Postpartum depression: The worst kept secret

Having a baby is one of the happiest times in life, but it can also be one of the saddest.

For most new mothers, the first several days after having a baby is an emotional roller coaster ride. Thrilling moments of happiness and joy are abruptly interrupted by a plunge into moments of depressive symptoms including weeping, anxiety, anger, and sadness. These "baby blues" usually peak in the first two to five days after delivery, and in most women, go away as quickly as they came.

Except sometimes they don't go away.

For some women, depressive symptoms continue well past those first two weeks or develop over the next several months after having a baby.

A recent article by Drs. Stewart and Vigod published in the New England Journal of Medicine explores postpartum depression, this potentially debilitating condition that affects between 6.5% and 12.9% of new mothers.

What causes postpartum depression?

We don't fully understand what causes postpartum depression. It is thought that the abrupt decrease in hormone levels after having a baby can lead to the development of postpartum depression in susceptible women.

We also can't say for sure what makes a woman particularly vulnerable to postpartum depression. We do know that the strongest predictor of postpartum depression is a personal history of a mood disorder or anxiety, especially if present and untreated during pregnancy. In fact, women with a history of depression during pregnancy are seven times more likely to experience significant postpartum depression. Other factors that may contribute to postpartum depression include social stressors including poor family support and financial concern.

Exactly how postpartum depression unfolds is somewhat unpredictable. For most women, the symptoms go away without treatment, but about 20% of women will still have significant depressive symptoms after one year.

Catching postpartum depression quickly

Because postpartum depression affects the health of the woman, her infant, and her entire family, it is very important to screen for postpartum depression risk. Most obstetricians are now implementing some type of screening tool during the postpartum checkup. Screening is very important because studies have shown that many women with postpartum depression are ashamed  of their symptoms and are afraid of the social stigma associated with the diagnosis.

Although symptoms of postpartum depression can vary, the typical symptoms include:

• sleep disturbances
• anxiety
• irritability
• feeling overwhelmed
• preoccupation with baby's health or feeding

Making the diagnosis of postpartum depression is based on more than just the presence of these symptoms. Some of these can be normal, especially after a difficult sleepless night caring for a newborn. It is the intensity of the symptoms and how they affect a woman's ability to adjust and cope with life stressors that are key to making the diagnosis of postpartum depression.

Treating postpartum depression

Drs. Steward and Vigod's article discussed the importance of early treatment and support for women at risk of postpartum depression including those with mild symptoms that don't meet the specific criteria for a formal diagnosis of postpartum depression. Studies have shown that supportive and psychological care right after birth can decrease an at-risk woman's chance of developing postpartum depression. Interventions that decrease feelings of isolation, and provide emotional support are key; they include:

• home visits
• telephone based peer support
• interpersonal therapy

When a formal diagnosis of postpartum depression is made, it is very important to make sure a new mother gets the care she needs. The appropriate treatment is based on the severity of a woman's symptoms and how she responds to the intervention. For postpartum women with mild symptoms the approach is very similar to the prevention strategies for at risk women. These include:

• psychological interventions that address support for the new mother
• support groups
• home visits from a nurse

For women with moderate symptoms or for women with mild symptoms that did not respond to initial intervention, treatment consists of formal psychotherapy alone or in combination with an antidepressant medication. Antidepressants may also be used alone if the woman prefers or if getting to therapy is difficult.

A common concern is whether antidepressant medications are safe while breastfeeding. Selective serotonin reuptake inhibitors (SSRIs) are the first choice to treat postpartum depression and minimal amounts of the drug are found in breast milk.

Although there are no long-term data regarding the effects of antidepressants on breastfed babies, experts generally agree that women do not need to stop breastfeeding. However, an important point noted by authors of the article is that "clinicians should support women in their choice not to breast feed when difficulties in the breast feeding process, or lack of sleep, are perpetuating depressive symptoms."

The key to the prevention and successful treatment of postpartum depression is early intervention. Women may not realize they are depressed after having a baby, or may realize they are struggling but feel too embarrassed to seek help. This is why it is very important to screen all new mothers. Encouraging women not to keep postpartum depressive symptoms a secret should be a major priority in the care of all new mothers.