The Postpartum Period
Upto one year following childbirth is called the post partum period. During the postpartum period, about 85% of women experience some type of mood disturbance. Majority experience mild and short-lived symptoms; however, 10 to 15% of women develop more significant symptoms of depression or anxiety.
Postpartum psychiatric illness is typically divided into three categories: (1) postpartum blues (2) postpartum depression and (3) postpartum psychosis; with postpartum blues being the mildest and postpartum psychosis the most severe form of postpartum psychiatric illness.
About 50 to 85% of women experience postpartum blues during the first few weeks after delivery. Women with the blues more commonly report mood lability, tearfulness, anxiety or irritability. These symptoms typically peak on the fourth or fifth day after delivery and may last for a few hours or a few days, remitting spontaneously within two weeks of delivery. While these symptoms are unpredictable and disturbing, they do not interfere with a woman’s ability to function. No specific treatment is required. But, it should be noted that sometimes the blues predate the development of a more significant mood disorder, particularly in women who have a history of depression. If symptoms of depression persist for longer than two weeks, the patient should be evaluated to rule out a more serious mood disorder.
PPD typically emerges over the first two to three postpartum months but may occur at any point after delivery. Some women may report milder depressive symptoms during pregnancy. Symptoms of Postpartum depression are clinically indistinguishable from depression occurring at other times during a woman’s life. The symptoms of postpartum depression include:
Significant anxiety symptoms may also occur. Generalized anxiety is common, but some women also develop panic attacks or hypochondriasis. Postpartum obsessive-compulsive disorder has also been reported, where women report disturbing and intrusive thoughts of harming their infant. Especially with milder cases, it may be difficult to detect postpartum depression because many of the symptoms used to diagnose depression (i.e., sleep and appetite disturbance, fatigue) also occur in postpartum women in the absence of depression.
The Edinburgh Postnatal Depression Scale is a 10-item questionnaire that may be used to identify PPD. On this scale, a score of 12 or greater or an affirmative answer on question 10 (presence of suicidal thoughts) raises concern and indicate a need for more thorough evaluation.
Postpartum psychosis is the most severe form of postpartum psychiatric illness. It is a rare event that occurs in approximately 1 to 2 per 1000 women after childbirth. Its presentation is often dramatic, with onset of symptoms as early as the first 48 to 72 hours after delivery. The majority of women with puerperal psychosis develop symptoms within the first two postpartum weeks.
It appears that in most cases, postpartum psychosis represents an episode of bipolar illness; the symptoms of puerperal psychosis most closely resemble those of a rapidly evolving manic (or mixed) episode. The earliest signs are restlessness, irritability, and insomnia. Women with this disorder exhibit a rapidly shifting depressed or elated mood, disorientation or confusion, and erratic or disorganized behavior. Delusional beliefs are common and may center on the infant. Auditory hallucinations that instruct the mother to harm herself or her infant may also occur. Risk for infanticide, as well as suicide, is significant in post partum psychosis.
Factors Causing Post Partum Depression
Multiple factors may play a role in the etiology of PPD. The postpartum period is characterized by a rapid drop in estrogen and progesterone hormone levels. Presence of other risk factors like marital dissatisfaction and/or inadequate social supports, stressful life events occurring either during pregnancy or near the time of delivery, sleep deprivation, personal or family history of mental health disorders increase the likelihood of depression.
While all of these factors may act together to cause PPD, the emergence of this disorder probably reflects an underlying vulnerability to mood disorders. Women with histories of major depression or bipolar disorder are more vulnerable to develop PPD, and women who develop PPD will often go on to have recurrent episodes of depression unrelated to pregnancy or childbirth.
All women are vulnerable to postpartum depression, regardless of age, marital status, education level, or socioeconomic status. While it is impossible to predict who will develop PPD, certain risk factors for PPD have been identified, including:
Treatment for Postpartum Illness
The type of treatment selected is based on the severity and type of symptoms present. Initial evaluation should include a thorough history, physical examination, and routine laboratory tests to rule out medical disorders.
Non-pharmacological therapies are useful in the treatment of postpartum depression. Studies support short-term cognitive-behavioral therapy (CBT) and Interpersonal therapy (IPT) as an effective treatment in postpartum depression. These are particularly attractive to those patients who are reluctant to use psychotropic medications (e.g., women who are breast-feeding) or for patients with milder forms of depressive illness.
Women with more severe postpartum depression may choose to receive pharmacological treatment, either in addition to or instead of these non-pharmacological therapies.
Puerperal psychosis is considered a psychiatric emergency that typically requires inpatient treatment. Acute treatment with either typical or atypical anti-psychotic medications is indicated.
Using Medications While Breastfeeding
Women who plan to breastfeed must be informed that all psychotropic medications, including antidepressants, are secreted into the breast milk. Concentrations in the breast milk appear to vary widely. The amount of medication to which an infant is exposed depends on several factors, including dosage of medication, rate of maternal drug metabolism, and frequency and timing of feedings.