Postpartum Depression

Postpartum depression is significant, often called clinical depression that occurs soon after having a baby. Some health professionals call it postpartum nonpsychotic depression.

You've just had a baby, one of the most important and happiest events in your life. "What could make a woman happier than a new baby?" you wonder. So why are you so sad?

We don't know for sure, but you are not alone. Many women experience some mood disturbances in the time after pregnancy (known as the postpartum period). They may feel anxious, upset, alone, afraid, or unloving toward their baby, and experience some guilt for having these feelings.

For most women, the symptoms are mild and go away on their own. But statistics indicate that some women develop a more prominent and disabling form of mood disorder called postpartum depression (PPD).

Charlotte Perkins Gilman, a prominent American writer, and sociologist wrote about her own struggles with postpartum depression in the 19th and 20th centuries. Tragic, infamous cases that involved a claim of postpartum depression or psychosis include those of mothers Andrea Yates and Susan Smith, each of whom killed their children.

• The "baby blues" are a passing state of heightened emotions that occurs in about half of women who have recently given birth.
  • This state peaks three to five days after delivery and lasts from several days to two weeks.
  • A woman with the blues may cry more easily than usual and may have trouble sleeping or feel irritable, sad, and "on edge" emotionally.
  • Because baby blues are so common, expected, and go away without treatment or without interfering with the mother's ability to function, they are not considered an illness.
  • Postpartum blues do not interfere with a woman's ability to care for her baby.
  • The tendency to develop postpartum blues is unrelated to a previous mental illness and is not caused by stress. However, stress and a history of depression may influence whether the blues go on to become major depression.
• Postpartum depression is significant, often called clinical depression that occurs soon after having a baby. Some health professionals call it postpartum nonpsychotic depression.
  • This condition occurs in some women, usually within a few months of delivery.
  • Risk factors for postpartum depression include previous major depression, psychosocial stress, inadequate social support, and previous premenstrual dysphoric disorder (see premenstrual syndrome for more information).
  • Symptoms include depressed mood, tearfulness, inability to enjoy pleasurable activities, trouble sleeping, fatigue, appetite problems, thoughts of suicide, feelings of inadequacy as a parent, and impaired concentration.
  • If you experience postpartum depression, you may worry about the baby's health and well-being. You may have negative thoughts about the baby and fears about harming the infant (although women who have these thoughts rarely act on them).
  • Postpartum depression interferes with a woman's ability to care for her baby.
  • When a woman with severe postpartum depression becomes suicidal, she may consider killing her infant and young children, not from anger, but from a desire not to abandon them.
• Postpartum (puerperal) psychosis is the most serious postpartum disorder. It requires immediate treatment.
  • This condition is rare. A woman with this condition experiences psychotic symptoms within three weeks of giving birth. These include false beliefs (delusions), hallucinations (seeing or hearing things that are not there), or both.
  • This condition is associated with mood disorders such as depression, bipolar disorder, or psychosis.
  • Symptoms can include the inability to sleep, agitation, and mood swings.
  • A woman experiencing psychosis can appear well temporarily, fooling health professionals and caregivers into thinking that she has recovered, but she can continue to be severely depressed and ill even after brief periods of seeming well.
  • Women who harbor thoughts of hurting their infants are more likely to act on them if they have postpartum psychosis.
  • If untreated, postpartum psychotic depression has a high likelihood of coming back after the postpartum period and also after the birth of other children.

Signs and symptoms usually appear any time from 24 hours to a few months after delivery.

• If you have these, it is important to see a health care professional, who will look for other conditions that can cause similar symptoms.
  • Sad mood, frequent crying
  • Lack of pleasure or interest in activities that once gave pleasure
  • Sleep disturbance
  • Weight loss
  • Loss of energy
  • Agitation or anxiety
  • Feelings of worthlessness or guilt
  • Trouble concentrating or making decisions
  • Thoughts of death, suicide or homicide of the baby
  • Decreased interest in sex
  • Feelings of rejection
• Physical symptoms such as frequent headaches, chest pain, rapid heart beat, numbness, shakiness or dizziness, and mild shortness of breath suggest anxiety. Postpartum anxiety disorder is a separate disorder from postpartum depression, but the two often occur together.
• See the introduction to this article for symptoms specific to the types of postpartum depression.

No specific cause of postpartum depression has been found.

• Hormone imbalance is thought to play a role.
  • Levels of the hormones estrogen, progesterone, and cortisol fall dramatically within 48 hours after delivery.
  • Women who go on to develop postpartum depression may be more sensitive to these hormonal changes.
• Other known risk factors
  • Mental illness before pregnancy
  • Mental illness, including postpartum depression, in the family
  • Postpartum mental disorder after an earlier pregnancy
  • Conflict in the marriage, loss of employment, or poor social support from friends and family
  • Pregnancy loss such as miscarriage or stillbirth
    • The risk of major depression after miscarriage is high for women who are childless. It occurs even in women who were unhappy about being pregnant.
    • The risk for developing depression after miscarriage is highest within the first few months after the loss.
• Childbirth is a time of great change for a woman. The adjustment to these changes can contribute to depression.
  • Physical changes after delivery
    • Many changes occur after delivery, including changes in muscle tone and difficulty losing weight.
    • Many new mothers are very tired after giving birth and in the weeks afterward.
    • Soreness and pain in the perineal area (area around the birth canal) makes many women uncomfortable. Physical recovery after cesarean delivery may take even longer than after vaginal delivery.
    • Changes in hormones can affect mood.
  • Common emotional changes after delivery
    • Feelings of loss of an old identity, feeling trapped at home
    • Feeling overwhelmed with responsibilities of motherhood
    • Feeling stress from changes in routine
    • Feeling fatigue because of broken sleep patterns
    • Feeling less attractive physically and sexually
• A mother's age and the number of children she has had do not relate to her likelihood of getting postpartum depression.
• Men whose partners suffer from postpartum depression have been found to be at higher risk for developing a similar condition or other mental health problems at that time.

Call your health care professional in any of the following situations:

• When you have mood swings or feel depressed for more than a few days after the birth of your baby
• When you feel you are unable to cope with the daily activities in your life, including caring for your newborn or your other children
• When you have strong feelings of depression or anger one to two months after childbirth

Call a neighbor, friend, or loved one who is nearby and 911 right away if you are experiencing any of the following:

• Inability to sleep more than two hours per night
• Thoughts of hurting or killing yourself
• Thoughts of hurting your baby or other children
• Hearing voices or seeing things
• Thoughts that your baby is evil

The diagnosis of postpartum depression can be missed because the less severe symptoms are so common after childbirth. The symptoms are the same as those of many other mental illnesses, especially depression. Here is what to expect during an evaluation.

• Your health care professional will ask you about your symptoms: what they are, how bad they are, and how long they have lasted.
• He or she will also ask whether you have ever had similar symptoms before.
• You will also be asked about risk factors for depression, such as family or marital problems, other stresses, mental illness in family members, and drug and alcohol use.
• Your health care professional may also ask questions about your medical history to determine if there is a physical cause for your symptoms.
• Your health care professional may use the questions of the Edinburgh Postnatal Depression Scale, a screening tool. You answer 10 questions, and your answers indicate your probability of having postpartum depression. Depending on your score, you may be referred for further evaluation.

While self-care cannot take the place of medical care in depression, there are things you can do to improve your mood and your ability to function at home.

• Surround yourself with supportive family members and friends, and ask for their help in caring for the baby.
• Take care of yourself. Get as much rest as you can. Nap when the baby naps.
• Try not to spend much time alone.
• Spend some time alone with your husband or partner.
• Take a shower and get dressed every day.
• Get out of the house. Take a walk, see a friend, do something you enjoy. Get someone to take care of the baby if you can; if you can't, take the baby with you.
• Don't expect too much from yourself. Don't worry too much about the housework. Ask friends and family for help.
• Talk to other mothers. You can learn from each other, and their experiences can be reassuring.
• If the depression persists for longer than two weeks or is very severe, talk to your health care professional. Self-care alone is not recommended.

Treatment for postpartum depression depends on the form and how severe it is.

• Your health care professional may refer you for psychological help and individual or group therapy.
• Support groups can be helpful.
• Marriage counseling may be part of your treatment plan.
• It's important for friends and family to understand the illness so they can help.
• Medications can be helpful.

For postpartum blues, no specific treatment may be necessary because the condition goes away by itself and usually does not result in severe symptoms. If symptoms don't go away within two weeks, call your health care professional.

For postpartum depression, the severity of the illness will guide the health care professional in choosing treatment. Milder forms may be treated with psychological therapy. More severe forms may require medication. A combination is sometimes helpful.

Vitamins: While postpartum depression in the United States is rarely related to nutritional problems, it is probably a good idea to continue to take prenatal vitamins and iron after delivery.

Antidepressants: Drugs such as fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), escitalopram (Lexapro), or venlafaxine (Effexor) may be needed for as long as a year (possibly longer). Other classes of medications known as mood stabilizers or anti-psychotics also might be utilized.

Other still unproven therapies include the use of bright light and nutritional therapy (especially increasing omega-3 free fatty acids). What some refer to as natural remedies, these therapies have not shown that they are effective substitutes for more conventional interventions.

If you are breastfeeding, medicine you take can be passed to your baby. Some antidepressants can be used safely with little risk to your baby and are therefore viable treatments while breastfeeding.

Generally, psychotherapy and medications are used together. Psychotherapy alone may be effective in mild cases, particularly if the mother prefers to have treatment without prescribed drugs.

Interpersonal psychotherapy (IPT) is an alternative to medication that may be appropriate for some women. IPT assists with social adjustments. It usually consists of 12 one-hour long sessions with a therapist. IPT has been shown to improve measures of depression in some women.

Teaching mothers skills such as soothing the baby's crying often reduces depressive symptoms during the first two to four months after delivery.

If your symptoms can't be controlled with counseling or medicine, and you are thinking about hurting yourself or your baby, then your doctor may consider putting you in the hospital.

Follow the recommendations of your health care professional. If he or she prescribes medication and/or counseling, be sure to follow through.

If you are given medication, take it as directed. Do not stop taking your medication until you have talked to your health care professional.

Too often, depressive symptoms are dismissed as normal for a woman who has just experienced childbirth.

If you have had depression in the past, or have risk factors for depression, talk with your doctor before getting pregnant or early in your pregnancy.

All new mothers should be screened for depressive disorders.

Postpartum depression usually goes away during the months after delivery. Some women have symptoms for months or years. With the help of appropriate treatment, the prognosis for postpartum depression is usually quite good.

If untreated, the illness can cause prolonged misery for the mother and her family.

• It can hurt the mother-baby relationship.
• It could even be dangerous if the mother considers hurting her child or herself.

A support group can help you cope with your illness.

• Depression After Delivery: 800-944-4PPD
• National Women's Health Information Center: 800-994-9662
• Postpartum Support International (PSI): 805-967-7636