Statement on Postpartum Depression

Ralph Wittenberg, MD

Postpartum Depression (PPD) Overview

Depression causes more days lost to disability in a lifetime than any other disease except coronary artery disease. The rate of depression in women is twice that of men. Major depression is the leading cause of suicide. In the United States, the most conservative estimate is that 6,000 women lose their life to it each year. The most frequent age of onset of depression in women is during the childbearing years. Postpartum depression, a type of major depression, is the single most frequent serious complication of pregnancy. It affects one in ten new mothers; or 400,000 new cases per year in the United States alone. With postpartum depression not only are the mothers are affected. Studies have established that maternal depression has profound effects on the offspring and even the grandchildren. Not only do babies suffer from delayed mental development, they develop behavioral problems as well. Maternal depression is associated with severe marital problems. The rate of spousal abuse peaks around the birth of a child, although it is not clear which is the cause or which is the effect. The other children in the family also suffer.

Symptoms

The symptoms to make the diagnosis of postpartum depression must include at least five of the following that last over two weeks.

• Weeping and general unhappiness.

• Loss of interest in things the mother normally enjoys.

• Changes in weight or appetite.

• Difficulties with concentration and memory.

• Irritability.

• Increased or decreased rate of activity, patient may speak and move very slowly or be frantic and going non-stop.

• Loss of interest in sex.

• Thoughts of suicide.

Mood disorders like postpartum depression are accompanied by many physical symptoms, as well. The list may include too much or too little sleep, poor memory and concentration, altered appetite, lack of energy, sweating, palpitations, as well as headaches and nausea. Sometimes the physical symptoms predominate so that it comes as a surprise for these women to learn they are suffering from a depression.

Other Mood Disorders

Major depression is not the only psychiatric problem that appears around pregnancy. A number of related mood disorders exist.

• The "baby blues" a condition characterized by weepiness, irritation and trouble sleeping affects almost 80% of new mothers. It goes away by itself, not lasting more than two weeks.

• Many women develop severe anxiety disorders, either along side of or in the absence of depression. These include panic disorder and obsessive-compulsive disorder (OCD). Panic attacks are so severe that the women think they are dying or going crazy and often have to go to hospital emergency rooms. Women with OCD are preoccupied with worries that they might cause some harm to their baby or need to check them constantly to reassure themselves they are all right.

• Some patients will experience their first episode of bipolar disorder formerly called manic depression, a very serious mental illness. The manic phase severely impairs sleep, causes hyperactivity, non-stop talk, and unrealistic and/or paranoid convictions. At times these patients feel happiness in the extreme, but this can be followed by very severe depression. Either mood can be accompanied by psychotic behavior and require hospitalization. These women are at high risk for committing suicide or homicide. Physicians must be careful to make a correct diagnosis, because standard anti-depressants can trigger a manic episode in seven percent of people who are bipolar.

• One in a thousand women develop postpartum psychosis, a life-threatening illness with a high rate of suicide, and homicide as well. Postpartum psychosis is characterized by a loss of touch with reality, delusions and hallucinations. The patient may hear voices instructing her to carry out harmful actions; or to believe she is guilty of some horrific, unpardonable sin. These patients must be hospitalized for their own and their families’ protection.

Any of the conditions described above can appear during rather than after pregnancy. Often they are conditions suffered prior to pregnancy. There is a close connection between serious mood disorders and hormonal changes in women, which occur over the female life cycle. Hormonal changes of the menstrual cycle can cause serious emotional impairment. As pregnancy and childbirth are accompanied by enormous hormonal change, it is no surprise these changes can trigger serious mood disorders.

There are degrees of severity. About 20 percent may need hospitalization. Milder conditions can be treated in several ways: social support, medication, and psychotherapy. Some success has been reported using replacement hormones and some patients respond to intense light treatment, or interruption of sleep.

Only about 20 percent of women with postpartum depression get adequate treatment despite a number of risk factors that should alert a doctor to the diagnosis. Risk factors include: Prior history of depression, post-menopausal dysmorphic disorder, family history of mood disorders, presence of multiple stressors such as poverty, lack of supportive relationships, a difficult baby, lack of sleep, etc. Currently, the best primary care physician, i.e. an obstetrician or pediatrician, will detect only 40 percent of these patients. Because diagnosis is possible and treatment of these disorders is very successful, this is a tragedy and must be addressed.

Screening and Detection

Short questionnaires, or screening tests, can detect almost every case of postpartum depression. Screening tests do not make a diagnosis, but rather alert the clinician to the possibility. One such device, the Edinburgh Postpartum Depression Scale (EPDS), consists of ten short questions that can be filled out by the patient in less than five minutes and scored even more quickly. It was developed in England a number of years ago, translated into 14 other languages, and extensively tested. The test score signals further patient evaluation. Sometimes the primary care physician feels competent to do this, but often will refer the patient to a mental health professional.

As part of the standard of care, women are routinely tested for various conditions known to complicate pregnancy and childbirth. These include blood pressure, red blood count, and blood sugar. The same should be true for perinatal psychiatric disorders. This can happen when a woman typically sees her doctor, such as at the six-week postpartum visit.

Because there are many psychiatric problems that can occur before the baby is born, screening should be carried out during pregnancy. Many of the cases that are seen in the postpartum period are actually cases where the depression has been present all along. The same is true for anxiety disorders. With psychosis symptoms are usually dramatic enough not be missed. What is missing is the perception that this is a life-threatening emergency.

Barriers To Treatment

Mothers

One would think screening and referral solves the problem. But, it does not. Depressed mothers are very reluctant to seek help for the following reasons.

• They feel like failures, ashamed they can’t manage alone.

• They believe they are expected to be happy but know they are not.

• They feel guilty and inadequate because they cannot relate to their babies.

• They fear the stigma of mental illness.

• They fear medication, especially if they are nursing.

• They are afraid of being diagnosed as ‘crazy’ and committed to a hospital.

Primary Care Physicians

Further complicating the situation, many primary care doctors have a difficulty dealing with depressed patients. They can feel inadequate, especially if the mother is visibly upset or crying. They frequently mistake postpartum depression for the "baby blues" and falsely reassure the patient they "will get over it." Patients with perinatal mood disorders and anxiety disorders do not just "get over it." Thirty percent of women with PPD are still symptomatic after a year. Left untreated, for many this can be the beginning of a lifelong illness. Studies show conclusively, the earlier these conditions are detected and treated the better the outcome.

Even if patients wanted psychiatric treatment, there aren’t enough psychiatrists available. For this reason, the only place to begin is with a primary care provider, such as the obstetrician, pediatrician or family practitioner. Today, this includes nurse practitioners and physician’s assistants.

Training and Education for Professionals

To be successful a primary care screening project must educate primary care physicians, nurse practitioners and physician’s assistants. The training should include the following:

• The breadth and depth OF the problem

• The mechanics of screening for depression

• Guidelines on making the diagnosis

• Guidelines on assessing the severity of the problem

• Making a successful referral

• And, if it applies, how to treat the patient

Peer Support

To assist women who have been screened and told they need further evaluation, peer support can prove indispensable. Studies have shown the efficacy of support groups in encouraging patients to seek and then to comply with treatment. Women who have survived episodes of these illnesses volunteer to help others like themselves. Strategies for peer support include a Warmline, where a call for help puts the patient in touch with a volunteer. The volunteer can shepherd the woman through evaluation and treatment or help the family to do so. There are also educational support groups that explain the problem and provide a number of ways to deal with it. Also effective is the "phone a friend" service where a volunteer will call a woman identified by a health provider as needing support.