations of hormone levels for prolactin, progesterone, estrogen, and cortisol are not significantly different from those of patients who do not suffer from postpartum depression. However, some research indicates a change in a brain chemical that controls the release of cortisol.

Research seems to indicate that postpartum depression is unlikely to occur in a patient with an otherwise psychologically uncomplicated pregnancy and past history. There is no association of postpartum depression with marital status, social class, or the number of live children born to the mother. However, there seems to be an increased chance to develop this disorder after pregnancy loss.

Certain characteristics have been associated with increased risk of developing postpartum depression. These risk factors include:

medical indigence— being in need of health care and not being able to receive it, possibly due to lack of medical insurance
being younger than 20 years old at time of delivery
being unmarried
having been separated from one or both parents in childhood or adolescence
receiving poor parental support and attention in childhood
having had limited parental support in adulthood
poor relationship with husband or boyfriend
economic problem with housing or income
dissatisfaction with amount of education
low self-esteem
past or current emotional problem(s)
family history of depression

Symptoms

The symptoms can range from mild depression to a severe depression with thoughts of ending one's life ( suicide ). The disorder should be suspected during its peak (four to six weeks after delivery) in a patient who demonstrates signs and symptoms of clinical depression (feelings of worthlessness and hopelessness, changes in eating and sleeping patterns, irritability, difficulty with motivation, and difficulty getting out of bed in the morning). Additionally, patients may be emotionally detached from the infant and unable to display loving affection towards family members. Physical and emotional stress during delivery in conjunction with great demands for infant care may cause the patient to neglect other family members, increasing the woman's feelings of self-worthlessness, isolation, and being trapped. Patients may also feel as if they are inadequate mothers, causing them guilt and embarrassment.

Demographics

There is a 20% to 30% risk of postpartum depression for women who had a previous depressive episode that was not associated with pregnancy. Additionally, there is an increased risk of recurrence in subsequent pregnancies since 50–100% of patients will have more than one episode.

Diagnosis

Patients should undergo careful clinical assessment from a psychologist or psychiatrist , who can determine the risk factors and diagnose the condition. A careful, comprehensive psychological assessment interview could reveal a previous depressive cycle or a family history of depression—important risk factors. The most widely used standard for diagnosis is the Edinburgh Postnatal Depression Scale (EPDS). This is a simple and short 10-question scale. A score of 12 or greater on the EPDS is considered high risk for postpartum depression.

Treatments

Treatment should begin as soon as the diagnosis is established. A typical treatment plan includes psychotherapy and medications. Recent studies have found that a group of medications known as the selective serotonin reuptake inhibitors (SSRIs) are effective in treating postpartum depression. These antidepressants have fewer side effects than other antidepressants and can be taken by breast-feeding mothers. SSRIs are secreted into breast milk, however, in varying amounts. Some studies indicate that paroxetine secretes the least amount of medication into breast milk. Breast-feeding women considering taking an antidepressant should discuss medication choices with their doctor. SSRIs can be given two to three weeks before delivery to patients who had a previous episode to avoid recurrence. Some SSRIs include: fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), and citalopram (Celexa).

When medications are combined with psychological therapy, the rates for successful treatment are increased. Interpersonal therapy and cognitive-behavioral therapy have been found to be effective.

Prognosis

The prognosis for postpartum depression varies because this disorder is usually implicated with difficult social factors, a personal history of emotional problems, and adverse pregnancy outcomes, such as miscarriage. The prognosis is better if depression is detected early

Care for a newborn can be overwhelming, and some women experience postpartum depression shortly after birth.

(Layne Kennedy/CORBIS. Photo reproduced by permission.)

during its clinical course and a combination of SSRIs and psychotherapy is available and inititated.

Prevention

The best method to prevent the disorder is through education. Mothers should be advised prior to hospital discharge that if the "maternity blues" last longer than two weeks or pose tough difficulties with family interactions, they should call the hospital where their baby was delivered and pursue a referral for a psychological evaluation. Education concerning risk factors and reduction of these is important. Prophylactic (preventive) use of SSRIs is indicated two to three weeks before delivery to prevent the disorder in a patient with a past history of depression, since recurrence rates are high if the mother had a previous depressive episode.

Resources

BOOKS

Gabbe, Steven, Jennifer R. Niebyl, Joe Leigh Simpson. Obstetrics: Normal & Problem Pregnancies. 4th ed. Philadelphia : W. B. Saunders Company, 2002.

Ryan, Kenneth J., Ross S. Berkowitz, Robert L. Barbieri, and others. Kistner's Gynecology & Women's Health. 7th ed. Saint Louis: Mosby, Incorporated, 1999.

PERIODICALS

Evins, G. G., J. P. Theofrastous, and S. L. Galvin. "Postpartum Depression: a comparison of screening and routine clinical evaluation." American Journal of Obstetrics and Gynecology 182, no. 5 (May 2000).

ORGANIZATIONS

Online PPD Support Group. <http://www.ppdsupportpage.com> .

Laith Farid Gulli, M.D.

Nicole Mallory, M.S., PA-C