This is a disorder that has been in existence for longer than most people care to admit. It is only within the past 10 or so years that it has been diagnosed and received attention. It has particular relevance given the release of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) on May 18, 2013.
The release of DSM-5 should be a cause for celebration for women, as peripartum depression is officially recognized for the first time. In addition to acknowledging the significant prevalence of depression during the postpartum period, the criteria have been expanded to acknowledge the fact that depression can begin even four weeks prior to birth. Hopefully, this will lead to women being more open about how they feel both during pregnancy and after giving birth, and receiving the treatment they need and deserve.
WHAT ARE THE CHARACTERISTICS?
It is important to distinguish between the so-called baby blues and the peripartum depression. The baby blues affects about three quarters of new mothers, and are characterized by symptoms that commonly occur during the menstrual cycle: tearfulness, anxiety, and mood swings. Baby blues are considered a normal part of postpartum adjustment, and the symptoms are typically mild and transient. They typically begin around the second or third day post partum, and they usually resolve within 2 to 3 weeks. They don’t generally require any intervention. With reassurance, support, and good self-care, women get through this quite well.
Symptoms of peripartum depression typically began two weeks to approximately 6 months after childbirth. However this is a generalization, and women have been known to experience peripartum depression up to one year after birth. There are several risk factors associated with peripartum depression. These include:
depression or anxiety during pregnancy
personal or family history of depression or anxiety
social isolation or poor support
childcare related stressors
having a history of mood changes while taking birth control or fertility medications
In addition, there is a 50 to 80% risk of having peripartum depression if a woman has experienced a previous episode.
WHAT IF I HAVE ANXIETY AND NOT DEPRESSION?
Anxiety occurs in approximately 15 to 20% of women with the illness and it can be paralyzing. In fact, it is now thought that anxiety occurs in numbers even greater than 20%. The anxiety tends to stops women in their tracks. It’s not that they don’t want to respond to their babies, it’s that they feel that can’t. The anxiety impairs them in such a dramatic way that they are unable to function.
About 10% of women with peripartum depression will experience panic-related symptoms. These can range from waking out of sleep with their heart pounding to difficulty breathing. Furthermore, 3%-5% will experience obsessive-compulsive symptoms that can include thoughts and/or behaviors. Behaviors can include checking things or counting things repetitively.
WHAT IF I HAVE THOUGHTS OF MY BABY EXPERIENCING HARM?
It is also relatively common for women to have intruding images or have intruding thoughts about harm coming to herself, or, more commonly about harm coming to the baby. Understandably, this is of great concern to these women.
Sometimes clinicians confuse intruding thoughts and images with postpartum psychosis. However, in women with obsessive-compulsive symptoms due to peripartum depression, they are typically very disturbed by their thoughts. For example, they may be saying to themselves, “What kind of mom could I possibly be if I have these crazy kinds of thoughts?” They typically don’t want to talk about them. It can be very helpful for these women to be told that it is very normal for women with peripartum depression to have intruding thoughts and images. This can normalize the situation a little bit, enough to open the door so that women feel safe talking about it. Very often women are afraid that, if they tell anyone what they’re really thinking, their children will be taken away from them.
Two of the common intrusive thoughts or images consist of a knife slipping or dropping the baby. Such thoughts are caused by alterations in brain chemistry and are generally very responsive to medication, but they are not postpartum psychosis.
HOW IS POSTPARTUM PSYCHOSIS DIFFERENT?
In postpartum psychosis, when women have these intruding thoughts and images, it is part of their new reality. There is limited ability to recognize that there is something wrong.
Postpartum psychosis is rare and occurs in 1-2 out of every 1,000 women who give birth. Postpartum psychosis is a life threatening emergency. It requires immediate hospitalization for stabilization and treatment. It is known that when a woman has postpartum psychosis, the risk for suicide goes up to 5% while the risk for infanticide goes up to 4%. For anyone who may remember the Andrea Yates case from several years ago, she was a woman who suffered from postpartum psychosis.
WHAT IS THE CAUSE OF PERIPARTUM DEPRESSION?
We know that the attachment relationship starts while the fetus is in the uterus. Peripartum depression is caused primarily by hormonal changes that cross the placenta. This in turn, has an impact on the developing brain of the fetus. After birth, there is a significant drop in estrogen, which in turn can trigger changes in a woman’s brain that can lead to peripartum depression.
In addition to the hormonal changes, there are several other factors that can contribute to peripartum depression. These include:
fatigue and sleep deprivation
awareness and anxiety about the increased responsibility of having a newborn
the physical and emotional stress of birthing
the emotional letdown after giving birth
the potential disappointment due to lack of partner support.
ARE THERE ANY RISKS TO ME OR MY BABY IF I DON’T GET TREATED?
Several recent studies have shown that untreated depression, both during and after birth, can have risks to both the mother and her baby. Untreated depression during pregnancy has been associated with the following:
low weight gain in the mother
increased rates of preterm birth
low birth weight of the baby
less compliance with prenatal care
In addition, babies that are exposed to stress and/or depression before they are born have been shown to have increased behavioral problems. They also tend to have a higher rate of childhood psychiatric symptoms and diagnoses.
HOW IS IT DIAGNOSED?
Treatment cannot occur without peripartum depression first being diagnosed. Several state governments and healthcare providers have increased their routine screening of women. This sometimes can occur while the woman is still hospitalized, but most often happens during the woman’s first postnatal visit. It is shown that this tends to occur more often in OB/GYN settings versus pediatrician offices. The most common instrument used is the Edinburgh Postnatal Depression Scale (EPDS). This is a very easy to use 10 question self rated instrument. The goal is that increased screening leads to increased diagnosis, which hopefully leads to increased treatment.
Once diagnosed, referral to a mental health professional who is skilled in the assessment and treatment of perinatal depression has been shown to make a big difference in the outcome. It has also been shown that lack of a clinician’s knowledge about prenatal and postpartum depression and anxiety can be another big obstacle to treatment.
HOW IS IT TREATED?
Multiple factors, including accessibility of treatment options and patient preference for specific types of treatment, determine whether mothers with peripartum depression obtain treatment. For example, a postpartum mother may be unwilling to take an antidepressant due to her possible concerns about risks during breast-feeding to the newborn.
Psychotherapy is an important first line option for peripartum depression. Interpersonal psychotherapy and cognitive behavioral therapy have been the most studied and have both been shown to be effective for the prevention and treatment of peripartum depression. Group therapy is particularly helpful to women with postpartum depression because there is a sense of isolation that these women experience. There is often the notion that “no one else feels like this” or “Am I the only one who’s going through this?” in these women. Group therapy lessens that sense of being alone. There is connection with others, which alone can be healing.
WHAT IF MY TREATMENT OPTIONS ARE TOO FAR AWAY?
There has recently been a significant increase in the use of telemedicine, or Internet communication. Telemedicine holds great promise for assisting women in coping with peripartum depression and anxiety, especially when they are concerned about the social stigma of seeking mental health treatment or the fear of not knowing what to expect when meeting with a psychiatrist.
Although psychotherapy alone may be sufficient for some women, for others medication may be an important first line treatment. However, the discussion of medication options is beyond the scope of what will be covered here.
SOME FINAL THOUGHTS…
Despite the above mentioned options, there are many things that get in the way of women getting the help they need. These include the cost of treatment, the limited amount of time, especially with a newborn and the pressure to return to work, child care issues, and also the potential loss of pay from missing work. These barriers are some of the reasons that telemedicine holds such promise for making care available to more women, especially those in remote and underserved areas.
I would like to stress the importance of a psychiatrist or other trained mental health professionals’ role. Peripartum depression has great public health significance because it affects a large number of women and their families. Screening, preferably during pregnancy, but also after birth, may increase the identification of women who are suffering from this disorder. In order for these women to receive treatment and experience meaningful changes in their lives, they must receive timely and expert evaluations and treatment that is efficacious and also accessible.
If you have any questions please feel free to reach out to us at (919)636-5240. We are happy to speak to you.
Dr. Nicola Gray