Postpartum Depression

Postpartum Depression

Postpartum Depression

Postpartum depression (PPD), also called postnatal depression or depressive disorder with peripartum onset, is a mood disorder associated with childbirth. Peripartum onset is defined as starting anytime during pregnancy or within the four weeks following delivery; however, it can begin as late as six months after giving birth. PPD is likely caused by hormonal changes and the response to the sudden change in one’s role and responsibilities. PPD can also affect men.

While most women experience up to two weeks of milder depressive symptoms than PPD following delivery, called postpartum blues or “baby blues,” postpartum depression should be suspected when symptoms are severe and last longer than two weeks.

Prevalence

Postnatal mood disorders are the most common complication of childbirth. Postpartum blues can occur in up to 80%, and PPD in approximately15%, of all women following delivery. It is estimated that up to 26% of new fathers develop this condition. Postpartum psychosis happens in 1 in every 1,000 pregnancies and usually requires hospitalization.

Symptoms of Postpartum Depression:

If symptoms do not go away after two weeks of them starting, or if you have thoughts of harming yourself or your baby, medical help is vital.

Symptoms of post-partum depression — see a doctor for any of these symptoms:

  • Drastic mood swings, long bouts of crying
  • Finding it hard to bond with the baby
  • Avoiding interaction with family and friends, withdrawing from anything that requires energy or thinking
  • Difficulty “staying present” or concentrating on conversations or events
  • Extremely tired all the time
  • Easily irritated and quick to get angry
  • Feeling worthless, not good enough, not a good mother
  • Feeling hopeless, helpless
  • Everything feels like living in a fog
  • Feeling fear, panic
  • Thoughts of harming self or the baby
  • Inadequate self-care

Postpartum psychosis is a psychiatric emergency that occurs in 1 in 1,000 women within the first two weeks of childbirth. Postpartum psychosis can happen suddenly and is characterized by profound changes in mood, severe confusion, lack of self-control and impulsivity, paranoia, sleep disturbances, and perceptual disturbances such as auditory hallucinations and delusions. Mothers with postpartum psychosis require urgent hospitalization and are often treated with antipsychotic medications.

If you are experiencing suicidal thoughts, you can call the Suicide Prevention Hotline and talk for free at 1-800-SUICIDE (1-800-784-2433) or 1-800-273-TALK (1-800-273-8255). They can also provide you with information about low-cost clinics and therapists for your depression.

Also consider talking to a partner, family, friends, a primary doctor, or a leader in your faith community.

Call 911 if you are seriously contemplating or vocalizing thoughts of suicide or self harm or have thoughts of harming your baby.

Diagnosing Postpartum Depression:

A doctor will do bloodwork and a physical exam to rule out any other causes of depression first, such as an underactive thyroid. He/she might also use the Edinburgh Postnatal Depression Scale questionnaire to assess the severity of the symptoms described, and will study the mother’s past medical history for any mood disorder diagnoses, as many women with bipolar II disorder also have PPD.

The criteria required for the diagnosis of PPD are the same as those required to make a diagnosis of non-childbirth-related major depressive disorder, and they include at least five of the following nine symptoms, within a two-week period:

  • Low mood or extreme mood swings – nearly every day, for most of the day
  • Anhedonia – loss of interest or pleasure in activities
  • Weight loss or gain – greater than a 5% change in a month
  • Insomnia or hypersomnia – sleeping too little or too much
  • Agitated movement or muscular activity or significantly impaired intellectual and adaptive functioning
  • Overwhelming tiredness or loss of energy
  • Feeling worthless and inadequate, or feeling excessive or inappropriate guilt
  • Decreased concentration
  • Thoughts of suicide

Causes of Postpartum Depression

While the causes of PPD are not fully understood, multiple factors have been identified that increase the risk of developing this condition which include:

  • Hormonal changes – Childbirth causes hormone levels to drop considerably, which can negatively affect emotions and energy levels considerably.
  • Pregnancy history – Prenatal depression or anxiety, stressful life events, complications experienced during pregnancy or childbirth, previous stillbirth or miscarriage
  • Childhood – Adverse childhood experiences and trauma, such as sexual abuse
  • Circumstances – Poverty; a lack of strong emotional support from spouse, partner, family, or friends; marital disharmony or single marital status; feeling alone; child born with special needs; breastfeeding difficulties; the baby was unplanned; the baby cries a lot; financial difficulties
  • Anxiety – about not being “enough” in what is thought to be important
  • History of depression – or another mood disorder
  • Family history of depression – or another mood disorder

Complications of Post Partum

PPD can :

  • Interfere with normal mother-infant bonding
  • Negatively affect short- and long-term child development
  • Impair a mother’s ability to provide consistent childcare such as feeding routines and health maintenance – to the baby and any other children
  • Impair a mother’s ability to provide consistent childcare such as feeding routines and health maintenance – to the baby and any other children
  • Place a mother at increased risk of suicide and self-harm and of harming her baby
  • Increase the risk of a future episode of major depression
  • Alter the family dynamic and increase the risk of the baby’s father also becoming depressed

Treatment of Postpartum Depression:

The treatment of choice depends on the severity of the PPD and patient preference. Postpartum depression is best treated with a combination of psychotherapy (talk therapy) and medications such as antidepressants, and people usually improve over the subsequent months of treatment. Many recover completely within a year. Alternative treatment options are often available while a mother is breastfeeding.

  • Talk therapy (psychotherapy) – such as:

    • Cognitive behavioral therapy (CBT) – helps people recognize triggers and adopt healthy ways to respond, plus ways to change negative thought patterns for positive ones.
    • Interpersonal psychotherapy/problem-solving therapy – 3- to 4-month therapy that helps people stop letting life circumstances dictate their mood and teaches problem-solving skills and strategies to face and process them.
  • Electroconvulsive Therapy (ECT) – might be used if nothing else seems to be working or the person cannot take medications, although it runs the risk of some memory loss. An electrical current is sent through the brain to reawaken brain cells.
  • Transcranial Magnetic Stimulation (TMS) – is non-invasive brain stimulation (currently in the testing phase) for those who are not good candidates for other treatments or medications. It is used alongside psychotherapy.
  • Practical and emotional support – from family and friends makes a big difference in the early months, and it can even prevent PPD. Invite people over. Ask for help with housework, cooking, babysitting.
  • Self-care – spend time with friends when you can — in person or on the phone, shower, get dressed every morning, congratulate yourself for the little things. Exercise, eat healthy food at scheduled times, and get enough regular sleep and sunlight.

Medications for Postpartum Depression:

Antidepressant medications – A psychiatrist will usually prescribe these for women (or men) with moderate or severe PPD symptoms. Benefits can begin in as few as two weeks. People who have had previous bouts of depression and found a medication they responded well to will usually go back on that medication again for PPD.

*There is a danger of some antidepressants causing manic episodes in women with bipolar II disorder, so a treatment plan that takes all medical history into consideration, and any existing medication, is vital.

*It might take up to three months to find the most effective medication and the right dosage.

*If breastfeeding, the baby’s health must also be monitored to check for side effects of medication.

  • Selective serotonin reuptake inhibitors (SSRIs) increase the amount of serotonin uptake in the brain. Sertraline, escitalopram, or citalopram are the preferred meds for PPD because they have fewer side effects, with people starting on very low doses and building them up over time until they seem effective. Only a small amount of the drug is passed though breastmilk.
  • Serotonin and norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine can help reduce PPD symptoms, especially anxiety.
  • Monoamine inhibitors are usually not a safe option for breastfeeding mothers, while some tricyclic antidepressants (TCAs) such as nortriptyline are.
  • Benzodiazepines can be prescribed alongside the antidepressants for initial short-term help with anxiety.
  • Antipsychotics such as haloperidol or risperidone (safer if breastfeeding than others) might be prescribed to boost the effects of an antidepressant, or lithium.

Psychotic PPD
Medication for psychotic PPD is designed to stabilize the person first and foremost. One such drug is brexanolone, but antipsychotics, mood stabilizers, and benzodiazepines (see above) are the main drugs prescribed.

  • Brexanolone – A new FDA-approved drug used for psychotic or severe PPD that is given in titrated doses via an IV continuous infusion over 60 hours in a clinical setting. It can cause dangerous side effects of hypoxia and excessive sedation or loss of consciousness in some people, so it must be constantly monitored by a medical professional.
  • Once stabilized, a treatment plan is designed for long-term recovery.

Symptoms of Postpartum Depression:

If symptoms do not go away after two weeks of them starting, or if you have thoughts of harming yourself or your baby, medical help is vital.

Symptoms of post-partum depression — see a doctor for any of these symptoms:

  • Drastic mood swings, long bouts of crying
  • Finding it hard to bond with the baby
  • Avoiding interaction with family and friends, withdrawing from anything that requires energy or thinking
  • Difficulty “staying present” or concentrating on conversations or events
  • Extremely tired all the time
  • Easily irritated and quick to get angry
  • Feeling worthless, not good enough, not a good mother
  • Feeling hopeless, helpless
  • Everything feels like living in a fog
  • Feeling fear, panic
  • Thoughts of harming self or the baby
  • Inadequate self-care

Postpartum psychosis is a psychiatric emergency that occurs in 1 in 1,000 women within the first two weeks of childbirth. Postpartum psychosis can happen suddenly and is characterized by profound changes in mood, severe confusion, lack of self-control and impulsivity, paranoia, sleep disturbances, and perceptual disturbances such as auditory hallucinations and delusions. Mothers with postpartum psychosis require urgent hospitalization and are often treated with antipsychotic medications.

If you are experiencing suicidal thoughts, you can call the Suicide Prevention Hotline and talk for free at 1-800-SUICIDE (1-800-784-2433) or 1-800-273-TALK (1-800-273-8255). They can also provide you with information about low-cost clinics and therapists for your depression.

Also consider talking to a partner, family, friends, a primary doctor, or a leader in your faith community.

Call 911 if you are seriously contemplating or vocalizing thoughts of suicide or self harm or have thoughts of harming your baby.

Diagnosing Postpartum Depression:

A doctor will do bloodwork and a physical exam to rule out any other causes of depression first, such as an underactive thyroid. He/she might also use the Edinburgh Postnatal Depression Scale questionnaire to assess the severity of the symptoms described, and will study the mother’s past medical history for any mood disorder diagnoses, as many women with bipolar II disorder also have PPD.

The criteria required for the diagnosis of PPD are the same as those required to make a diagnosis of non-childbirth-related major depressive disorder, and they include at least five of the following nine symptoms, within a two-week period:

  • Low mood or extreme mood swings – nearly every day, for most of the day
  • Anhedonia – loss of interest or pleasure in activities
  • Weight loss or gain – greater than a 5% change in a month
  • Insomnia or hypersomnia – sleeping too little or too much
  • Agitated movement or muscular activity or significantly impaired intellectual and adaptive functioning
  • Overwhelming tiredness or loss of energy
  • Feeling worthless and inadequate, or feeling excessive or inappropriate guilt
  • Decreased concentration
  • Thoughts of suicide

Causes of Postpartum Depression

While the causes of PPD are not fully understood, multiple factors have been identified that increase the risk of developing this condition which include:

  • Hormonal changes – Childbirth causes hormone levels to drop considerably, which can negatively affect emotions and energy levels considerably.
  • Pregnancy history – Prenatal depression or anxiety, stressful life events, complications experienced during pregnancy or childbirth, previous stillbirth or miscarriage
  • Childhood – Adverse childhood experiences and trauma, such as sexual abuse
  • Circumstances – Poverty; a lack of strong emotional support from spouse, partner, family, or friends; marital disharmony or single marital status; feeling alone; child born with special needs; breastfeeding difficulties; the baby was unplanned; the baby cries a lot; financial difficulties
  • Anxiety – about not being “enough” in what is thought to be important
  • History of depression – or another mood disorder
  • Family history of depression – or another mood disorder

Complications of Post Partum

PPD can :

  • Interfere with normal mother-infant bonding
  • Negatively affect short- and long-term child development
  • Impair a mother’s ability to provide consistent childcare such as feeding routines and health maintenance – to the baby and any other children
  • Impair a mother’s ability to provide consistent childcare such as feeding routines and health maintenance – to the baby and any other children
  • Place a mother at increased risk of suicide and self-harm and of harming her baby
  • Increase the risk of a future episode of major depression
  • Alter the family dynamic and increase the risk of the baby’s father also becoming depressed

Treatment and Drugs:

The treatment of choice depends on the severity of the PPD and patient preference. Postpartum depression is best treated with a combination of psychotherapy (talk therapy) and medications such as antidepressants, and people usually improve over the subsequent months of treatment. Many recover completely within a year. Alternative treatment options are often available while a mother is breastfeeding.

  • Talk therapy (psychotherapy) – such as:

    • Cognitive behavioral therapy (CBT) – helps people recognize triggers and adopt healthy ways to respond, plus ways to change negative thought patterns for positive ones.
    • Interpersonal psychotherapy/problem-solving therapy – 3- to 4-month therapy that helps people stop letting life circumstances dictate their mood and teaches problem-solving skills and strategies to face and process them.
  • Electroconvulsive Therapy (ECT) – might be used if nothing else seems to be working or the person cannot take medications, although it runs the risk of some memory loss. An electrical current is sent through the brain to reawaken brain cells.
  • Transcranial Magnetic Stimulation (TMS) – is non-invasive brain stimulation (currently in the testing phase) for those who are not good candidates for other treatments or medications. It is used alongside psychotherapy.
  • Practical and emotional support – from family and friends makes a big difference in the early months, and it can even prevent PPD. Invite people over. Ask for help with housework, cooking, babysitting.
  • Self-care – spend time with friends when you can — in person or on the phone, shower, get dressed every morning, congratulate yourself for the little things. Exercise, eat healthy food at scheduled times, and get enough regular sleep and sunlight.

Medications for Postpartum Depression:

Antidepressant medications – A psychiatrist will usually prescribe these for women (or men) with moderate or severe PPD symptoms. Benefits can begin in as few as two weeks. People who have had previous bouts of depression and found a medication they responded well to will usually go back on that medication again for PPD.

*There is a danger of some antidepressants causing manic episodes in women with bipolar II disorder, so a treatment plan that takes all medical history into consideration, and any existing medication, is vital.

*It might take up to three months to find the most effective medication and the right dosage.

*If breastfeeding, the baby’s health must also be monitored to check for side effects of medication.

  • Selective serotonin reuptake inhibitors (SSRIs) increase the amount of serotonin uptake in the brain. Sertraline, escitalopram, or citalopram are the preferred meds for PPD because they have fewer side effects, with people starting on very low doses and building them up over time until they seem effective. Only a small amount of the drug is passed though breastmilk.
  • Serotonin and norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine can help reduce PPD symptoms, especially anxiety.
  • Monoamine inhibitors are usually not a safe option for breastfeeding mothers, while some tricyclic antidepressants (TCAs) such as nortriptyline are.
  • Benzodiazepines can be prescribed alongside the antidepressants for initial short-term help with anxiety.
  • Antipsychotics such as haloperidol or risperidone (safer if breastfeeding than others) might be prescribed to boost the effects of an antidepressant, or lithium.

Psychotic PPD
Medication for psychotic PPD is designed to stabilize the person first and foremost. One such drug is brexanolone, but antipsychotics, mood stabilizers, and benzodiazepines (see above) are the main drugs prescribed.

  • Brexanolone – A new FDA-approved drug used for psychotic or severe PPD that is given in titrated doses via an IV continuous infusion over 60 hours in a clinical setting. It can cause dangerous side effects of hypoxia and excessive sedation or loss of consciousness in some people, so it must be constantly monitored by a medical professional.
  • Once stabilized, a treatment plan is designed for long-term recovery.