Postpartum Depression!

Published: 17th November 2006
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Postpartum depression is a complex mix of physical, emotional, and behavioural changes that occur in a mother after giving birth. It is a serious condition, affecting 10% of new mothers. Symptoms range from mild to severe depression and may appear within days of delivery or gradually, perhaps up to a year later. Symptoms may last from a few weeks to a year.

Baby blues
'Baby' or maternity blues are a mild and transitory form of 'moodiness' suffered by up to 80% of postpartum women. Symptoms typically last from a few hours to several days, and include tearfulness, irritability, hypochondriasis, sleeplessness, impairment of concentration, and headache. The maternity blues are not considered a postpartum depressive disorder.
Diagnosis
The diagnostic criteria for postpartum depression (PPD) are the same as for major depression, except that to distinguish PPD from the mild, transitory baby (maternity) blues, the symptoms must be present one month postpartum. Depression can also occur during pregnancy (ante-natal depression).
There are other types of postpartum distress that do not involve depression. For example, the mother may present with postpartum anxiety and postpartum OCD (including pure-O OCD). Symptoms of post-partum OCD include recurring intrusive thoughts, obsessive thoughts, avoidance behaviour, fears, anxiety, and depression.

Causes
While not all causes of PPD are known, several factors have been identified. Beck (2001) has conducted a meta-analysis of predictors of PPD. She found that the following 13 factors were significant predictors of PPD (effect size in parentheses -- larger values indicate larger effects):

Prenatal depression, i.e., during pregnancy (.44 to .46)
Low self esteem (.45 to.47)
Childcare stress (.45 to .46)
Prenatal anxiety (.41 to .45)
Life stress (.38 to .40)
Low social support (.36 to .41)
Poor marital relationship (.38 to .39)
History of previous depression (.38 to.39)
Infant temperament problems/colic (.33 to .34)
Maternity blues (.25 to .31)
Single parent (.21 to .35)
Low socioeconomic status (.19 to .22)
Unplanned/unwanted pregnancy (.14 to .17)

These factors are known to correlate with PPD. That means that, for example, high levels of prenatal depression are associated with high levels of postpartum depression, and low levels of prenatal depression are associated with low levels of postpartum depression. But this does not mean the prenatal depression causes postpartum depression -- they might both be caused by some third factor. In contrast, some factors, such as lack of social support, almost certainly cause postpartum depression. (The causal role of lack of social support in PPD is strongly suggested by several studies, including O'Hara 1985, Field et al. 1985; and Gotlib et al. 1991.)

Although profound hormonal changes after childbirth are often claimed to cause PPD, there is little evidence that variation in pregnancy hormone levels is correlated with variation in PPD levels: Studies that have examined pregnancy hormone levels and PPD have usually failed to find a relationship (see Harris 1994; O'Hara 1995). Further, fathers, who are not undergoing profound hormonal changes, suffer PPD at relatively high rates (e.g., Goodman 2004).

Finally, all mothers experience these hormonal changes, yet only about 10-15% suffer PPD. This does not mean, however, that hormones do not play a role in PPD. Block et. al. (2000), for example, found that, in women with a history of PPD , a hormone treatment simulating pregnancy and parturition caused these women to suffer mood symptoms. The same treatment, however, did not cause mood symptoms in women with no history of PPD. One interpretation of these results is that there is a subgroup of women who are vulnerable to hormone changes during pregnancy. Another interpretation is that simulating a pregnancy will trigger PPD in women who are vulnerable to PPD for any of the reasons indicated by Beck's meta-analysis (summarized above).
Profound lifestyle changes brought about by caring for the infant are also frequently claimed to cause PPD, but, again, there is little evidence for this hypothesis. Mothers who have had several previous children without suffering PPD can nonetheless suffer it with their latest child (Nielsen Forman et al. 2000). Plus, most women experience profound lifestyle changes with their first pregnancy, yet most do not suffer PPD.

In severe cases, postpartum psychosis (also known as puerperal psychosis) can develop, characterized by hallucinations and delusions. This happens in about 0.1 - 0.2% of all women after having given birth. In some cases, postpartum psychosis can develop independent of postpartum depression. Sometimes a pre-existing mental illness can be brought to the forefront through a postpartum depression.
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Evolutionary psychological hypothesis
Evolutionary approaches to parental care (e.g., Trivers 1972) suggest that parents (human and non-human) will not automatically invest in all offspring, and will reduce or eliminate investment in their offspring when the costs outweigh the benefits. Reduced care, abandonment, and killing of offspring have been documented in a wide range of species. In many bird species, for example, both pre- and post-hatching abandonment of broods is common (Ackerman et al. 2003; Cezilly 1993; Gendron and Clark 2000).

Human infants require an extraordinary degree of parental care. Lack of support from fathers and/or other family member will increase the costs borne by mothers, whereas infant health problems will reduce the evolutionary benefits to be gained (Hagen 1999). If ancestral mothers did not receive enough support from fathers or other family members, they may not have been able to "afford" raising the new infant without harming any existing children, or damaging their own health (nursing depletes mothers' nutritional stores, placing the health of poorly nourished women in jeopardy).
For mothers suffering inadequate social support or other costly and stressful circumstances, negative emotions directed towards a new infant could serve an important evolved function by causing the mother to reduce her investment in the infant, thereby reducing her costs. Numerous studies support the correlation between postpartum depression and lack of social support or other childcare stressors (Beck 2001; Hagen 1999).
Mothers with postpartum depression can unconsciously exhibit fewer positive emotions and more negative emotions toward their children, are less responsive and less sensitive to infant cues, less emotionally available, have a less successful maternal role attainment, and have infants that are less securely attached; and in more extreme cases, some women may have thoughts of harming their children (Beck 1995, 1996b; Cohn et al. 1990, 1991; Field et al. 1985; Fowles 1996; Hoffman and Drotar 1991; Jennings et al. 1999; Murray 1991; Murray and Cooper 1996). In other words, most mothers with PPD are suffering some kind of cost, like inadequate social support, and consequently are mothering less.

On this view, mothers with PPD do not have a mental illness, but instead need more social support, more resources, etc; with treatment focusing on helping mothers get what they need. (See Hagen 1999 and Hagen and Barrett, n.d.).
Effects on the parent-infant relationship
Post-partum depression may lead mothers to be inconsistent with childcare. They may not respond quickly or positively or at all to the infant's cues. This can affect development of a secure attachment. If a mother (or other caregiver) does not respond consistently in a warm, caring way -- holding, rocking, cooing, stroking, or talking softly -- the baby may have trouble feeling safe, secure and trusting. An insecure infant may have trouble interacting with the caregiver -- rejecting them or becoming upset when with them. The infant may be withdrawn, passive or have trouble reaching milestones on target.

Older children may also develop attachment issues. They may be less independent and less likely to interact with other people. They may have discipline, behaviour and aggression issues. Some children with these issues have a higher risk of mental health issues, such as anxiety and depression.

Maternal depression reduces consistent and readable communication between mother and child, and as a result poor language development may occur, with vocabulary deficits still present at early school age.

Treatments
Treatments for PPD are largely the same as for clinical depression in general. If the cause of PPD can be identified, treatment should be aimed at the root cause of the problem.
Post-partum psychosis (Not to be confused with PPD)
Post-partum psychosis or PPP, (also called Post-natal Psychosis or PNP and puerperal psychosis (PP) in the UK) is a mental illness, which involves a complete break with reality. Although correctly termed as a postnatal stress disorder or postpartum depressive reaction, Post-partum psychosis is different from Post-partum depression. The majority of PPP occurs within the first two weeks after childbirth with a classic 10-14 day meltdown, likely caused by the radical hormonal changes combined with neurotransmitter over activity. When correctly diagnosed at the earliest signs and immediately treated with anti-psychotic medication, the illness is recoverable within a few weeks. If undiagnosed, even for just a few days, it can take the woman months to recover. In cases of PPP, the sufferer is often unaware that she is unwell. [1]

Psychosis can also take place in combination with an underlying psychiatric disorder, such as bipolar affective disorder, schizophrenia, or undiagnosed depression. In some women, a part-partum psychosis is the only psychotic episode they will ever experience, but, for others, it is just the first indication of a psychiatric disorder. Only 1 to 2 women per 1,000 births develop post-partum psychosis. [1] It is a rare condition, and often treatable. However, much media coverage of post-partum depression has focused on psychosis, especially following the Andrea Yates case. Whilst postpartum/puerperal psychosis is a serious psychiatric illness, the risks of a mother suffering this illness harming her baby are low: infanticide rates are estimated at 4%, and suicide rates in postpartum/puerperal psychosis are estimated at 5%.
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Andrea Yates case
Main article: Andrea Yates
After the National Organization for Women (NOW) insisted that Andrea Yates had postpartum depression, the Individualist Feminists of Ifeminist.com pointed out that postpartum depression is quite common and that most sufferers do not murder their children. In fact, Yates suffered from postpartum psychosis. After Ifeminist.com pointed out that this stigmatized a large number of mothers and made them less likely to seek professional help, NOW removed their claims from their official website. Some believe that Yates' fundamentalist church bears some responsibility for the murder, as the church allegedly urged her to ignore her psychiatrist's orders. Yates methodically drowned her children in a bathtub in her Clear Lake City, Houston, Texas house on June 20, 2001.

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Books and other resources:
Morning Star?by Danna Hobart is an honest account of one woman's experience with postpartum depression/psychosis.
References
Ackerman, J. T., Eadie, J. M., Yarris, G. S., Loughman, D. L., & Mclandress R. M. (2003) Cues for investment: nest desertion in response to partial clutch depredation in dabbling ducks. Animal Behavior, 66, 871-883.
Beck, C.T. The effects of postpartum depression on maternal-infant interaction: a meta-analysis. Nursing Research 44:298-304, 1995.
Beck, C.T. A meta-analysis of predictions of postpartum depression. Nursing Research 45:297-303, 1996a.
Beck, C.T. A meta-analysis of the relationship between postpartum depression and infant temperament. Nursing research 45:225-230, 1996b.
Bect, C.T. (2001) Predictors of Postpartum Depression: An Update. Nursing Research, 50, 275-285.
Canadian Pediatric Society. "Depression in Pregnant Women and Mothers: How Children are affected." October 2004. Accessed 22 November 2005 at http://www.caringforkids.cps.ca/babies/Depression.htm.

Cezilly, F. (1993) Nest desertion in the greater flamingo, Phoenicopterus ruber roseus. Animal Behavior, 45, 1038-1040.
Cohn, J.F., Campbell, S.B., Matias, R., and Hopkins, J. Face-to-face interactions of postpartum depressed and non-depressed mother-infant pairs at 2 months. Developmental Psychology 26:15-23, 1990.
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Goodman J.H. (2004) Paternal postpartum depression, its relationship to maternal postpartum depression, and implications for family health. Journal of Advanced Nursing, 45, 26-35.
Harris, B. Biological and hormonal aspects of postpartum depressed mood: working towards strategies for prophylaxis and treatment. Special Issue: Depression. British Journal of Psychiatry 164:288-292, 1994.
Hoffman, Y., and Drotar, D. The impact of postpartum depressed mood on mother-infant interaction: like mother like baby? Infant Mental Health Journal 12:65-80, 1991.
Jennings, K.D., Ross, S., Popper, S., and Elmore, M. Thoughts of harming infants in depressed and nondepressed mothers. Journal of Affective Disorders, 1999.
Murray, L. Intersubjectivity, object relations theory, and empirical evidence from mother-infant interactions. Special Issue: The effects of relationships on relationships. Infant Mental Health Journal 12:219-232, 1991.
Murray, L., and Cooper, P.J. The impact of postpartum depression on child development. International Review of Psychiatry 8:55-63, 1996.
Nielsen Forman D, Videbech P, Hedegaard M, Dalby Salvig J, Secher NJ (2000) Postpartum depression: identification of women at risk. British Journal of Obstetrics and Gynaecology, 107, 1210-7.
O'Hara, M.W. Depression and marital adjustment during pregnancy and after delivery. American Journal of Family Therapy 13:49-55, 1985.
O'Hara, M.W. Postpartum Depression: Causes and Consequences. New York: Springer-Verlag, 1995.
O'Hara, M.W., and Swain A.M. Rates and risk of postpartum depression - A meta-analysis. International Review of Psychiatry 8:37-54, 1996.
Trivers, R. L. (1972) Parental investment and sexual selection. In B. Campbell (Ed.), Sexual Selection and the Descent of Man (pp. 136-179). London: Heinemann.??

Fray, Kathy: "Oh Baby...Birth, Babies & Motherhood Uncensored", pages 364-381, Random House NZ, 2005


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