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

0

10

20

30

40

50

60

70

Ad

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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.

4 Postpartum syndromes are:

2. Postpartum Psychosis

1. Maternity or Postpartum Blues

3. Adjustment Disorder of the Postpartum Period

4. Major Depression in the Postpartum (Postpartum Depression)

Unfortunately, common reference to all four conditions as “Postpartum Depression” creates confusion and fear.

Postpartum Psychosis, most severe and dangerous condition, is relatively rare quite different from Postpartum Depression, as the next slide demonstrates.

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

Incid

en

ce

Incid

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ce

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

• BABY BLUES• You’ve just had a baby. You expected to be basking in new

mom bliss. You expected to be celebrating the arrival of your little one with your friends and family. But instead of celebrating, you feel like crying. You were prepared for joy and excitement—not exhaustion, anxiety, and weepiness.

You may not have been expecting it, but mild depression and mood swings are common in new mothers.

In fact, this post-delivery depression is so common that it has its own name: the baby blues.

Up to 85% of new mothers experience the baby blues.

Maternity or Postpartum Blues

• Mood swings from weepiness to extreme happiness and heightened reactivity

Many new moms feel happy one minute and sad the next. If you feel better after a week or so, you probably just had the "baby blues."

“Blues” = heightened reactivity, not clinical depression

If it takes you longer to feel better, you may have postpartum depression.

Occurs 3 to 5 days after childbirth.

It is self limiting, resolving in about a week.

If occurs, increases risk for Postpartum Depression.

• In addition to moodiness and sadness, the baby blues can include difficulty sleeping, irritability, appetite changes, and concentration problems.

Symptoms typically show up within a few days of giving birth and last from several days to a couple of weeks.

The baby blues are considered to be a normal part of new motherhood—probably caused by the hormonal changes that occur following birth.

If you have them, there is no cause for undue worry. The baby blues usually don’t last very long and will go away on their own once your hormones level out.

Aside from the support of your loved ones and plenty of rest, no treatment is necessary. However, if your symptoms don’t go away within two to three weeks, or they are severe (such as suicidal thoughts or an inability to care for your newborn), you may be suffering from a more serious condition known as postpartum depression.

The rest of the syndromes to be described are all considered

psychiatric illnesses and

benefit from clinical treatment.

1. Postpartum Psychosis• Is relatively rare, occurring one to three cases per

1000 birthsIs 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

1. 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

Very rarely, new moms may stop eating, have trouble sleeping and become frantic or paranoid.

Women with this condition usually need to be hospitalized.

2. 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.

2. 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.

3. POSTPARTUM DEPRESSION

• Occurs in 10% of birthing mothers– 20% if the mother has had Maternity Blues

Occurs usually within 6 weeks of birth but

Unlike the "baby blues," postpartum depression does not go away quickly.

can occur up to a year after birth

3. Onset of Symptoms in Postpartum Depression

Time of Onset of Postpartum Depression in 413 Patients

The more severe, the earlier the onset.

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Within Two Weeks Six Weeks Six Months

Per

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Severe, needed hospital admission

Mild, treated by general practitioner

3. 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

3. POSTPARTUM DEPRESSION

• in some women, the first signs don’t appear until months after they’ve given birth. Because of the possibility of delayed onset, if you have a depressive episode within six months of having a baby, postpartum depression should be considered.

Postpartum depression manifests as symptoms of depression can make you feel restless, anxious, fatigued and worthless.

Some new moms worry they will hurt themselves or their babies.

Can develop gradually or suddenly/abruptly after birth

usually sets in soon after childbirth and develops gradually over a period of several months.

• • Anxiety is also more prominent in postpartum depression. If you

have postpartum depression, you may worry to excess over your baby’s health and well-being.

• In addition to obsessing over the safety of your newborn, you may be troubled by intrusive thoughts about harming your baby.

SIGNS AND SYMPTOMS OF POSTPARTUM DEPRESSION Lack of interest in your baby Negative feelings towards your baby Worrying about hurting your baby Lack of concern for yourself Loss of pleasure Lack of energy and motivation Feelings of worthlessness and guilt Changes in appetite or weight Sleeping more or less than usual Recurrent thoughts of death or suicide

symptoms are either longer lasting or more severe.

3. POSTPARTUM DEPRESSION

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

3. 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.

The Impact of Postpartum Depression on ChildrenBehavioral problems Children of depressed mothers are more likely to develop

behavioral problems down the line, including sleep problems, temper tantrums, aggression, and hyperactivity.

Delays in cognitive development

Development is often delayed in babies and children who have depressed mothers. They may learn to walk and talk later than other children. They may also have many other learning difficulties, including problems with school.

Social problems Children of depressed mothers have difficulty establishing secure relationships. They may find it hard to make friends in school. They may be socially withdrawn, or they may act out in destructive ways.

Emotional problems Studies have show that children of depressed mothers have lower self-esteem, are more anxious and fearful, are more passive, and are less independent.

Depression The risk of developing major depression early in life is particularly high for the children of mothers with postpartum depression.

CausesThe rapid hormonal changes that accompany pregnancy and delivery may trigger depression.

After childbirth, women experience a big drop in estrogen and progesterone hormone levels.

Thyroid levels can also drop, which leads to fatigue and depression.

These hormone dips—along with the changes in blood pressure, immune system functioning, and metabolism that new mothers experience—can all play a part in postpartum depression.

Women who have just given birth are also dealing with numerous changes, both physical and emotional.

They may still be coping with physical pain from the pregnancy and delivery.

They may also have difficulties losing the baby weight, leading to insecurities about their physical and sexual attractiveness.

In addition to changes to their body, they are also dealing with lifestyle changes. The lifestyle adjustment can be particularly difficult for first time moms, who must get used to an entirely new identity. The stress of caring for a newborn can also take a toll. New mothers are often sleep deprived. In addition, they may feel overwhelmed and anxious about their ability to properly care for their baby. All of these factors can contribute to and trigger postpartum depression.

Causes

Risk Factors that predispose women to postpartum disorders.

• 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…

…Diminished extended family Involvement.Unrealistic expectations of the postpartum mother

Distorted and glamorized perceptionsof pregnancy…

…and of recovery

in the postpartum...

…frequentlypromoted

in themedia.

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

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.

Postpartum Depression Action PlanPatient __________________________Physician/NP/PA __________________nic ____________________________Phone Number ____________________Choose one area and add other areas as you begin to feel better.

1. Stay active.

Make time every day to do some physical activity, such as walking for 10 to 20 minutes or dancing to a favorite song.

Every day during the next week I will spend at least ______ minutes doing ___________________________ .

2. Do something that you think is fun each day.

Even though you may need to work a little more at having fun, try doing something that has always been fun such as a hobby, listening to music or watching a favorite TV show.

Every day during the next week I will spend at least ______ minutes doing ___________________________ .

3. Spend time with people who help or support you.

When you are feeling down it is easy to avoid people, but you should not be alone all the time. Choose people who you can talk to or who can do your activities with you. Try to talk to them about how you feel. But it's okay if you can’t talk about it your feelings at first, too.

During the week I will make contact for at least ______ minutes with ______________________ (name), doing or talking about ______________________ .

4. Relaxing.

For many people with depression, it is hard to stop feeling sad or having unhappy thoughts. Learning to relax can help. Try taking slow deep breaths, saying comforting things quietly to yourself or taking a warm bath.

Every day during the next week I will practice relaxing at least ____ times for at least ____ minutes each time.

5. Set simple goals.

Do not expect too much too soon. Do simple things such as reading a few pages of a magazine or fixing a cup of tea or cocoa. Delay big decisions until you are feeling better. Give yourself credit for each thing you do. Break work into small steps.

What I want to do is ________________________________________________________________________________________________

Step 1 _________________________________________________________

Step 2 __________________________________________________________

How likely are you to do the above things during the next week?

Very likely Maybe Unsure Not very likely