Postpartum Depression

Postpartum Depression: An Issue in Women’s Health and The Road to RecoveryVirginia D. Martinez
Psychology 201 G
Dona Ana Community College

Abstract
The purpose of this paper is to provide some insight on a common and increasing issue among many women following the birth of a child, Postpartum Depression (PPD). This disorder will be discussed in terms of the signs and symptoms, characteristics of influence, complications and consequences, and methods of testing and the diagnosis process. In addition, prevention, treatment, and the recovery process associated with PPD will be discussed.

Many women of childbearing age, depression has become one of the most disabling disorders among women ages 15-44 in the United States. Postpartum Depression (PPD) can be described as clinical depression that occurs during the first year following the birth of a child. PPD can occur at any time within this period, from several days to a year after childbirth. During the postpartum period, women become more receptive to depression (Zauderer, C., 2009). Women who have suffered from PPD following a previous pregnancy, show an increase to developing the disorder with a succeeding birth. Studies have shown that women had a major depressive episode during the first 12 weeks and this increased when minor depression was included PPD has been called “the most significant obstetrical complication after delivery” and was recently elevated to a “global health challenge” by the World Health Organization and the March of Dimes” (Zauderer, C., 2009).

The days following birth is usually associated with various obstacles that can lead to feelings of frustration, anxiety, sadness, and exhaustion. These symptoms are known to be normal reactions to the birth of a child, but when persisting for several weeks or months these can be the warning sign of an underlying case of PPD (Guille, C. MD, Newman, R. MD, Fryml,L.D. BS, Lifton,C.K. BS, Epperson, N. MD, 2013). These common behavioral features associated with the prenatal and postnatal period causes many cases of PPD to go undetected. Tearfulness, hopelessness, feelings of guilt, lack of appetite, suicidal thoughts, disturbed sleep, feelings of inadequacy and inability to cope with child, poor concentration and memory, fatigue and irritability are all prominent symptoms (Zauderer, C. 2009). Many of these women who are affected by PPD see themselves as bad or unloving mothers. To meet the criteria of PPD, a woman must experience symptoms for at least 2 weeks and they must interfere with everyday
life (Guille, C. MD, Newman, R. MD, Fryml,L.D. BS, Lifton,C.K. BS, Epperson, N. MD, 2013). The signs and symptoms of PPD overlap with two similar psychiatric mood disorders and these must be ruled out by physicians during the diagnosis process. Severity continuum of postpartum affective disorders, between postpartum blues and postpartum psychosis. Postpartum blues is a mild depressive episode that is characterized by symptoms of sadness, emotional instability, anxiety and lack of sleep and appetite (Zauderer, C., 2009). This disorder occurs within the first couple of days after delivery and can persist for a few hours to several days, but no more than two weeks. Postpartum blues is the most common mood disturbance.

A mother with postpartum blues often just needs simple reassurance from those close to her. In some cases, postpartum blues gradually transforms into the more serious PPD. Postpartum psychosis is a severe form of bipolar disorder that is characterized by extreme mood swings, mania, and hallucinations (Zauderer, C., 2009). Postpartum psychosis is less common. This severe postpartum disorder appears within the first few weeks following delivery and can last from several weeks to months (Guille, C. MD, Newman, R. MD, Fryml,L.D. BS, Lifton,C.K. BS, Epperson, N. MD, 2013). The symptoms for this form of postnatal illness are depression, disorganized behavior, constant changes in mood. In many cases, hospitalization is required to treat this disabling disorder. Studies have found that mood disorders following childbirth are not significantly different. The most consistent risk factors of depression and or anxiety during pregnancy are a history of psychiatric illness, postpartum blues, childcare stress, marital conflict, and lack of social support.

Having an unwanted or unplanned pregnancy and being single are some reasons why some women develop PPD. Because of this, some studies have found that low levels of education were more frequently observed among women who developed PPD. Other risk factors such as difficult pregnancies, obstetrical complications, season of delivery and unsuccessful breastfeeding often makes women feel as if they failed as a mother. Women at the highest risk for PPD are those with a previous history of postpartum psychosis, history of PPD and those who experienced depressive symptoms while pregnant. Genetic factors have been implicated as one of the probable causes of PPD. Variations of genetic adaptive traits have been recognized including those associated with serotonin transport, glucocorticoid receptor sensitivity, and brain derived neurotropic factor. Some studies have addressed the influence of the 5-HTT (serotonin transporter) gene on depression (Guille, C. MD, Newman, R. MD, Fryml,L.D. BS, Lifton,C.K. BS, Epperson, N. MD, 2013).
Experimental analysis of this illness suggests that women who develop PPD may be sensitive to these hormonal fluctuations. Receiving social support through a stressful time is thought to be a positive protective factor, therefor, when a mother lacks support this increases a woman’s chance of developing PPD. The idea of social support sources can be derived from a spouse, relatives, friends, as well as co-workers. Some studies have shown a negative relationship between PPD and emotional and instrumental support during pregnancy. Women with depression scored significantly lower in the domains of emotional, informational, affectionate, and positive social support. In comparison of psychosocial variables, which I learned in my psychology class, a significant association between PPD and distressed relationships revealed that having marital problems during and following pregnancy, often lead to lack of support, that results with an increased risk of PPD. Women, who perceive themselves as having low levels of social support, even if this was not true, are also at high risk for PPD.
Some mothers on maternity leave were at the same risk as employed mothers, women looking for work were more likely to have PPD symptoms. Research has found that rates of unemployment, financial issues, and low education are higher among women with PPD. (Nichols, H., 2017) financial hardship was a risk factor for PPD whether women had experienced prior depressive symptoms. Having a very difficult pregnancy is also seen as a strong predictor for PPD, as well as expressing caring for the child as extremely difficult PPD has been linked to severe obstetrical complications during pregnancy and at delivery such as adverse birth and neonatal outcomes (Nichols, H., 2017). These complications include preeclampsia, hyperemesis, premature labor, caesarean section, instrumental delivery, premature delivery and excessive bleeding. Women who delivered a low birth weight infant had a three times higher risk of developing PPD (Nichols, H., 2017).

A woman with an unwanted pregnancy has a higher risk of developing PPD in comparison with mistimed and intended pregnancy at 3 and 12 months (Zauderer, C. 2009). With an unintended pregnancy, there is a minimally increased chance of development at 3 months and two times increase at 12 months. Women who experienced an unintended pregnancy were less likely to be married compared to those who had an intended pregnancy. An unwanted pregnancy may have a long-term effect on health and wellbeing, even though the woman chooses to follow through with the pregnancy (Lieber, A. 2018). One way to predict postpartum depression is if the mother has a previous history of depressive illness or experiencing depression or anxiety during pregnancy. (O’Hara, W.M., McCabe E.J. 2013) thirty- one percent of women with prenatal depressive symptoms also suffered from PPD symptoms, while only 6% of women who lacked these symptoms experienced PPD.

Having higher levels of anxiety during pregnancy was a predictor of increased levels of PPD symptoms. Women with a history of a psychiatric illness are at a significantly increased risk of PPD. Studies consistently show that having previously experienced depressive symptoms at any time, not just in relation to childbirth, leads to an increased risk of PPD ( Pearlstein, T. 2009) Having a positive family history of any psychiatric illness further substantially confers risk of PPD. If left untreated, the consequences of PPD can be serious for not only the mother, but her newborn, and the entire family. Mothers who are depressed may experience unnecessary suffering, deteriorating health status, marital discord, and suicidal ideation (Pearlstein, T. 2009). PPD can lead to persistent depression, intense sadness, and interrupted interaction with child, suicide and infanticide in rare cases. Women may also experience intense irritability and anger, anxiety, feelings of guilt, and a sense of being unable to care for the baby (Pearlstein, T. 2009). Additionally, PPD can have physical manifestations such as headache, fatigue, decrease appetite, insomnia and lack of energy. The consequences of PPD are particularly worrisome among adolescents due to an increased risk of birth defects and difficulties parenting (Pearlstein, T. 2009).

Not only do these deteriorating health and social consequences of PPD influence the mother but have been determined to impact the development of the child as well. The newborns of depressed mothers have been found to have emotional, cognitive, and physical developmental setbacks (O’Hara, W.M., McCabe E.J., 2013). PPD was has also been associated with interruptions in this critical period of bonding for the mother and her newborn child. PPD has a moderate to severe effect on the interaction between mother and child following birth. Infants of depressed mothers were seen to be fussier and make fewer positive responses, such as facial expressions and vocalizations. Research has also suggested an association between PPD and physical and mental problems in the child of the depressed (O’Hara, W.M., McCabe E.J., 2013). Numerous studies have found that mothers affected by PPD tend to be more detached, antagonistic, critical, and less sensitive toward their child (Zauderer, C. 2009). Children affected by these consequences may develop an insecure attachment with their mother, this which could result in sleep pattern interruptions, language and cognitive developmental delays and poor regulation of emotions. Women who are affected by PPD most of cases dissipate within months, but for many this is the trigger that fosters recurrent or chronic episodes of depression (Lieber, A. 2018). Women who have previously suffered from PPD are also at an increased chance of suffering further episodes following another birth (Lieber, A. 2018).
Early recognition is one of the major challenges in dealing with this mood disorder (Guille, C. MD, Newman, R. MD, Fryml,L.D. BS, Lifton,C.K. BS, Epperson, N. MD, 2013). The growing evidence of the devastating effects of PPD further emphasizes the need to screen women for their risk of developing this disorder. The Postpartum Depression Predictors Inventory (PDPI) was formed from the findings of two meta-analyses of PPD risk factors (Beck, 2002). The PDPI is a checklist that consists of eight risk factors determined to be significantly associated with PPD (Guille, C. MD, Newman, R. MD, Fryml,L.D. BS, Lifton,C.K. BS, Epperson, N. MD, 2013) predictors are prenatal depression, prenatal anxiety, and history of previous depression, social support, marital satisfaction, life stress, child care stress, and maternity blues. This inventory check list can be used both during pregnancy and following the birth of the child to determine the likelihood that a woman will develop PPD (Zauderer, C., 2009).

Women complaining of a depressive episode at 4 and 8 weeks postpartum were considered a useful tool for screening of PPD (Zauderer, C., 2009). While prenatal and postnatal screening tools to identify women with an elevated risk of PPD have been developed. Due to differences in life circumstances, screening instruments developed for the general population of pregnant women may not provide accurate results. In a study (Zauderer, C., 2009). found that when applied to adolescent populations, their predictive model developed for the general population of pregnant women did not offer accurate results. This just means that current screening tools may not be adequate for prenatal risk assessment of PPD among pregnant adolescents. The differences between ages supports the idea that screening for women at risk of PPD should be specific to maternal age. The development of age (Zauderer, C., 2009) specific screening tools should consider the role of coping, self-esteem, and future aspiration. These screening measures provide a significant basis for physicians to conduct further evaluation to determine for PPD (Zauderer, C., 2009). having an increased awareness of mood during pregnancy and asking women how they feel may be helpful in preventing the onset of PPD ( Dennis CL, Hodnett, E. Cochrane, 2007 Oct). Clinicians should identify women at higher risk for PPD so to conduct closer follow-up and intervention where needed. These vulnerable groups women experiencing marital strife, those who have experienced stressful life events, those from lower socioeconomic status, and those under financial pressure. As unintended pregnancy is a risk factor for PPD (Dennis CL, Hodnett, E. Cochrane, 2007 Oct) clinical providers should consider asking about pregnancy intention at early prenatal visits. Women who report an unintended or unwanted pregnancy may benefit from earlier or more specified screening for depression both during and after pregnancy (Lieber, A., 2018). Based on previous findings, prenatal assessment of social support among pregnant adolescents may be very useful in targeting interventions to treat and prevent PPD (Lieber, A., 2018). A recent study argues that receiving informational support from many social network members was protective against PPD. A supportive relationship with the father has also been determined to help alleviate the stresses of being a new mother (Zauderer, C., 2009). As one of the most common disorder among women following the birth of a child, it is imperative that women who screen positive for PPD receive immediate treatment.

Involvement of the woman’s support system in the treatment process may help the mother feel less stressed with the decision of deciding a treatment. Psychotherapy is known as the first-line treatment option for women with a mild or moderate case of PPD. Cognitive-behavioral therapy and interpersonal therapy (IPT) are treatment approaches given over 10 to 20 weekly sessions. Both of which have been determined to have a moderate to large (Dennis CL, Hodnett, E. Cochrane, 2007 Oct). Women with moderate to severe PPD, who are not breast-feeding, may decide to use antidepressants with or without psychotherapy as treatment (Zauderer, C., 2009). There is no antidepressant that has shown significant benefits over others, therefore those that have been helpful in previous cases are preferred (Zauderer, C., 2009). There have been studies conducted on the relationship between PPD antidepressant treatment and breast-feeding. Although there have been numerous health benefits associated with breast- feeding, a woman affected by PPD should weigh the risks of not receiving treatment and the risks and benefits of antidepressant use while breast-feeding (Zauderer, C., 2009). A mother who is breast-feeding can receive treatment through psychotherapy alone without harming their baby, but depressive symptoms should be closely monitored.
All in all, postpartum depression is a form of clinical depression that can affect a woman at any time within the first year following the birth of a child. All women are susceptible to developing PPD, however, there are certain risk factors that make a women’s chance of experiencing this illness significantly more likely. PPD is characterized by persistent physical and emotional challenges that interfere with the ability of the mother to care for her child and carry out everyday tasks. Women who are affected may experience various symptoms closely associated with PPD, such as frustration, sadness, despondency, loss of appetite, suicidal ideation, sleep disturbances, poor concentration and memory, fatigue and irritability. The single cause of PPD is not known but is believed to be multifactorial in which various influencing characteristics contribute to its subsequent development.

Directions for future research
Treatment is readily available and comes in various forms, that which depends on the extent of symptoms, patient preference, previous treatment response and the availability of resources. However, PPD can be prevented and the most beneficial way of preventing this disorder is early identification of women at risk. While there is much research on the topic of PPD further needs to be conducted on the risk factors to get a better understanding of this broad category of influencing characteristics as well as the developmental effects of the child and the screening process.