The birth of a child is one of the most exciting and most life altering changes that a family system can experience. This blog is the first of a two-part series devoted to demystifying the diagnosis of Postpartum Depression. The first part of the two-part series is devoted to understanding the diagnosis of Postpartum Depression. The second part is devoted to coping strategies that are helpful not only for the mother but for the father or partner as well. The overall goal of this two-part series is to empower women and to strengthen the family system upon the birth of a child.
During pregnancy, the mother goes through a lot of hormonal, physical, emotional, and psychological changes. The act of childbirth is a difficult and exhausting process. Following the childbirth, a mother can experience a range of emotions filled with both joy and happiness to sadness with crying spells. These feelings of sadness and tearfulness are often called the “baby blues” and most often tend to decrease over the course of the first two weeks following delivery. However, some women experience a more in depth feeling of aloneness and feelings of deep sadness, hopelessness and helplessness.
About one in seven new mothers develop postpartum depression often referred to as PPD. Even more rare is the development of postpartum psychosis which occurs in approximately one to two women per 1, 000 births. While women with the baby blues tend to recover quickly, women with PPD the depression tends to be longer and can severely affect the women’s ability to return to normal functioning. PPD affects the relationship between the woman and the infant and ultimately the family system. The maternal brain response and behavior is compromised with PPD. It is estimated that as many as half of PPD in new mothers goes undiagnosed due to issues related to privacy, not wanting to disclose to close family members and the stigma surrounding new mothers in that disclosure may lead to abandonment and a fear for a lack of support from friends and family.
PPD can occur in females having depression and anxiety in any trimester during pregnancy. There are some risk factors which may contribute to the development of PPD. Women with a history of depression, anxiety, premenstrual syndrome or prior psychological disorders such as bipolar disorder, schizoaffective disorder or major depressive disorder may be at a greater risk to develop PPD following the birth of their child. Women with a negative attitude towards the baby, reluctance to accept the baby’s gender, a history of sexual assault or abuse can be perpetual factors in the development of PPD. Women who experience a greater number of obstetrical risks such as experiencing an emergency cesarean section or hospitalizations during a difficult pregnancy. Meconium passage, umbilical cord prolapse, preterm or low birth weight and low hemoglobin levels are also associated with PPD. Women who find themselves pregnant and with a lack of social support can also experience PPD. Domestic violence in the form of spousal sexual, physical, and verbal abuse can also be a causative factor in the development of the disease.
Lifestyle choices may also be a contributing factor toward the development of PPD. A woman’s eating habits, sleep cycle, physical activities, exercise and exposure to alcohol, drugs or smoking may also affect PPD. Vitamin B6 has known to be involved via the conversion to tryptophan and later to serotonin which in turn affects mood. The decrease in sleep, lack of physical activity and exercise impacts the endogenous endorphins and opioids that bring upon the positive effects of the woman’s mental health. Good sleep, physical exercise and maintaining a healthy lifestyle will increase the new mother’s self-esteem and self-confidence thus increasing problem-solving capacity and helps to keep the woman focused on their surrounding environment.
Postpartum depression most likely occurs within 6 weeks after childbirth and occurs in about 6.5% to 20% of women. It most often occurs in adolescent females, mothers who deliver premature infants, women who have multiples at birth and among women in urban areas. African American and Hispanic mothers have reported the onset of PPD withing 2 weeks of delivery unlike Caucasian mothers who report the onset of symptoms later following childbirth. It can occur up to one year following the birth. Although the pathogenesis of PPD is currently unknown. It has been suggested that genetics, hormonal, psychological, and social life stressors likely play a role in the development of PPD.
The role of reproductive hormones in depressive behavior suggests that neuroendocrine pathophysiology for PPD. The hormonal levels for the woman drastically change immediately following the birth of the infant(s) to the woman’s pre-pregnancy levels. Multiple biological and endocrine systems are involved such as the immunological system, the hypothalamic-pituitary-adrenal axis (HPA) and lactogenic hormones are known to be involved in the disease process of postpartum depression. The HPA axis causes the release of cortisol in trauma and stress. If the HPA axis function is abnormal, then the response decreases the release of catecholamines leading to the poor stress response. HPA releasing hormones increase during pregnancy and remain elevated up to 12 weeks after childbirth.
The rapid changes in reproductive hormones like estradiol and progesterone after delivery can be a potential stressor for some women as these changes can lead to the onset of depressive symptoms. Oxytocin and prolactin also play a role in the development of PPD. These hormones regulate the milk let-down reflex as well as the synthesis of breast milk. It is often found that the failure to lactate and the onset of PPD occur at the same time. Low levels of oxytocin are particularly present in PPD and unwanted early weaning. The third trimester yields lower levels of oxytocin which is associated with increased depressive symptoms during the pregnancy and following the delivery.
Postpartum depression is diagnosed by the presence of at least five depressive symptoms over the course of a two-week period according to the DSM V. It is defined as a major depressive episode that occurs with the onset of pregnancy or within 4 weeks of delivery. The symptoms are present almost every day and represent a change from the individual’s normal routine. The diagnosis should also include feelings of depression and/or anhedonia or the loss of interest in doing things. In addition to those five symptoms the following may occur:
· Depressed mood either subjective or observed present for most of the day
· Loss of interest in doing things or loss of pleasure which is present for most of the day
· Insomnia or hypersomnia
· Psychomotor retardation and/or agitation
· Feelings of worthlessness or guilt
· Fatigue of lack of energy
· Suicidal ideations and/or attempt with recurrent thoughts of death
· Difficulty with concentration and/or making decisions
· Increased or decreased appetite (at least a 5% weight change over one month)
· Decreased or loss of libido
These symptoms can lead to significant distress and/or impairment not to
mention difficulty in bonding with the infant child or failure of breast feeding. It is also imperative to determine that these symptoms are not present due to substance abuse or another medical condition.
In rare instances, a psychotic disorder may develop. It is important to note that the psychotic disorder does not cause the episode nor does a prior manic or hypomanic episode. In 2016 a local Memphis woman was arrested for the murder of her four children ages 4, 3, 2, and 6 months. A fifth child age 7 escaped from her mother and ran for help. The young 29-year-old mother of 5 had slit the throats of her children with a butcher knife. Sadly, as I listened to the account on the evening news, I knew immediately that the young woman most likely had suffered from postpartum depression. Even sadder yet was the phone call that I received several years later from the young woman’s mother only to discover that it was her daughter who had committed the murders. The grandmother of the children as it turned out had been a former employee of mine. My heart was even saddened further by this discovery.
Screening for postpartum depression should be done within the first 2 to 6 months after childbirth. One of the most widely used screening tools is the Edinburgh Postnatal Depression Scale (EPDS). It is a 10-item questionnaire that is filled out by women and takes only a few minutes to complete. An EPDS cutoff score of equal to or greater than 13 is required to determine if women are at risk of developing PDD.
The first line treatment for PPD is a combination of psychotherapy and antidepressants. Generally, SSRIs are used as the first choice for pharmaceutical intervention. If these medications do not prove helpful, then physicians will often try switching the antidepressant to an SNRI or mirtazapine if the SSRI is ineffective. Once a therapeutic dose of medications is reached continued treatment should continue for 6 to 12 months to prevent a potential relapse of symptoms. In cases where a woman is breast feeding, one must evaluate the potential risks associated with antidepressant use during lactation versus the risks of untreated illness. An alternative to pharmacological intervention can be the use of transcranial magnetic stimulation (TMS). TMS is noninvasive and uses magnetic waves to stimulate and activate nerve cells within the brain. It is usually performed five times a week for 4 to 6 weeks to be effective. Generally, it is safe and well tolerated but there can be some side effects such as headaches, lightheadedness, scalp discomfort and facial muscle twitching. Rare side effects include seizures, possible hearing loss if adequate protection is not used and mania in people with bipolar disorder. Should a woman fail refractory to four consecutive medication trials, then ECT is often recommended. It is particularly useful in patients with psychotic depression with intent or plans on committing suicide or infanticide and refusal to eat where there is a risk of malnutrition or dehydration. In March 2019, the FDA approved for the use of Brexanolone to be the first drug to be specifically designated for the treatment of postpartum depression. This medication, however, is only available at certified healthcare facilities and patients are required to enroll in the Risk Evaluation and Mitigation Strategy Program.
Postpartum depression has repercussions far beyond the physical harm to the child. Studies reveal that the condition affects the mother-infant bonding. Often the child is treated inappropriately and with a terribly negative attitude all of which can have a significant impact upon the growth and development of the child. Children born to mothers with postpartum depression have been found to have significant changes in their behavior, altered cognitive development and early onset of depressive illness. More importantly these children tend to be obese and experience dysfunction in social interactions. Not only does PPD affect the mother, the child, or children but the father or partner as well. The entire family system is disrupted by the presence of PPD.
Seeking help for PPD is the best hope for the mother, the infant and the family system in general. Should you find yourself experiencing any of these signs and/or symptoms, please reach out and give us a call. We will ensure that you are directed to appropriate resources to meet your needs whether that includes counseling, referrals for medications and/or a support group. Below is a flyer for a local support group for young mothers. Not only is the course of pregnancy and childbirth challenging but the days to follow are equally as challenging. For information on the support group, please contact the office at 901-232-1956 to sign up today.
This article is dedicated to my friend, Cynthia.
Article prepared by Judy P. King, LCSW, BCD
Licensed Clinical Social Worker
Judy is now accepting patients for weekend hours and offering Telehealth appointments due to COVID-19. Payment sources accepted: Cigna, Optum and Private Pay. To book an appointment call: 901-232-1956