Post-Partum Depression. Is it Mother’s fault?

Introduction. Postpartum depression

The baby is born and everyone is happy, and the mother is expected to be the happiest of all. But often the opposite is true.

After giving birth the mother is often sad, exhausted, overwhelmed not understanding what’s happened to her. She may feel guilty by not being able to show the love, maybe even see yourself as a “bad” mother.

Such condition is frequent after the delivery and described as a post-partum depression.

Developing post-partum depression

Postpartum depression, also known as postnatal depression, is the most common mental disorder after childbirth. It involves prolonged depressive episodes within the first two years after the birth of the child, characterized by sadness, apathy, and feelings of guilt. The immediate environment often shows little understanding. A mother who can’t develop feelings for her child is considered taboo.

Many affected individuals suffer in silence out of shame. They neglect themselves and the infant or provide only mechanical care. This will inevitably lead to attachment disorders and behavioral problems in the child. Furthermore, untreated suffering intensifies and worsens for the affected individual. In the worst case, it can lead to suicide or extended suicide, where the mother sees no way out and kills herself or herself and the child.

The birth of a baby triggers hormonal changes which are associated with powerful emotions. The emotions are mostly positive in nature. However, in some cases, the emotions can turn in a short-lasting sadness, called “baby blues” or into a serious psychiatric condition known as postpartum depression. Psychiatrists prefer to use the term “perinatal depression”. A perinatal depression relates to depressive episodes appearing during the pregnancy or within one year after the delivery.

Important indications of postpartum depression, are symptoms of depression developing gradually and closely related to childbirth. Depending on the severity of the symptoms, three forms are generally distinguished: “Baby blues”, postpartum depression and the most severe condition, which is postpartum psychosis

Erly signs of postpartum depression

“Baby blues” is a transitory condition associated with mood swings, sadness and fatigue. However, if the symptoms persist for more than two weeks, become entrenched and intensify, it may indicate the onset of postpartum depression. It typically develops gradually, with initial signs appearing around 4 to 6 weeks after birth but can occur even later, up to one years after childbirth. Approximately 10 to 15 percent of all new mothers develop postpartum depression. Postpartum depression often goes unrecognized, sometimes until much later or even not at all. Unlike postpartum blues, postpartum depression does not resolve on its own. It can have significant effects on the health of both mother and child, necessitating professional medical treatment.

“Baby blues”

A few days after birth, around the time of lactation, the majority of all mothers experience postpartum mood changes called “baby blues”. The condition appears as mild emotional fluctuations, accompanied by sadness, feelings of inadequacy, frequent crying, sleep problems, and exhaustion.

These very common “crying days,” as they are also called, are usually short-lived. They are caused by a strong drop in estrogen and progesterone hormones immediately after birth. Estrogen, in particular, has a mood-enhancing and stabilizing effect in the brain. Added to this are the many changes in daily life and the couple’s relationship that a baby brings, as well as sleep deprivation.

The symptoms usually subside after few days along with the stabilizing hormon levels and growing daily routine while dealing with the baby. Treatment of “baby blues” is typically not required. Particularly helpful during this sensitive phase are understanding and support from the partner and other close caregivers.

Postpartum depression. Diagnosis

Less frequently the symptoms are more severe and long lasting showing all signs of depression called postpartum depression (PPD), or postnatal depression. Approximately 15% of all women after the birth of a child are affected by postpartum depression. Postpartum depression usually begins between two weeks to a month after delivery. In about half of the cases the symptoms of depression already start during the pregnancy.

Many women report experiencing profound lack of energy, loss of interest, emotional emptiness, and frequent crying. Other commonly mentioned symptoms include difficulties with concentration, appetite and sleep disturbances, as well as headaches, dizziness, heart palpitations, and other psychosomatic complaints. Additionally, there may be feelings of anxiety, irritability, panic attacks, and intrusive thoughts such as compulsive destructive images or thoughts about harming the child.

Diagnostic manuals, such as DSM 5 or ICD 10 describe the postpartum depression as depression with “peripartum onset”. It’s called perinatal depression which means that the onset of the symptoms happens either during pregnancy or in the time following the delivery.

Diagnostic criteria of post-partum depression

The symptoms required by DSM 5 for the diagnosis of postpartum depression are the same as those required for the diagnosis of non-childbirth related Major Depressive Disorder (MDD). The diagnosis of postpartum depression DSM 5 requires at least five of the following 9 symptoms:

• Feelings of sadness, emptiness, or hopelessness, nearly every day, for most of the day or the observation of a depressed mood made by others
• Loss of interest or pleasure in activities
• Weight loss or decreased appetite
• Changes in sleep patterns
• Feelings of restlessness
• Loss of energy
• Feelings of worthlessness or guilt
• Loss of concentration or increased indecisiveness
• Recurrent thoughts of death, with or without plans of suicide

Causes of postpartum depression

The exact causes of postpartum depression are still not fully understood. However, it is clear that there is not a single cause responsible for the condition, but rather a combination of different factors. These factors include:

Hormonal changes

One important factor in the development of postpartum depression is the significant hormonal changes that occur after childbirth. The concentration of female sex hormones progesterone and estrogen, in particular, drops sharply. Since estrogen plays a stabilizing and mood-enhancing role in the brain, the sudden hormone drop often manifests as a mood slump. Most women are familiar with such mood swings, albeit in a milder form, from hormonal changes within the menstrual cycle. Women who are particularly sensitive to hormonal changes, such as those suffering from premenstrual dysphoric disorder or experiencing mood swings in response to hormonal contraceptives, have an increased risk of developing postpartum depression.

Sleep deprivation

Childbirth and the subsequent care of a baby are extremely demanding. Many women experience severe sleep deprivation, which can lead to physical and mental exhaustion, as well as metabolic imbalances. Added to this are frequent uncertainties and overwhelm due to the new situation, the changing role, the impact on the partnership, and the constant concern of doing everything right.

Pre-existing conditions as risk factors

Personal or family history of depression, psychoses, and anxiety disorders during pregnancy are also significant risk factors. According to a study from 20061), women with untreated depression during pregnancy have a 7-fold increased risk of developing postpartum depression after giving birth.

Social risk factors

Poor marital relationship or single marital status, lack of support from the partner and social environment. Unplanned/unwanted pregnancy. Loss of mother’s autonomy (feeling of loss of freedom and control over life). Low socioeconomic status. Domestic violence, previous separation or divorce, unintended pregnancy, multiple births, as well as the child’s health problems or excessive crying, are also considered risk factors for the development of postpartum depression.

Trauma as a risk factor

A traumatic birth experience, traumatic events and neglect during one’s own childhood, the death of a loved one during pregnancy, as well as other stressors and critical life events can contribute to the development of postnatal depression.

What is postpartum psychosis?

Postpartum psychosis is the most severe form of postpartum depression. It occurs very rarely, affecting approximately 0.1 to 0.3 percent – that is, one to three out of a thousand mothers. It involves a severe depression in which, in addition to symptoms of postpartum depression, features of psychosis also emerge.

The initial signs of postpartum psychosis typically manifest within the first six weeks after childbirth. Alongside the typical characteristics of postpartum depression, such as profound sadness, apathy, lack of motivation, anxiety, and so on, there are also symptoms of psychosis such as delusions and hallucinations, often disorganized thinking. Other symptoms are low mood, low self-esteem, sleeplessness, social withdrawal, anxiety, and irritability. The mother feels inadequate taking care of and bonding with the baby.

Sometimes mothers with post-partum psychosis can develop overprotective behaviour and irrational thoughts that something bad can happen to the baby. In other cases, the mothers can develop thoughts of death or suicide related to herself and even to the baby.

Delusional thinking causes changes in personality and is often associated with suicidal thoughts. These can pose an acute danger to both mother and child. Therefore, postpartum psychosis is always a medical emergency that should be treated in a hospital setting. that can pose an acute danger to both mother and child. Therefore, postpartum psychosis is always a medical emergency that should be treated in a hospital setting.

Postpartum Depression: Consequences for mother and child

A mother who cannot find joy in her child is still considered taboo within society. Therefore, affected mothers often hesitate to speak about their problems. As a result, the clinical picture of postpartum depression is often recognized and treated late. This leads to a sustained high level of suffering for the mother, which can potentially lead to suicide or extended suicide in the worst case.

Depressed mothers engage in less verbal and visual communication with their infants. The child may experience sleep and growth disorders, feeding confusion, behavioral abnormalities, and attachment issues. In the long term, emotional and cognitive development disorders can also occur, which can have lasting effects into adulthood.

Among 16-year-olds, the risk of developing an affective disorder is four times higher if the mother has experienced postpartum depression. Prompt treatment of the mother can protect the child from long-term consequences.

Common comorbidities of postpartum depression

In addition to postpartum depression, other psychological comorbidities can occur, including:

•  Anxiety disorders with exaggerated fears about the well-being of the baby, as well as intense fears and self-doubt about being able to care for the child properly. Additionally, panic attacks can also occur.

•   Obsessive-compulsive disorder associated with postpartum depression, can appear as obsessive cleaning, disinfection rituals to develop, and distressing intrusive thoughts about harming oneself or the child.

Mothers

Untreated postpartum depression usually lasts for a few months. However sometimes PPD evolves into a chronic depressive disorder, which can last for years. Children of mothers who have untreated postpartum depression are more likely to have childhood or adulthood emotional and behavioral problems. In their adult lives, they are more prone to suffer from socio-behavioral problems, such as an inability to create stable relationships and develop successful, professional careers.

PPD in fathers

Research on postpartum depression has focused primarily on mothers. Only recently has been observed that fathers can also be affected. There is a positive correlation between maternal PPD and postnatal depression in fathers. The most likely reason is the marital satisfaction. The prevalence of father’s PPD is lower than in women.

Joh Bolby and the Attachment Theory

John Bowlby a British psychologist, psychiatrist, and psychoanalyst, known for his interest in child development wrote a report for the World Health Organization on the mental health of homeless children in post-war Europe. The result was a text on Maternal Care and Mental Health published in 1951.

Bowlby’s main conclusion was that infants and young children should experience a warm, close, and continuous relationship with their mothers. Emotional of physical absence of the mother will end in serious and irreversible effects on child’s mental health.

According to his attachment theory, attachment in infants is primarily a process of proximity seeking to an identified attachment figure. Caring and loving parents facilitates healthy, unhindered emotional growth of children. Strong ties with the caretaker shape attachment patterns and guide individuals’ positive emotions, thoughts, and expectations in subsequent relationships.

Preventing postpartum depression

Postpartum depression often goes unrecognized and untreated in many women due to the lack of comprehensive screening after the birth. Low energy and the feeling of shame or guilt, are too overwhelming for the mothers to seek help actively. This can have long-term consequences. If left untreated, the symptoms of post-partum depression tend to increase with elevated risk for suicide. Apart of that affected mothers have difficulties to bond with the child. Lack of emotional connection leads to behavioral problems. Therefore, early screening and prompt treatment are absolutely necessary.

Mothers have to be closely monitored during pregnancy and after childbirth by gynecologist (in case of pre-existent depression by psychiatrist) for signs and symptoms of depression.

Gynecologists and obstetricians should ideally inquire about a woman’s mental well-being during postpartum check-ups or at least provide a self-screening questionnaire (EPDS). If necessary or suspected, they should refer the patient to a psychiatrist.

In mothers with history of postpartum depression, the psychiatrist should monitor them closely after the following deliveries.

The Edinburgh Postnatal Depression Scale (EPDS scale), has proven particularly effective in identifying postpartum depression. The patient completes the questionnaire, and the sum of the points provides an indication of postpartum depression.

Alternatively, a risk can be detected with two questions:

-Have you frequently felt down, sad, depressed, or hopeless in the past month?

-Have you had noticeably less interest and pleasure in doing things you usually enjoy in the past month?

Treatment

The clinical picture of postpartum depression is highly complex, encompassing not only the root-causes but also the symptoms and co-existing illnesses. The challenge in treatment of post-partum depression is not only symptoms suppression but also the restoration of the relationship between the mother and her child. Conventional medicine recommends the use of psychotherapy, assistance and relief in daily life, and the administration of psychopharmaceuticals.

Psychotherapy

Cognitive Behavioral Therapy (CBT) and Interpersonal Psychotherapy (IPT) are commonly used in treating postpartum depression. However, there are also other therapeutic technics which proved to be effective.

Cognitive Behavioral Therapy focuses on thoughts’ impacting the feelings empowering the mother to control and change them. It involves identifying reciprocal thoughts circles, exploring underlying beliefs, and developing coping strategies.

Interpersonal Psychotherapy, aims for symptom relief through direct and active therapist involvement. IPT addresses four problem areas: grief, role transitions, interpersonal disputes, and individual’s deficits. Communication skills are taught to build relationships, social support, and confidence.

Dialectic Behavioural Therapy (DBT), teaches mindfulness, emotional regulation, and interpersonal effectiveness skills to reduce distressing symptoms.

Psychodynamic psychotherapy explores unconscious conflicts influencing the current behavior. The insight of the conflict dynamics helps mothers to identify the vicious circle reducing the stress and promoting healing.

Eye Movement Desensitization and Reprocessing (EMDR) is effective for postpartum PTSD, using bilateral stimulation to reprocess traumatic memories.

Solution-Focused Brief Psychotherapy focuses on positive change by setting goals and emphasizing strengths and skills. It avoids delving into past problems and offers a short-term solution-based approach.

Group therapy utilizes community support and dynamics to identify and address problem areas and interpersonal distress. Postpartum depression support groups combine psycho-education with validation, creating a space for mothers to be heard and share coping strategies.

Couples therapy allows partners to address negative patterns, enhance communication, and navigate challenges during the postpartum period. This therapy offer valuable support for individuals and couples facing postpartum difficulties.

Medication

Anti-depressants, such as the selective serotonin reuptake inhibitors (SSRIs), are safe and effective in treatment of peripartum depression. The are several antidepressants, for example Fluoxetine or Sertraline, used for decades to treat the depression during the pregnancy and after the delivery. Studies didn’t show any side effects to the babies by using this medication. In the opposite, the untreated depression during the pregnancy would often end in complications including a miscarriage. While treating the mother with antidepressants during the pregnancy, the plasma level of the antidepressant in her and babies’ body are nearly identical. By breast feeding a significantly lower level of the antidepressant can pass into the baby. So, the problems of breast feeding and use of antidepressants after delivery are extensively exaggerated.