Women Mental Health:

Postpartum Depression

A.Fitrikasari Sutomo
INCIDENCE OF DEPRESSION

Each year, 15% to 20% of adults in the United
States experience a major depression

The incidence among women is twice that of
men and peaks between 18 to 44 years of age
- the childbearing years
DEPRESSION IN WOMEN
Women are at increased risk of mood
disorders during periods of hormonal
fluctuation-
premenstrual
postpartum
perimenopausal

Women are at serious risk for
developing a psychiatric illness after
childbirth.
D. Wolocko, Daily News
Postpartum mothers are at significant
risk of developing a psychiatric illness
severe enough to require hospitalization
as the next slide demonstrates.
This increased risk lasts for about two
years after childbirth.
Postpartum Depression is a
general term used in our society to
describe any psychiatric illness
occurring after childbirth.
In reality,
Postpartum Depression describes
only one of four syndromes that can
occur after childbirth.
The four syndromes are:
Maternity or Postpartum Blues
Postpartum Psychosis
Adjustment Disorder of the Postpartum Period
Major Depression in the Postpartum
(Postpartum Depression)
Unfortunately, common reference to all four
conditions as
Postpartum Depression creates confusion
and fear.
It is important to understand that
Postpartum Psychosis, the most severe and
dangerous condition, is relatively rare and
quite different from Postpartum Depression,
as the next slide demonstrates.
Cohen LS. Depress Anxiety. 1998:1:18-26.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Transient,
nonpathologic
Medical
emergency
Serious,
disabling
Postpartum Blues
Postpartum Depression
Postpartum Psychosis
50% to 70%
10%
0.01%
2/3 have onset by
6 wks postpartum
risk for Postpartum
Depression
70% are affective
(Bipolar, Major
Depression)
Spectrum of Postpartum
Mood Changes
I
n
c
i
d
e
n
c
e

Postpartum Psychosis
is often mislabeled in the
media as
Postpartum Depression, creating
much anxiety and fear in women
with the less severe postpartum
disorders.
Maternity or Postpartum Blues
Is not considered a psychiatric illness and is
unrelated to psychiatric history .
Occurs in 26 to 85% of birthing mothers. The
exact incidence is unclear.
Present in all cultures studied
Appears unrelated to environmental
stressors


Maternity or Postpartum Blues
Blues = heightened reactivity,
not clinical depression
Mood swings from weepiness to extreme happiness
and heightened reactivity
Occurs 3 to 5 days after childbirth. It is self limiting,
resolving in about a week.
If occurs, increases risk for Postpartum
Depression.
The rest of the
syndromes to be described
are all considered
psychiatric illnesses and
benefit from clinical treatment.
Postpartum Psychosis
Is relatively rare, occurring one to three cases per 1000
births
Is a severe and life threatening condition for both
mother and infant
Develops soon after birth, often within two weeks,
usually within a month
Requires intense treatment and hospitalization: A
medical emergency
Is usually followed by Postpartum Depression
Symptoms of Postpartum Psychosis
Delusions: False beliefs, often of a religious
nature and very frequently involving the infant
Perceptual distortions: Seeing or hearing
things which are not present
Often, feelings of excessive well being or
importance
Adjustment Disorder of the
Postpartum Period
Occurs in about 20% of birthing mothers but
incidence is unclear as many women with this
problem do not seek treatment.
Manifests as excessive difficulties adjusting to
motherhood.
If emotional symptoms exist, they are not as severe
as those seen in Postpartum Depression

Bright. Am Fam Physician. 1994; 50: 595.
Suri and Burt. J Pract Psychiatry Behav Health. 1997; 3: 67.
Adjustment Disorder of the
Postpartum Period
Can resolve without treatment over time but
can cause ongoing difficulties for the mother.
Can develop into Postpartum
Depression if more severe and
untreated.
Responds well to short term
psychotherapy.
Bright. Am Fam Physician. 1994; 50: 595.
Suri and Burt. J Pract Psychiatry Behav Health. 1997; 3: 67.
Postpartum Depression
Occurs in 10% of birthing mothers
20% if the mother has had Maternity Blues.
Occurs usually within 6 weeks of birth but can
occur up to a year after birth
Bright. Am Fam Physician. 1994; 50: 595.
Suri and Burt. J Pract Psychiatry Behav Health. 1997; 3: 67.
6.8% to 16.5% of women experience post
partum depression (PPD) also known as poat
partum major depression (PMD)
Onset can be as early as 24 hours or as late as
several months following delivery
Onset of Symptoms in
Postpartum Depression
Two Studies
2. Time of Onset of Postpartum Depression in 413 Patients
The more severe, the earlier the onset.
0
20
40
60
Within Two Weeks Six Weeks Six Months
P
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c
e
n
t
a
g
e

o
f

P
a
t
i
e
n
t
s

Severe, needed hospital admission
Mild, treated by general practitioner
1. Time of Onset of Postpartum Depression in 315 Women
Within 14 Days 46%
Within 6 Weeks 14%

Within 3 Months 22%
Within 6 Months 18%
Postpartum Depression: Symptom
Onset
40%: After first postnatal visit
At 6 weeks
20%: Coincided with weaning
16%: At return of menstruation
At 2 to 3 months if not breast feeding
14%: Initiation of oral contraceptives
Postpartum Depression
Manifests as symptoms of depression, often
with marked anxiety/agitation and obsessions
about harm coming to the child.
Can develop gradually or abruptly after
birth

Bright. Am Fam Physician. 1994; 50: 595.
Suri and Burt. J Pract Psychiatry Behav Health. 1997; 3: 67.
What are the symptoms of
Depression?
Sadness of mood most of the day, nearly every day
Diminished interest or pleasure in usual
activities
Major change in appetite or weight
Not able to sleep or sleeping too much
Agitation or feeling slowed down
Fatigue or loss of energy
Feelings of worthlessness or excessive or inappropriate guilt
Diminished ability to think or concentrate, or indecisiveness
Recurrent thoughts of death, dying, or suicide

APA Diagnostic and Statistical Manual. 1994

SYMPTOMS OF POSTPARTUM
DEPRESSION
Hopelessness Loss of pleasure in activities
Helplessness Mood changes
Persistent sadness Inability to adjust to role of
motherhood
Irritability Inability to concentrate
Low self-esteem Sleep /appetite disturbances
Symptoms
Frequently Seen in
Postpartum Depression
Marked agitation and anxiety
Mother can not sleep even when the baby
is sleeping
Obsessions and compulsions about the
baby
RANGE OF SYMPTOMS
Symptoms range-
from mild dysphoria
to suicidal ideation
to psychotic depression

DURATION OF SYMPTOMS
Untreated, symptoms can last:

several months

into the second year postpartum
THE ETIOLOGY OF POSTPARTUM
DEPRESSION
Various theories based in physiological
changes have been postulated:
hormonal excesses or deficiencies of estrogen,
progesterone, prolactin, thyroxine, tryptophan,
among others

ETIOLOGY OF POSTPARTUM DEPRESSION
Other theories cite numerous psychosocial
factors associated with PMD:
marital conflict
child-care difficulties (feeding, sleeping, health
problems)
perception by mother of an infant with a
difficult temperament
history of family or personal depression

INDICDENCE OF POSTPARTUM
DEPRESSION AMONG 2000 UTAH
PRAMS RESPONDENTS
24.1% of PRAMS respondents indicated
that in the months after delivery they
were moderately to very depressed
Higher rates of depression were noted
among women who:
Had less than a high school
education
Reported being abused before
or during pregnancy
Were less than 19 years old Had 0 to 1 person as a source
of social support
Resided in a household with
an income <$15,000
Were not married
Experienced an unintended
pregnancy
Reported 6 to 18 stresses
during pregnancy (sick family
member, divorce, etc.)

THE IMPACT OF POSTPARTUM
DEPRESSION
LONG TERM CONSEQUENCES OF PMD

Negative impact on the infant s social,
emotional and cognitive development

2 month old infants of mothers with PMD had
decreased cognitive ability and expressed more
negative emotions during testing

LONG TERM CONSEQUENCES OF
PMD
Babies of mothers
with PMD were
perceived by their
mothers as more
difficult to care for
and more
bothersome.
POSTPARTUM DEPRESSION &
MATERNAL MORTALITY IN UTAH

In recent years, there have been two
maternal deaths due to suicide by women
within one year of giving birth.
Neither woman had been screened for
postpartum depression
There are risk factors that
predispose women to postpartum
disorders.
RISK FACTORS FOR PMD
-Family history of mood
disorder
-Child-care difficulties:
feeding, sleeping, health
-Client history of mood
disorder prior to pregnancy
-Marital conflict
-Anxiety/depression during
pregnancy
-Stressful life events
-Previous postpartum
depression
-Poor social support
-Baby blues following current
delivery
First pregnancy
Young age
Psychiatric illness during pregnancy
Prior history of postpartum illness
Prior history of mental illness
Family history of mental illness
Recent stressful life events
Problems in the marriage
In addition, there are many societal
and cultural factors that may
predispose women to postpartum
problems including...
Isolation
Diminished extended family involvement
Distorted and glamorized perceptions of
pregnancy

Recovery in the post partum
Frequently promoted in the media
Unrealistic expectations of the postpartum
mother
TREATMENT

Educate the woman and her support system
regarding the diagnosis of
postpartum depression.
TREATMENT OPTIONS
Pharmacological intervention

Counseling, individual and/or group

Support groups
PHARMACOLOGICAL INTERVENTION
Use of tricyclic antidepressants and selective
serotonin reuptake inhibitors (SSRIs) may be
indicated for both non-nursing and nursing mothers
Have low incidence of infant toxicity and adverse
effects during breastfeeding*
Decisions regarding use while breastfeeding must be
on a case by case basis
OTHER CONSIDERATIONS:
Provider must be familiar with agents and the
hepatic function of mother and infant
Client must be informed of risks/benefits of
treatment Vs. no treatment for herself and her
infant
unknown impact of long-term use of medications
on neurodevelopment of infant
Other Considerations - Cont.
If the woman chooses to breastfeed while
on psychotropics, she should work
collaboratively with a psychiatrist and her
pediatrician
If the infant experiences insomnia or other
behavior changes, his serum should be
assayed for the presence of medication
Document all discussions regarding
treatment in the clients chart
COUNSELING
Know referral sources in your locale,
especially those that:
accept Medicaid
utilize a sliding fee
will develop a payment plan with the client
offer free counseling
Be familiar with indigent drug programs
available through various pharmaceutical
manufacturers
Counseling - Cont.
Any woman with symptoms of psychosis or
with serious suicidal/homicidal ideation
should be referred for emergency psychiatric
evaluation
SUPPORT GROUPS

Numerous postpartum support groups are
available. Contact:
Local mental health agencies
Hospitals
Websites

What about
breast feeding?
The incidence of breast feeding in
birthing mothers is increasing as the
next slide shows.
Although the presence of obsessions
and compulsions indicates need for
treatment, these mothers are rarely
dangerous to the infants. They are
actually at higher risk to hurt themselves
as a result of their fear of possibly
hurting the infant.
Incidence of Breast Feeding
1926-2001
80%
49%
28%
20%
37%
52%
67%
61%
1926-
1930
1951-
1955
1966-
1970
1972 1975 1998 2000 2001
Briggs, Freeman, Yafee, Drugs in Pregnancy and Lactation, 1998
Maternity Survey, Parents Express, Phil.,PA., 4/01, 4/02
a reasonable option
in Postpartum
Depression ?
Breast feeding
What are obsessions and
compulsions?
An obsession is a repetitive, intrusive and disturbing
thought that enters the mind and is out of the
individual's control.
A compulsion is a repetitive act that is done in an
attempt to be rid of the obsessional thought.
Both cause great anxiety and discomfort in the
individual.
Postpartum obsessions
Commonly focused on infant
Thoughts(obsessions) of hurting the infant
Dropping infant
Drowning infant
Stabbing infant
Putting infant in oven or microwave
Sexually abusing infant
Thoughts that someone will steal or harm the
infant


Postpartum compulsions
Commonly follow the obsessions as an attempt to
alleviate the thought
Avoid holding baby by staircases, etc
Avoid bathing infant
Hide knives
Avoid kitchen area
Avoid changing diapers or bathing infant
Avoid leaving the house

Although all medications cross into
breast milk, there are a few
antidepressants that appear to cross
less than others and may be safer in
breast feeding. Consult your
doctor.
In summary, postpartum psychiatric
illness exists. It can be debilitating
and dangerous to both mother and
child.
Effective treatments are available.
Support groups of mothers in recovery
are also available in many areas of
the country.

References
1. Beck AT, Ward, CH, Mendelson M, Mock J, Erbaugh J. An inventory for
measuring depression. Archives of General Psychiatry. (June 1961). 4:6:561-
571.
2. Cox JL, Holden, JM, Sagovsky R. Edinburgh Postnatal Depression Scale
(EPDS). British Journal of Psychiatry. (1987). 150:782-786.
3. Epperson CN. Postpartum major depression: detection & treatment.
American Family Physician. (April 15, 1999). 59:8:2247-2254.
4. Mandl KD, Tronick EZ, Brennan TA, Alpert HR, Homer J. Infant health care
use and maternal depression. Archives of Pediatric Adolescent Medicine.
(1999). 153:(8):808-813.
5. Stowe Z. Depression after childbirth: I it the baby blues or something
more? Pfizer Inc. January 1998.
6. Stowe ZN, Nemeroff CB. Women at risk for postpartum-onset major
depression. American Journal of Obstetrics & Gynecology. (August 1995).
173:2:639-645.
7. Utah Department of Health. (2001). [Untitled]. Unpublished Maternal
Mortality Review Program data.

References (cont.)
8. Utah Department of Health. (2001). [Untitled]. Unpublished PRAMS data.
9. Whiffen VE, Gotlib IH. Infants of postpartum depressed mothers: temperament
and cognitive status. Journal of Abnormal Psychology. (1989). 98:3:274-279.