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Postpartum Depression

Robin Ellam, Margarita Ibarra, and Esmeralda Huerta

May 5, 2005

“As I rode and rode and rode, I felt even more anxiety coming upon me about not wanting to live. I felt I couldn't be a good mom anymore, but I didn't want my children to grow up without a mom. I felt I had to end our lives to protect us from any grief or harm. I had never felt so lonely and so sad in my entire life. I was in love with someone very much, but he didn't love me and never would. I had a very difficult time accepting that. But I had hurt him very much, and I could see why he could never love me. When I was at John D. Long Lake, I had never felt so scared and unsure as I did then. I wanted to end my life so bad and was in my car ready to go down that ramp into the water, and I did go part way, but I stopped. I went again and stopped. I then got out of the car and stood by the car a nervous wreck".----Susan Smith

Welcome to the complex world of postpartum depression. The authors of this website hope to answer all questions and correct any stereotypes you may have about this psychological disorder. As you may or may not know, postpartum depression is actually a blanket term of a three-phase disorder. What is commonly known as the "baby blues" can progress to postpartum depression which can then progress to a very serious condition known as postpartum psychosis. It can happen to anyone, anywhere, at anytime. If not treated correctly results could be tragic, including suicide and/or the death of a child. Unfortunately, the little knowledge we do have of this disease causes us to catch it too late, as with the case of Andrea Yates and Susan Smith. Although postpartum depression has affected over 10-20% of American women , little scientific research or support has gone into correcting this hush-hush disorder. As you will discover, postpartum depression is a real form of depression and not just an issue of "over-emotional" women. All Americans will benefit from more education and recognition of this psychological disorder, and hopefully will not have to suffer from the devastating effects that is postpartum depression.

History

During the 19th century postpartum psychosis did not exist as a separate syndrome. Women with postpartum psychosis were diagnosed as being manic depressive, suffering from dementia praecox, toxic confusion, and/or neurotic states.

Presently, postpartum psychosis continues to go unrecognized by psychiatrists. In 1968, The Diagnostic and Statistical Manual (DSM) II described, "294.4 Psychosis with childbirth". In 1980, the DSM III eliminated the category stating, "There is no compelling evidence that postpartum psychosis is a distinct entity".

In October 1994 in South Carolina, Susan Smith reported that a carjacker had stolen her car and children. One week later, she confessed to killing her two boys by driving her car into a lake while the children slept in their car seats. She is currently serving a life sentence for murder.

On June 20, 2001, Andrea Yates confessed to police that she drowned her five children in a bathtub because she had been a bad mother who hopelessly damaged them. In March 2002 a jury convicted Yates in the drowning of her 6-month-old daughter Mary, and her sons Noah, 7, and John, 5 and was sentenced to life in prison. The charges did not include the deaths of her two other sons, Paul, 3, and Luke, 2.The difference between a verdict of guilty and one of not guilty by reason of insanity in the Yates trial hinged on one key issue: whether Yates knew what she was doing when she drowned the children was wrong. Both the defense and prosecution agreed Yates is mentally ill, but prosecutors convinced the jury that she was aware that what she was doing was wrong. She pled not guilty by reason of insanity, citing her history of postpartum psychosis. Unfortunately, her lawyers found the condition hard to defend or even prove because the hormones go away after time and treatment. Under Texas law, defendants can be declared not guilty by reason of insanity only if it is determined they did not know right from wrong at the time of the crime.

Early this year, a Texas appeals court reversed Yates' capital murder convictions citing the false testimony of a prosecution witness. Yates has not yet been released from prison and continues to receive medical treatment for postpartum psychosis.

Etiology

Biological:

-Sharp drop in estrogen and progesterone (female reproductive hormones) after the placenta is removed after delivery. (Increases 10x during pregnancy.) Increased drops in progesterone leads to increased risk of depression.

-Decrease in tryptophan levels

-Decline in prolactin in mothers who do not breast-feed

-Adrenal steroid changes, including

1. Changes in plasma cortisol

2. Increase in aldosterone which leads to a decrease in potassium concentration

3. Changes in glucose tolerance/low blood sugar

- Decrease in cyclic adenosine monophosphete (AMP) from pregnancy level.

-PMS, Obsessive-compulsive disorder (OCD),birth control, alcohol, and drug use can all contribute to higher rates of disorder

-Hormones produced by the thyroid gland, which regulates metabolism (storing energy from food), drop sharply and cause fatigue and depression. The baby’s thyroid can produce antibodies against the mother’s thyroid and causes it to under-function.

-Changes in the amount of blood in the body, blood pressure, and the immune system after childbirth

-Long chain polyunsaturated omega-3 fatty acid deficiency, particularly docosahexaenoic acid (DHA)

-Reduced serum cholesterol levels

-Elevated copper

-Decreased serotonin levels

Psychological:

A diminished sense of importance or purpose--feeling let down--after getting through pregnancy and childbirth.
No longer being pregnant and carrying the baby inside the body can trigger past losses.
Worrying about the responsibility of caring for a new baby.
A woman's personal history of what it can mean to be a mother parenting a child may bring up extremely negative or uncertain feelings.

Role expectations/conflict for females and mothers

Weight gain after birth

Low self-esteem

Operative intervention in childbirth (Cesarean section)

Mothers of pre-term infants

Early discharge from the hospital

A baby with high level needs

Problems with breast feeding

**Birth related Post Traumatic Stress Disorder (PTSD): having obsessive thoughts about the birth, feelings of panic when near the site where the birth occurred, disturbing memories of the birth experience, nightmares and flashbacks.

Sociological

Usually new mothers are ashamed to show their feelings of unhappiness because it is at this time that society expects them to be joyous.

Postpartum depression and its symptoms are relatively unknown in non-westernized countries. PPD is found primarily in the United States due to our society's lack of:

1. Social support and/or postpartum events

2. Social recognition of the role transitions for new mothers

3. Meaningful assistance to new mothers (child and self care)

Studies have shown that poorer social conditions can also contribute to postpartum depression.

Feeling stress from work and home; unrealistic goal to be "super mom".

Having less free time and having to stay indoors for longer periods of time.

Having less time to spend with the baby's father, having an unsupportive partner, or having no partner at all.

Symptoms, Patient Characteristics, and Treatment

Click on the following links to learn about the symptoms, patient characteristics, and treatments for each branch of PPD:

Baby Blues

Postpartum Depression

Postpartum Psychosis

BABY BLUES

Symptoms:

Do not enjoy the things they used to

Worry about things they never worried about

Can’t sleep well

Find that they are feeling exhausted

Loss of appetite

Get mad easily at husband or children

Have unexplained anger

Can’t concentrate well

Isolate themselves from loved ones

Feel like they will never get better

Think children will be better off without them

Afraid that their husband will get tired of their feelings

Patient characteristics:

Women are more likely to get baby blues if:

They have a bad marriage

They have previously had postpartum depression

They do not have any family members or friends to turn to for help and support

Stressful events while pregnant or after child birth

Were victims of childhood sexual abuse

Physical or sexual assault by a stranger or someone you know

Physical assault while pregnant

Treatment:

Talk with your doctor about your feelings, they will offer counseling and / or medicine for help

Find time to do something for yourself, walking reading exercising, a hobby of your interest

Keep a diary, and write down all of your feeling in it, a good way to unload your emotions, and keep track by reading it to see how much you have improved

Find a support group

Get help from childcare, household cleaning, so that you have time for yourself

Have someone to talk to and turn to when you need help

Do not beat yourself up if you have not finished everything you want, and/ or feel like you have to be the best mom

Do not be afraid to ask for help with your children or household, let others know that you cannot do it all

POSTPARTUM DEPRESSION

Symptoms:

Symptoms of PPD include:

Feeling impatient or short-tempered

Feeling miserable, down or crying a lot

Not having energy

Having headaches, chest pains, heart palpitations (when the heart beats fast and it feels like it is skipping beats), numbness, or hyperventilation (fast and shallow breathing)

Restless sleep as a result being very tired

Not being able to eat and losing weight

Overeating and gaining weight

Trouble focusing, remembering, or making decisions.

Being overly worried about the baby

Not having any interest in the baby.

Feeling worthless and guilty

Being afraid of hurting the baby or oneself

No interest or enjoyment in activities

Patient Characteristics:

PPD is stronger than the baby blues and must be present for more than two weeks to differentiate the two. Approximately 10-20% of mothers suffer from Postpartum Depression in the first year after birth. It is most likely to occur after the first born child, but it can also occur after the second or third child. PPD can last for up to one year and a half even longer if not treated.

A woman may feel anxious after childbirth and may have postpartum depression. Signs of this condition include strong anxiety and fear, rapid breathing, fast heart rate, hot or cold flashes, chest pain, and feeling shaky or dizzy.

Usually physicians identify women that are at risk during and after pregnancy. Patients that have suffered depression are those that have poor support and they need careful monitoring. Physicians usually use the Edinburgh Postnatal Depression Scale (EDPS) to suspect depression.

The EDPS consists of 10 self responses, each of which receives a score between 0 and 3, with a total of 0 and 30. A total score higher than 10 is considered to be an indication for high risk of PPD.

Treatment:

PPD is treatable and in 2 to 3 weeks will diminish. The treatment will depend on how serious PPD is. PPD can be treated with medication (antidepressants) and psychotherapy. Women with PPD are often recommended to attend a support groups and to talk with other women who are going through the same experience. If a woman is breastfeeding she is given special consideration and needs to consult her doctor. Some of these drugs affect breast milk and should not be used.

Do to the Yates case PPD awareness has risen. Representatives and senators are sponsoring the “Melanie Stokes PPD Research and Care Act” bill, which asks for funding for research and services.

POSTPARTUM PSYCHOSIS

Symptoms :

-Similar to general psychotic reactions, including:

*Alterations in mood

*Delusions (seeing things differently from what they are; false beliefs)

*Visual hallucinations (seeing things that aren’t there)

*Auditory hallucinations (hearing things that aren’t actually happening)

*Rapid speech or mania

*Refusal to eat

*Frantic, excessive energy

*Loss of memory

*Incoherence