A guide to young mothers: Understanding Postpartum Depression

Often, our attention is drawn to the subject of postpartum depression by sensational headlines about a celebrity’s ordeal or horrific outcome of an infanticide. High‐profile mothers like Brooke Shields and Gwyneth Paltrow have shared their stories of postpartum depression. In 2017, Ivanka Trump revealed on CNN her struggle. Last month, a 29-year-old Indian woman in New Jersey was charged with killing her five-day old baby girl, devastating the family.

Did you know that in 2006, New Jersey became the first state to require postpartum depression screening of women after childbirth? Some other states have followed this example. But this does not seem to be enough.

Pregnancy is a time of great joy, hope and excitement for the mother and her family. It can also be a time of great stress.

Sensational news of a tragic incident involving a new mother may not accurately reflect the nature of the mother’s psychiatric condition and may contribute to stigma, which is a barrier to seeking help. Andrea Yates drowned her five children in a bathtub in 2001. Initial reports were that of a woman who suffered from postpartum depression. This might in readers’ mind convey a stereotype that a woman with postpartum depression is at high risk of harming her children. Yates, it was found later, actually suffered from schizophrenia and postpartum psychosis for which she may not have had consistent and adequate treatment. Untreated severe mental illness can have tragic consequences. While postpartum depression is common, such incidences of killing an infant are rare.

Such news can result in judging the mother harshly and add to the guilt and shame she might already be experiencing. It is important to understand the differences in various types of postpartum experiences and psychiatric ailments. One needs to distinguish between normal ‘baby blues,’ severe postpartum depression and postpartum psychosis.



What are Baby blues?

Fifty to 80 percent of new mothers experience ‘baby blues.’ Mothers may feel sad, emotional, weepy, and overwhelmed. They may experience mild mood fluctuations, irritability, or anxiety. Peak symptoms typically occur between 2 to 5 days following childbirth and generally resolve within 2 weeks. Sleep deprivation and hormonal changes possibly contribute to such blues. These symptoms do not interfere with functioning.



What is Postpartum depression?

For most women, the mild postpartum blues do not turn into a severe depression which is often referred to as postpartum major depressive episode. If the sadness persists beyond a few days and if it starts to affect the mother’s functioning, postpartum depression should be suspected.

Postpartum depression is the most common complication of childbirth, occurring in about 10% to 20% of women. In other words, 1 to 2 in 10 women may experience it. The severity and nature of symptoms varies. For some it may be mild with minimal impairment in functioning while for others it may be severe, resulting in the mother feeling paralyzed to function.

They feel very down, often for no reason and may have crying spells. It can result in irritability, changes in appetite, fatigue and sleep difficulties. Some may experience thoughts of suicide. Suicide accounts for about 20% of postpartum deaths. So, it is important that the condition is taken seriously, and treatment sought.

It is not uncommon to experience some anxiety and worries about the baby and baby’s care. However, anxiety associated with postpartum depression can be severe. Some women might experience anxiety in absence of postpartum depression. Anxiety can be very overwhelming. The person may feel very nervous, restless, unable to relax and worry excessively, often about the baby.

Some women may experience recurrent intrusive, undesirable obsessive thoughts that do not make sense to the mother. Sometimes such thoughts are independent of postpartum depression and may have another treatable condition called postpartum obsessive-compulsive disorder (OCD). Women with postpartum OCD may worry about accidentally putting the baby in the microwave oven, leaving the baby in a hot car, or throwing the baby down the stairs.

Such thoughts are frightening and distressing to the mother and result in shame and guilt. Efforts are made to avoid such thoughts and actions. Women typically do not act on their aggressive thoughts. Some mothers are obsessively preoccupied with worries about their baby’s health and nutrition and cleanliness of the baby’s environment.

We don’t know exactly what causes postpartum depression although some experts have suggested a link between postpartum depression and the hormonal fluctuations common to women after child birth. During pregnancy, hormonal changes, physical changes in the body, impact on job and home, and increased financial burden may contribute to the stress. Pregnancy does not protect against mental illness, and the postpartum period is a time of great vulnerability for women, especially if they’ve had a prior history of psychiatric illness. Lack of good sleep is also a risk factor.



Who is likely to suffer postpartum depression?

Any woman can get it. However, those who have suffered depression, especially postpartum depression in the past, are at greater risk and should be more vigilant about this. Women with history of bipolar disorder also have a significantly higher risk. Untreated depression and anxiety during pregnancy increases the risk of postpartum depression. Women whose depression is adequately controlled with medication and decide to stop the medications during pregnancy or postpartum period also have a higher risk of relapse of depression

What is postpartum psychosis (PPP)?

This is a much more serious condition and fortunately much rarer, with 1 to 2 cases per 1,000 childbirths. The risk of infanticide (killing of the infant), although low, is elevated in untreated PPP, with approximately 4% of these women committing infanticide. Postpartum psychosis is considered an emergency that necessitates an urgent evaluation, psychiatric referral, and in all likelihood a hospitalization. A thorough physical and neurological examination is needed along with blood tests to look for any underlying contributing medical factors.

Severe symptoms can present suddenly within days to weeks of giving birth. Before the onset of severe symptoms a person may start experiencing sleep difficulties, mood fluctuations and irritability. Behavior becomes disorganized. A mother may experience strange beliefs (delusions) and obsessive thoughts. A mother might also experience confusion, agitation and hallucinations. Sometimes there are intense religious preoccupations.

The new mother may have little or no awareness that these symptoms might be a part of an underlying psychiatric illness. This along with waxing and waning of symptoms makes it challenging to recognize the condition in a timely manner. The uncertainty and confusion that the families experience further add to the delays in seeking treatment.

When a mother develops PPP, it is important to consider the risks of suicide, child harm, and infanticide. The disorganization in thinking that occurs with PPP may result in a mother’s neglect of her infant’s needs and unsafe practice. If a mother expresses thoughts of dying, suicide or harming the baby, these should be taken very seriously. A psychiatric consultation should be sought.

Most women with PPP have an underlying chronic severe mental illness although in a small minority the symptoms are limited to postpartum period. Of all women with PPP, 70% to 90% have bipolar illness or schizoaffective disorder, while approximately

12% have schizophrenia. All these conditions can be successfully treated.

In rare cases when the mother kills her infant, this might be a result of strange beliefs and suspicions. In some cases, the mother with PPP kills her infant “out of love,” believing that she is preventing the infant from suffering on this earth. A suicidal mother may decide to kill her infant and herself, rather than leave the infant in the world without a mother.



Is there treatment for postpartum depression and psychosis?

Fortunately, a broad range of effective treatments are available. The three major types of treatments are medications, psychotherapy and ECT.

When a mother experiences normal ‘baby blues,’ emotional and physical support provided by the family is extremely helpful and enough. It is important for the mother to get adequate sleep. This is especially critical if the mother has a prior history of bipolar disorder. Consider hiring a doula or other help for assistance and support.

There should be no excuse for not seeking the treatment. Women who seek treatment promptly have a more favorably outcome. Prognosis with treatment is good. A range of antidepressant medications are available for postpartum depression.

The postpartum psychosis (PPP) is considered as an emergency and is typically best treated in a hospital. Mood stabilizers and second-generation antipsychotics are often used for acute management of PPP.

Electroconvulsive therapy, often referred to as ECT or by some as ‘shock treatment’ is a safe and effective treatment for PPP and can be considered first-line treatment for high-risk individuals when rapid improvement is needed.

A small risk of taking selected medication for prevention during pregnancy may outweigh the potential risks of untreated mental illness for the fetus, infant and family. Abruptly stopping medication can increase the risk of relapse of depression or bipolar disorder. Families should get educated about the illness and available treatments.



Prevention

It is said that the best treatment is prevention. Here are some tips:

· Be very vigilant if the woman has a prior history of bipolar disorder, depression, postpartum depression or other serious mental illness.

· Observe mood for any signs of persistent sadness or difficulty in functioning during pregnancy and after childbirth. Observe interactions with the infant.

· When a woman shows mild symptoms, it is important to provide the support and encourage her to take care of herself. Her mood should be monitored in order to catch in a timely manner the onset of severe postpartum depression.

· If the woman has been on medications for depression or other conditions, and there are worries about effects of medications on the fetus, a thorough discussion should be held with the treating physician about the risks and benefits of stopping versus continuing the medications. Remember, untreated depression and anxiety also have adverse consequences for the pregnancy, mother, fetus and the newborn baby. Many factors have to be considered before making this decision. Decision is best made jointly with your treating physician.

· Woman can take self-administered online tests for depression. See links in the resources below for two tests - Edinburgh Postnatal Depression Scale and the PHQ-9. These are free and quick to take.

Unfortunately, infanticide grabs headlines and women who suffer postpartum psychosis and depression often worry about the stigma of revealing they’ve had the disease and avoid seeking treatment. Women and their families should not worry about what others might think. They should acknowledge the problem and seek an evaluation and treatment if indicated. The health of the mother and baby is more important than what others think. Remember, there are many safe and successful treatments available. These can be lifesaving and life-changing and restore the smile on the new mother’s face.

Screening helps to detect postpartum depression in a timely manner. Effective treatments are available. Left untreated, postpartum depression can have severe negative effects on the mother’s health and well-being, her relationships with family members and the baby’s subsequent development. People should not be quick to judge women who suffer from postpartum depression. They should be quick to provide their support.

(Vasudev N. Makhija, MD, is the president of SAMHIN, a non-profit organization, that addresses mental health needs of the South Asian community in the U.S.)



Resources

· www.samhin.org

· NJ Maternal and Child Health 1-800-328-3838 https://nj.gov/health/fhs/maternalchild/mentalhealth/about-disorders/

· https://mothertobaby.org/

· LactMed - TOXNET(Toxicology Data Network) Database https://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm

· Postpartum Support International

https://www.supportgroupscentral.com/groups_detail.cfm?cid=17&CFID=644686&CFTOKEN=14a7886f8e409ef6-2C8D44A9-C503-2E6D-96AAD8400FD626FA

· Edingburg Postnatal depression screening Cutoff score 10

https://psychology-tools.com/test/epds

· PHQ-9

https://www.phqscreeners.com/select-screener/36