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Wolocko, Daily News

Ricardo J. Fernandez, M.D., DFAPA
Councilor, NJ Psychiatric Association
“Postpartum Depression”

Psychiatric Syndromes
of the
Postpartum Period
This presentation is for
the exclusive use of the
New Jersey Psychiatric
Association website
and for the purposes of consumer
information and education.
It may not be otherwise
reproduced or presented without
the knowledge and consent of
Ricardo J. Fernandez, M.D.
Women are at serious risk
for developing a
psychiatric illness after

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
Admissions to a Psychiatric Hospital:
2 Years Pre and Post Delivery







–2 Years – 1 Year Childbirth +1 Year +2 Years

Kendell RE et al. Br J Psychiatry. 1987;150:662; presented at WMH, Berlin 2001.

First, let us discuss the
proper terminology for
these disorders.
“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
Spectrum of Postpartum
Mood Changes
Transient, Serious, Medical
nonpathologic disabling emergency

100% Postpartum Blues

↑risk for Postpartum
90% ↑ Depression
80% Postpartum Depression

50% to 70%
70% 2/3 have onset by
60% 6 wks postpartum

50% Postpartum Psychosis

70% are affective
40% (Bipolar, Major
10% Depression)

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

Postpartum Psychosis
is often mislabeled
in the media as
Postpartum Depression,
creating much anxiety
and fear in women with
the less severe
postpartum disorders.
Now, lets discuss the
specific syndromes.
Maternity or Postpartum
• 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” = heightened reactivity,
not clinical
• 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
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
• 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

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
• Occurs usually within 6 weeks of
birth but can occur up to a year after

Bright. Am Fam Physician. 1994; 50: 595.

Suri and Burt. J Pract Psychiatry Behav Health. 1997; 3: 67.
Onset of Symptoms in
Postpartum Depression
Two Studies
1. Time of Onset of Postpartum Depression in 315 Women
Within 14 Days Within 3 Months

46% 22%
2. Within
Time of6 Weeks
Onset of Within
Postpartum 6 Months
Depression in 413 Patients
14% more severe, the 18%
earlier the onset.
60 Severe, needed hospital admission
Percentage of Patients

Mild, treated by general practitioner



0Within 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, 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

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
What are obsessions and
• 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 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.
How is Postpartum
Depression treated?
• Psychiatric medication
– Antidepressants:
• In particular, those that increase release
of serotonin in the brain
– Medicines for anxiety and to
help with sleep
• Individual, couples and family
What about
breast feeding?
The incidence of breast
feeding in birthing mothers
is increasing as the next
slide shows.
Incidence of Breast Feeding

49% 52%


1926- 1951- 1966- 1972 1975 1998 2000 2001

1930 1955 1970

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

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

…a reasonable
in Postpartum
Depression ?
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.
There are risk factors that
predispose women to
postpartum disorders.
Risk Factors
• 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

extended family
Distorted and glamorized perceptions
of pregnancy…
…and of
in the
in the
As well as unrealistic
expectations of the postpartum mother
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.
For more information:
• Consult with your doctor
• Contact:
– Depression-After-Delivery (DAD)
– Depression and Bipolar Support Alliance (DBSA)
• Phone: 800-826-3632
– New Jersey Psychiatric Association
• Phone: 800-345-0143