Postpartum Depression (PPD) - aapsus.org

1 American Journal of Clinical Medicine Spring 2009 Volume Six, Number Two 17. Postpartum Depression (PPD). Sara Thurgood, BS. Daniel M. Avery, MD. Lloyda Williamson, MD. Abstract In addition to the stigma of mental illness, the societal portrayal of idealized motherhood adds even more strain to the emotion- Postpartum Depression (PPD) affects 10-15% of new mothers, ally taxed mother. Women attempt to hide their distress and but many cases of PPD remain undiagnosed. The term Post- struggle alone in fear of being labeled an unfit parent or, worse, partum Depression encompasses several mood disorders that having their baby taken from them. They may minimize their follow childbirth and are discussed in this paper.

2 Important symptoms or attribute them to feeling overwhelmed by the de- developments in the study of PPD include its association with mands of a new baby, lack of sleep, or difficult infant tempera- symptoms of anxiety and bipolar disorders in addition to those ment. Some may deny traditional depressive symptoms in of Depression . lieu of experiencing irritability and/or anxiety as their primary complaint. Even the most informed physicians may not attribute Postpartum Depression (PPD) encompasses several mood dis- these feelings to PPD, assuming that they are due to the stress orders that follow childbirth. Postpartum Depression (PPD) af- of newfound To make matters worse, a woman's fects 10-15% of all new mothers, but may be as high as 35%.

3 Risk of recurring PPD with subsequent children is estimated at in certain demographic One study found that 50-100%!7 These women continue to suffer, most in silence and of new mothers were diagnosed with major or minor depres- bewilderment, about the pathology of their condition, a condi- sion within the first three months Postpartum , specifically tion which is treatable and possibly even preventable. with major In another study of 214 women, 86 re- ported high levels of depressive symptoms ( ), but only 25. ( ) were actually diagnosed as being Another Definitions and Distinctions survey revealed that one-third of women scoring within a de- The term Postpartum Depression is an umbrella, which en- pressive range at eight months Postpartum were still depressed compasses several mood disorders that follow childbirth.

4 It is 12-18 months later, but only 15% sought help or were referred vital to distinguish between these, as each may require very dif- to a mental health PPD is underdiagnosed and ferent treatment or none at all. These mood disorders overlap in remains the most common complication of childbirth and the symptomology, but have unique, differentiating features:6. most common perinatal psychiatric disorder, with women at greatest risk during their first Postpartum year (45-65% of ever- The baby blues describes the most common mood dis- depressed women).1 turbance in new mothers (50-80%), with an early onset, peaking at day five, and full resolution 10-14 days post- Many cases of PPD may remain undiagnosed due to constraints partum.

5 Symptoms include emotional lability, frequent such as time and concerns about the social acceptability of crying, anxiety, fatigue, insomnia, anger, sadness, and irri- screening. But the majority of undiagnosed cases are probably tability. While considered normal, the blues can evolve due to the social stigma of being labeled an unhappy mother, 5 into full-blown PPD if symptoms last longer than two not to mention the public image of PPD. Upon formal screen- weeks; indeed, it remains one of the strongest risk factors ing, many women scoring in a depressive range fully admit to for PPD with 25% of women developing a more chroni- being depressed, understanding that their symptoms are neither cally depressive ,2,6 The key difference between minor nor transient.

6 But they reject the term Postpartum de- the blues and PPD is the short time frame and the fact that pression because this implies to them that their feelings are the blues do not interfere with maternal role functioning, caused by their For these women, it is the stigma of making the blues a self-limiting disorder that does not de- PPD that causes shame, fear, embarrassment, and mand Postpartum Depression (PPD). 18 American Journal of Clinical Medicine Spring 2009 Volume Six, Number Two Postpartum Panic Disorder is diagnosed if the mother decreased concentration, and suicidality. The patient must also experiences panic attacks for the first time in her life.

7 Have either a depressed mood and/or loss of interest or pleasure These are discrete periods of intense fear involving pal- in daily activities with episodes beginning within four weeks pitations, sweating, shortness of breath, chest pain, dizzi- of ,2 Such parameter constraints would omit many ness, lightheadedness, numbness, fear of death, and feeling women experiencing legitimate PPD symptoms within a much of unreality or losing control. Symptoms peak within ten broader time frame. While 40-67% of PPD cases begin within minutes of the first 12 weeks Postpartum , anywhere from 30-70% of moth- ers may experience Depression for longer than one year!

8 6 Clini- Postpartum Obsessive Compulsive Disorder (PPOCD) cians, therefore, expand the Postpartum period to a risk range of is obsessive, unwanted thoughts with accompanying be- three months to two In addition, milder cases of PPD, haviors. It is important to note that women recognize their which may not fit all the criteria of the DSM-IV, are diagnosed obsessions as their own thoughts and feelings and under- as Depression not otherwise specified. 2. stand that follow-through would be wrong. They may even construct elaborate schemes to avoid situations in which thoughts might become actions ( , removing all The Mechanism of PPD. the knives from the home), yet often act upon compulsive The biological mechanism of PPD is believed to coincide with rituals ( , changing the baby even when dry).

9 2,8. that of major depressive disorder. Depression in general is a Postpartum Post Traumatic Stress Disorder (PPPTSD) disease of neuronal circuit integrity, which has been shown in is the result of birth trauma involving threatened or actual studies by a reduction in brain volume of individuals diagnosed serious injury or death to the mother or her infant ( of with major depressive disorder. Interestingly, the amount of all Postpartum women), resulting from feelings of power- volume loss correlates directly with the number of years of ill- lessness or ignored emotional needs during her tenure at the ness. Stress and Depression act to reduce numerous brain pro- hospital.

10 Symptoms may include nightmares, flashbacks, teins that promote neuronal growth and synapse formation, and exaggerated startle response, anger, or difficulty sleeping antidepressant medications have been shown to increase these and/or concentrating. Women may be so haunted by the and other protective proteins, thereby reversing the mechanism pain and stress of their labor and delivery that they avoid of Depression . These underlying neurobiological changes result driving anywhere near the hospital where they gave birth!2 from developmental interactions between genetic susceptibility and environmental factors ( , the psychosocial stresses ac- Postpartum Psychosis (PPP) is the most serious, but least companying motherhood) rather than a simple chemical im- common, of all Postpartum mood disorders.