One of the more devastating outcomes of pregnancy complications occurs as a result of postpartum #depression. Approximately 6.5 to 12.9 percent of women are effected, as well as men, particularly new fathers. Symptoms include sleep disturbance, #anxiety, irritability, and a feeling of being overwhelmed, as well as an obsessional preoccupation with the baby's health and feeding. Suicidal ideation and worries about causing harm to the baby have also been reported. The strongest risk factor for postpartum depression is a history of mood and anxiety problems, most especially untreated depression and anxiety during pregnancy.
The rapid decline in reproductive hormones after childbirth are thought to contribute to the development of depression, which is worse for those who aren't successfully breastfeeding. Other potential factors are genetic and social factors, including less social support, marital difficulties, violence involving the intimate partner, previous #abuse, and negative life events. As a midwife, my own clientele seemed to suffer less postpartum than typical, which I think relates to their having less traumatic birth experiences and more control over their birthing events, but even when seemingly uneventful and truly beautiful births occurred, with clients sharing very satisfying experiences, anxiety and depression did sometimes result. Twice in my practice, women suffered from psychosis.
Anecdotally, I would offer the opinion that sleep deprivation plays a significant role as does lack of social support. One typically anticipates the single mother needing support, although not often does she actually receive support, but one sort of assumes a married woman has sufficient support. This isn't always the case and potentially, these women in particular are more often overlooked. I can remember a number of times I visited women at the 48-hour postpartum visit and they were home alone caring for older children, or once even, at the laundry mat.
The natural course of postpartum depression is quite variable. It can resolve spontaneously within weeks of onset, or last beyond the first year or two. Nearly half will have a relapse in subsequent pregnancies or at any other point in their life. Postpartum depression has significant impact on the mother and child, as well as the marital relationship. Cognitive development is even impacted in the child, and in rare cases, psychosis can lead to #suicide or infanticide.
Screening & Diagnosis
In my own practice, pregnant women are evaluated for depression and anxiety at the onset of their pregnancy, each trimester, and at every postpartum visit. I also evaluate every client at their annual wellness visit. There are a number of ways this might be evaluated, although I have utilized the Edinburgh Postnatal Depression Scale as this is recommended by both the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics, and has solid support in the literature.
The United Kingdom's Institute for Health and Care Excellence recommends asking all women two specific questions during the postpartum period and if they answer yes to either, the Edinburgh or Patient Health Questionnaire 9 (PHQ-9) is utilized. The key is not just to identify anxiety or depression in postpartum women, but to also rule out psychiatric disorders and manage contributing medical and psychosocial issues.
During the past month, have you often been bothered by feeling down, depressed, or hopeless?
During the past month, have you often been bothered by little interest or pleasure in doing things?
Most all women suffer from the "baby blues" which peaks during that first week, resulting in weepiness, sadness, mood lability, irritability, and anxiety. This disorder doesn't seriously impair functioning or include any psychotic symptoms, and spontaneously resolves at about two weeks. Generally, at each postpartum visit with clients, I ask, "how often are you crying." Clients seem to feel safe to share when they recognize my expectation is that they have cried, at least once.
Identifying bipolar specifically is important as these clients are managed differently than those with depression or anxiety. They can progress towards psychosis much more readily as well. Depression can be the presenting feature of bipolar disorder, so all women suffering from depression should be asked if they have ever had four or more continuous days during which they had abnormally high, expansive, or irritable mood and increased activity or had a level of energy that was a change from their usual level, that other people maybe though was uncharacteristic of them or that got them into trouble in some way. If a client responds positively, these clients really should be referred for further evaluation by a mental health specialist.
Obsessive-compulsive disorder is somewhat common after birth, as we all want to assure we are maintaining a safe environment for our newborns, but sometimes this can flare up significantly as part of a postpartum mood disorder. I think this seemed to be most obvious to me when women were exceedingly anxious about breastfeeding. This is a challenge though because breastfeeding can be tough, women are many times quite passionate and desperately wanting to succeed, and sleep deprivation can really challenge her coping skills, but when I have a client share a very detailed spread sheet of feeding times, sides, diapers, and amounts, I dig in a bit to assure I am not dealing with new onset OCD.
All women should be asked about their social support as well as substance abuse, and violence involving their intimate partner. Keep in mind, some of these situations become normal to clients so they don't seem as alarming to them as they may to the provider. The thyroid should be evaluated, along with a basic blood chemistry. Suicidal and homicidal thoughts should be evaluated, and I've heard many very graphic images and thoughts from women that otherwise appeared to be the most gentle-spirited people. One simply can't make assumptions, because if projected onto the client, they will deny these thoughts and feelings.
Delusions, confusion, bizarre behavior, and disorganized thoughts are common to psychosis and sometimes they are so peculiar to the client and her partner, that they are sort of dismissed. They may accompany depressed or elevated moods, and while rare, they are exceedingly important to identify as early as possible. Don't feel as if you are over-reacting in calling out these concerns. These are psychiatric emergencies.
Prevention
My own practice clientele are generally those who lean a bit more to the holistic side and are more hesitant to partake in conventional medicine, especially pharmaceutical therapy. When anxiety and depression occur during pregnancy, many decline treatment or when already diagnosed, they will wean themselves from their medications. I think it's important to understand that the risk of postpartum depression is more than seven times in those with untreated depression during pregnancy, than in those who had no antenatal depression, and the impact to the child is significant which must be weighed alongside the risks of the pharmaceutical itself.
Supportive care and psychological care, such as home visits, telephone peer support, or interpersonal therapy, has been shown to reduce the risk of postpartum depression more so than standard care, such as informational books, routine antenatal classes, and routine prenatal and postpartum care. Healthy nutrition, regular exercise, and adequate sleep are also important.
Treatment
The severity of one's mood disorder really determines the type of treatment that is best for each individual mother. Mild to moderate symptoms are generally well managed by the primary care provider, but psychiatric referrals are warranted when symptoms do not respond to initial treatment or in urgent cases, especially with thoughts of hurting oneself or others, mania, or psychosis.
Antidepressant medications are recommended when depression does not resolve with psychological treatment alone, when symptoms are severe or when rapid treatment is necessary. A Cochrane systematic review has been conducted, reviewing six trials that evaluated antidepressants. One should know that most all SSRIs pass into the breastmilk, but this dose is only at about ten percent that of the mother's and so are considered compatible with breastfeeding. If the mother has already been taking a medication that works for her, changing this for purposes of breastfeeding is not recommended. Stick with what works. In a mother with new onset depression however, sertraline (Zoloft) is often the first-line therapy because it passes minimally through breastmilk. Dose typically initiates at 50mg daily and then reassessed at one week for side effects and suicidality, and then increased as needed, by 50mg every two weeks with a maximum dose of 200mg. Fluoxetine (Prozac and Serafem) and citalopram (Celexa) are two others with fairly extensive case study history.
A different drug class is recommended when these are ineffective, such as SNRIs or mirtazapine (Remeron), as each of these also minimally pass into the mother's milk. Safety otherwise is somewhat limited. There have been case reports of infant seizures with bupropion (Wellbutrin and Zypan) so generally, other medications are preferred. Newer antidepressants lack safety data. Tricyclic antidepressants and monoamine oxidase inhibitors are avoided while breastfeeding.
Pharmaceutical therapy should be continued for six months to a year, not just until symptoms resolve, to decrease reoccurrence. They should then be weaned gradually and discontinued. If depression returns, three years of treatment is generally recommended before attempting weaning. In cases of severe depression, additional drug therapy is often indicated. Benzos for example, may be utilized short term for severe anxiety, insomnia, or both. Adjunctive antipsychotics may also be required. Electroconvulsive therapy is again being utilized, with some success. Other treatments include hormone therapy, focal brain-stimulation treatment, and omega-3 fatty acids, folate, S-adenosylmethionine, St. John's wort, bright light therapy, exercise, massage, and acupuncture. Of these, omega-3 fatty acids has had a significant impact on my clients, but a good gut health program is essential. Genetics is the approach often with functional medicine practitioners, and while understood as related, there is little understanding.
Having said that, I am surprised how often medications are offered to women without first questioning if maybe they are simply grieving returning to work or struggling with sleep or within their relationship. Sometimes it is the father who is depressed, and this is impacting the mother. Maybe they need permission to make lifestyle changes that would decrease their stress and enhance their relationships? Potentially they need to evaluate their overall health? If they suffered anxiety, significant vaginal discharge, or irritable bowel, there is an underlying gut issue that should be addressed. Polymorphisms that impact detoxification may even play a role, as may oral health concerns.
References
Stewart, D. E. & Vigod, S. (2016). Postpartum depression. The New England Journal of Medicine, 375, 2177-2186.
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