D. Wolocko, Daily News

ByRicardo 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 childbirth.

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

childbirth.

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

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

0

10

20

30

40

50

60

70

Ad

mis

sio

ns

/Mo

nth

Pregnancy

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

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 demonstrates.

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

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Transient, Transient, nonpathologicnonpathologic

Medical Medical emergencyemergency

Serious, Serious, disablingdisabling

Postpartum BluesPostpartum Blues

Postpartum DepressionPostpartum Depression

Postpartum PsychosisPostpartum Psychosis

50% to 70%

10%

0.01%

2/3 have onset by 6 wks postpartum

risk for Postpartum Depression

70% are affective (Bipolar, Major

Depression)

Spectrum of Postpartum Mood Changes

Incidence

Incidence

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 Blues

• 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

“Blues” = heightened reactivity, not clinical

depression• 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

treatment.

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 Psychosis

• 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 Depression

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

Blues.

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

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

2. Time of Onset of Postpartum Depression in 413 Patients

The more severe, the earlier the onset.

0

20

40

60

Within Two Weeks Six Weeks Six Months

Per

cent

age

of P

atie

nts Severe, needed hospital admission

Mild, treated by general practitioner

1. Time of Onset of Postpartum Depression in 315 WomenWithin 14 Days

46%Within 6 Weeks

14%

Within 3 Months

22%Within 6 Months

18%

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

Symptoms 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 compulsions?

• 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 psychotherapy

What about breast feeding?

The incidence of breast feeding in birthing mothers

is increasing as the next slide shows.

Incidence of Breast Feeding 1926-2001

80%

49%

28%20%

37%

52%

67%61%

1926-1930

1951-1955

1966-1970

1972 1975 1998 2000 2001

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

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

……a reasonable a reasonable optionoption

in Postpartum in Postpartum Depression ? Depression ?

Breast feeding…Breast feeding…

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

including...

Isolation…Isolation…

…Diminishedextended family

Involvement.

Distorted and glamorized perceptionsof pregnancy…

…and of recovery

in the postpartum...

…frequentlypromoted

in themedia.

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)• www.DepressionAfterDelivery.com

– Depression and Bipolar Support Alliance (DBSA)• Phone: 800-826-3632• Web:www.DBSAlliance.org

– New Jersey Psychiatric Association• Phone: 800-345-0143