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MANAGEMENT OF POSTPARTUM DEPRESSION

 Netranee Anju Ramdinny- Purryagz

Consultant Psychiartist St. Jeen Pharmacy, Mauritius

 

Abstract

Postpartum depression (PPD), also called postnatal depression,is a complex physical, emotional and behavioral changes after giving child birth. According to DSM IV it is a mental disorder a form of major depression, which has on set four week after delivery.Studies report prevalence rates among women from 5% to 25%, but methodological differences among the studies make the actual prevalence rate unclear. Among men, in particular new fathers, the incidence of postpartum depression has been estimated to be between 1% and 25.5%.

Introduction

Postpartum depression is a type of psychiatric illness; approximately 85% of women experience some type of mood disturbance during postpartum illness. It can be divide three types postpartum blues, postpartum depression and postpartum psychosis. Women develop more significant symptoms of depression or anxiety in postpartum depression. Whereas postpartum blues is the mildest and postpartum psychosis, the most severe form of postpartum psychiatric illness.

Brief comparative overview with depression

The weeks following childbirth are a time of vulnerability to depressive symptomatology in women.1 The literature on postpartum depression has inconsistently defined its time of onset between 4 weeks and 6 months following delivery. DSM 1V, in an attempt to define the syndrome more rigorously, applies the term “postpartum onset” to depression occurring within 4 weeks of delivery. However, most epidemiological studies have not used this strict criterion. When defined as depression occurring in the first 6 months after delivery, rates are as high as 22% but drop to 12 to 16% if defined more rigorously as occurring in the first 6 to 9 weeks postpartum.2, 3Except for a postpartum specified, DSM-IV’s criteria for postpartum depression do not differ from major depressive disorder. But, guilt and agitation appear to occur more frequently in cases of postpartum depression and suicidability is less common.4

Risk factors

·         Family history of depressive disorder.

·         Personal history of major depressive disorder.

·         Depressive symptomatology during previous pregnancies.

·         Marital discord.

·         Stressful child care events (eg health problems in the baby).5,6

Research studies have consistently shown that the following risk factors are strong predictors of postpartum depression:

·         Depression or anxiety during pregnancy

·         Stressful recent life events

·         Poor social support

·         A previous history of depression

Moderate predictors of postpartum depression are

·         Childcare stress.

·         Low self esteem.

·         Maternal neuroticism.

·         Difficult infant temperament.

Mild predictors of postpartum depression include:

·         Obstetric and pregnancy complications.

·         Negative cognitive attributions.

·         Single marital status.

·         Poor relationship with partner.

·         Lower socioeconomic status including income.

No relationship was found for ethnicity, maternal age, and level of education, parity or gender of child in western countries. Hormonal events in pregnancy and during postpartum period. The months following childbirth are a time of heightened vulnerability to depressive mood changes. Because of the abrupt and dramatic changes occurring in hormone levels after delivery, many studies have examined the role of hormonal factors in postpartum depression. Potential hormonal etiologies in postpartum depression include progesterone, estrogen, prolactin, cortisol, oxytocin, thyroid and vasopressin. While evidence for an etiologic role is lacking for most hormones, changes in certain hormonal axes may contribute to depressive mood changes in some women following childbirth.7

During pregnancy, levels of oestrogen (oestradiol, estriol and estrone) and progesterone rise steadily in large part as a result of placental production of these hormones. With removal of the placenta at delivery, oestrogen and progesterone levels drop sharply, reaching pre-gravid levels by 5th postpartum day. Levels of beta-endorphin and cortisol also rise across pregnancy, reaching a maximum near term and declining at delivery. High oestrogen levels during pregnancy stimulate production of thyroid hormone-binding globulin, leading to a rise in the levels of bound T3 (triiodothy ronine) and T4 (thyroxine) with a simultaneous drop in the levels of free T3 and T4. As a consequence, thyroid stimulating hormone (TSH) increases to compensate for the low free thyroid hormones, and free T3 and T4 thus remain in the normal range.8

Prolactin levels rise during pregnancy, peak at delivery and in non lactating women, return to pregravid levels within 3 weeks postpartum. By inducing the release of oxytocin, a hormone that stimulates pituitary lactotrophic cells, breastfeeding maintains high prolactin levels. Even in breastfeeding women, however, prolactin levels eventually return to pregravid levels.Consequences of postpartum depression on children:

Influence on early interactions: Most of mother-infant interaction studies have focussed on infants aged between 3 and 6 months. The primary form of play during this period involves vocalising, smiling, imitation and game playing. These interactions, in turn are thought to be the “playing field’’ for infants learning communication skills. Fewer of these behaviours have been noted in depressed mothers and their infants, which may contribute to interaction disturbances.9

Inadequate care giving practices: several care giving activities appear to be compromised by postpartum depression effects on the parenting roles including feeding practices, especially breastfeeding, sleep routines and well-child visits and vaccinations.

Possible effects on children

·         Children of depressed mothers have been found to have difficulty in establishing secure relationships which may put them at risk for later difficulties.8

·         Young children of depressed mothers have been rated as drowsier, more passive, more temperamentally difficult, and less able to tolerate separation, more afraid or more anxious, than children of non depressed mothers. Studies have shown that depressed mothers are less involved with their children; they are inconsistent, sometimes nurturing and sometimes withdrawn.9

·         Compared to children of non depressed mothers, school age and adolescent children of depressed mothers have been found to function more poorly in a number of areas: they have more school problems, poor peer relationships, lower levels of self-esteem, more behaviour problems and to be at risk for a variety of depressive and anxiety disorder 10,11

Consequences of postpartum depression on mothers:

·         They are slow to respond to overtures for verbal or physical interactions by their children.

·         They make critical comments

·         They have difficulty in encouraging the child’s speech and language.

·         They have difficulty asserting authority and setting limits which would help the child learn to regulate his or her behaviour.

·         They initiate interactions less and derive less pleasure from them.

·         They talk less to their infants.

·         They don’t use the lilt and exaggeration (”motherese”) that are typical of non-depressed mothers.

·         They have difficulty in providing appropriate stimulation.

·         They are less aware and responsive to their infant’s cues.

On the other hand, some depressed mothers interact excessively and over stimulate their infants, which may result in the infants’ turning away.

More reasons not to underestimate postpartum depression are that women with postpartum depression are more likely to start smoking or abuse alcohol and illicit substances which can further exacerbate the severity of their symptoms and the negative effect on the child who are at greater risk for experiencing physical, emotional or sexual abuse.12

Postpartum depression and gender

Postpartum depression is not an illness that is exclusive to mothers. Fathers can experience it as well. In fact, it can affect as many as 10% of new fathers. As with women, symptoms in men can result in fathers having difficulty caring for themselves and for their children when suffering from postpartum depression.

Treatment

Treatment choices include:

Counselling for both the patient and her partner.

Cognitive behaviour therapy helps patients to take charge of the way they think and feel.

Interpersonal counselling is also a good treatment of choice. Interpersonal counselling focuses on relationships and the personal changes that come with having a baby. Interpersonal counselling gives emotional support and helps with problem solving and goal setting. For patients’ partners, counselling may help with the demands of having a baby. It also helps partners to provide support to their wives.

Antidepressant medications:

Certain SSRIs and tricyclic antidepressants are considered relatively safe for use while breastfeeding.

Counseling alone proves effective in mild postpartum depression.

Counseling and antidepressants together are effective in moderate to severe depression.

Of the SSRIs, sertraline is usually the medication of choice for breastfeeding mothers. It is the most studied and generally it does not seem to affect breastfeeding babies.

There have been reports of side effects in babies exposed to paroxetine, fluoxetine and citalopram.

Fluvoxamine has not been well studied.

Researchers are studying children who were breastfed while mothers took SSRIs. So far, there have been no signs of unusual problems in those children into their preschool years.

Preventive Measures

·         Eating a balanced diet. If one has poor appetite, she is advised to eat small snacks throughout the day. Nutritional supplements are also useful for keeping up energy.

·         Regular daily exercise helps improve mood.

·         Exposure to as much sunlight as possible. Shades and curtains should be kept open.

·         It is advised that women ask for help with food preparation and other daily tasks.

·         Alcohol and caffeine must be avoided. Self medicating with alcohol and other substances to feel better is not advised.

·         Women are advised not to overdo; they should get as much rest and sleep as possible. Fatigue can increase depression.

·         Outings and visits can be scheduled with friends and the family. Latter can be asked to call regularly. Isolation can worsen depression, especially when combined with the stress of caring for a newborn.

·         Following measures may also help: a part time or full time mother’s helper and parent coaching classes for strengthening mother-baby attachment.

Conclusion

Although obstetricians and pediatricians are most likely to have a unique opportunity to screen women for postpartum depression, particularly at the postpartum visit or even during the early third trimester, general practitioners may also encounter women with undiagnosed postpartum depression and should be able to recognize this highly prevalent condition. Prompt diagnosis and intervention with referral to the psychiatrist for treatment, as appropriate may be a great benefit to the lives of mothers with postpartum depression and their infants.

References

1.        Stowe ZN, Numeroff CB: Women at risk for postpartum onset major depression. Am J Obstet Gynecol 1995; 173: 639-645.

2.        Watson JP, Elliott SA, Rugg AJ et al. Psychiatric disorder in pregnancy and the 1st postnatal year. Br J Psychiatry 1984; 144:453-462.

3.        O’Hara MW: Social support, life events and depression during pregnancy and the puerperium. Arch Gen Psychiatry 1986; 43: 569-573.

4.        Whiffen VE: Is postpartum depression a distinct diagnosis? Clinical Psychology Review 1992; 12:485-508.

5.        O’Hara MW: Social support, life events and depression during pregnancy and the pueperium. Arch Gen Psychiatry1986; 43: 569-573.

6.        Whiffen VE: Is postpartum depression a distinct diagnosis? Clinical Psychology Review 1992; 12: 485-508.

7.        Hendrick V, Altshuler LL, Suri R. Hormonal changes in the postpartum and implications for postpartum depression. Psychosomatics 1998; 39(2): 93-101.

8.        Learoyd DL, Fung HYM, McGregor AM: Postpartum thyroid dysfunction. Thyroid 1992; 2:73-80.

9.        Field T. Prenatal depression effects on fetus and neonate. Emotional development 2006; 317-339.

10.     Downey G, Coyne JG. Children of depressed parents: An integrative review. Psychological Bulletin 1990; 108:50-76.

11.     Gelfand DM, Tetr DM. The effects of maternal depression on children. Clinical Psychological Review 1990; 10: 329-353.

12.     Fitelson E, Kim S, Baker AS, Leight K. Treatment of postpartum depression: clinical, psychological and pharmacological options. International Journal of Women’s Health 2011; 3: 1-14.