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.

Spectrum of Postpartum
Mood Changes
Transient,
nonpathologic

Medical
emergency

Serious,
disabling

Postpartum Blues
risk for Postpartum
Depression

Incidence

50% to 70%

Postpartum Depression
2/3 have onset by
6 wks postpartum

Postpartum Psychosis
10%

Cohen LS. Depress Anxiety. 1998:1:18-26.

70% are affective

(Bipolar, Major
Depression)
0.01%

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
1. Time of Onset of Postpartum Depression in 315 Women
Within 3 Months

Within 14 Days
46%
6 Weeks
2. Within
Time of
Onset

in 413 Patients

more severe, the 18%

earlier the onset.

Percentage of Patients

The
14%

of

22%
Within
6 Months
Postpartum
Depression

60
40

Severe, needed hospital admission

Mild, treated by general practitioner

20
0 Within Two Weeks

Six Weeks

Six Months

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,
day
Diminished interest or pleasure
activities

nearly every
in usual

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
Irritability

Inability to adjust to role of

motherhood
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:

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
-Client history of mood
disorder prior to pregnancy
-Anxiety/depression during
pregnancy
-Previous postpartum
depression
-Baby blues following current
delivery

-Child-care difficulties:
feeding, sleeping, health
-Marital conflict
-Stressful life events
-Poor social support

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 nonnursing 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%
61%

67%

52%

49%
37%
28%
20%

19261930

19511955

19661970

1972

1975

1998

2000

2001

Briggs, Freeman, Yafee, Drugs in Pregnancy and Lactation, 1998

Maternity Survey, Parents Express, Phil.,PA., 4/01, 4/02

Breast feeding

a reasonable
option
in Postpartum

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). 59:8:22472254.
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.