Postpartum Depression

  • Medical Author:
    Roxanne Dryden-Edwards, MD

    Dr. Roxanne Dryden-Edwards is an adult, child, and adolescent psychiatrist. She is a former Chair of the Committee on Developmental Disabilities for the American Psychiatric Association, Assistant Professor of Psychiatry at Johns Hopkins Hospital in Baltimore, Maryland, and Medical Director of the National Center for Children and Families in Bethesda, Maryland.

  • Medical Editor: William C. Shiel Jr., MD, FACP, FACR
    William C. Shiel Jr., MD, FACP, FACR

    William C. Shiel Jr., MD, FACP, FACR

    Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

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Postpartum depression facts

  • Postpartum depression (PPD) is a common problem associated with childbirth.
  • Peripartum depression is depression that a woman experiences during pregnancy or within four weeks of giving birth.
  • Postpartum depression is medically considered a subset of peripartum depression.
  • PPD can affect as many as 10% of fathers as well.
  • Biological, psychological, and social factors play roles in predisposing women to develop postpartum depression.
  • There is no one test that definitively indicates that someone has PPD.
  • Treatment options for PPD include illness education, support groups, psychotherapy, and/or medication. Particular care is taken when considering medication given the potential risks of exposing a baby to the medications through breastfeeding.
  • New moms who have suffered from peripartum depression are much more likely to have depression again sometime in the future. Children of a mother or father with PPD are at risk for emotional challenges.
  • Intensive nursing intervention can help prevent the development of peripartum depression.

What are postpartum depression and peripartum depression? Are there different types of peripartum depression?

Postpartum depression, now included in the describer of depression with peripartum onset (during pregnancy or within a month after giving birth), may be the most common problem associated with childbirth. It has been described as afflicting prominent historical figures like author/suffragist Charlotte Perkins Gilman in the 19th century. This illness is characterized by depression that a woman experiences either during pregnancy or within four weeks of giving birth, affecting about 3%-6% of women who give birth, up to 20% when only women with postpartum depression, rather than including those who are depressed during the pregnancy are counted. Peripartum depression occurs after one out of every eight deliveries in the United States, affecting about half a million women every year. Peripartum depression is also called major depression with peripartum onset. Delusional thinking after childbirth, called postpartum psychosis, affects about one in every 500 to 1,000 women.

Notably, postpartum depression is not an illness that is exclusive to mothers. Fathers can experience it, as well. As with women, symptoms in men can result in fathers having difficulty caring for themselves and for their children when suffering from postpartum depression.

Unfortunately, up to 50% of individuals with postpartum depression or postpartum psychosis are never detected. That can result in devastating outcomes for the patient and family. For example, postpartum psychosis is thought to have been a potential factor in Andrea Yates drowning her five children in 2001 and was explored as a factor in Susan Smith drowning her two sons in 1994.

Quick GuidePostpartum Depression: Symptoms, Causes, and More in Pictures

Postpartum Depression: Symptoms, Causes, and More in Pictures

Postpartum Depression Symptoms

Postpartum depression is more than just the "blues" after giving birth. The symptoms include

  • feelings of hopelessness or worthlessness,
  • depression,
  • anxiety,
  • problems bonding with the baby,
  • sadness,
  • possible feelings of wanting to hurt oneself or the baby.

In the case of suicidal thoughts or thoughts of harming the baby, postpartum depression is a medical emergency, and medical care should be accessed immediately.

What are causes and risk factors for postpartum depression?

Similar to many other mental health conditions, there is thought to be a genetic vulnerability to developing postpartum depression.

Rapid changes in the levels of reproductive hormones that occur during pregnancy and after delivery are thought to be biological factors in the development of this condition. People with any history of depression or anxiety prior to the pregnancy are at risk for developing depression during the pregnancy or soon after delivery. Interestingly, men are also known to experience changes in a number of hormones during the peripartum period that can contribute to the development of PPD. Also, the stress of any medical complications as a result of the pregnancy or delivery, as well as the stress that is inherent in caring for a newborn are considerable factors.

Further risk factors for developing postpartum depression include low self-esteem, low socioeconomic status, a lack of having social support before and after the birth of the baby, and marital problems, including any history of intimate partner violence.

What are postpartum depression symptoms and signs?

Symptoms of postpartum depression begin either during pregnancy or within four weeks after having a baby and include the following:

  • Feelings of profound sadness, emptiness, emotional numbness, irritability, or anger.
  • Feelings of irritability or anger
  • A tendency to withdraw from relationships with family, friends, or from activities that are usually pleasurable for the PPD sufferer
  • Constant fatigue or tiredness, difficulty sleeping, overeating, or loss of appetite
  • A strong sense of failure or inadequacy
  • Intense concern and anxiety about the baby or a lack of interest in the baby
  • Thoughts about suicide or fears of harming the baby

Postpartum psychosis occurs much more rarely and is thought to be a severe form of postpartum depression. Symptoms of that disorder include the following:

  • Delusions (false beliefs)
  • Hallucinations (for example, hearing voices or seeing things that are not real)
  • Thoughts of harming the baby
  • Severe depressive symptoms

How do doctors diagnose postpartum depression?

There is no one test that definitively indicates that someone has PPD. Therefore, health care providers diagnose this disorder by gathering comprehensive medical, family, and mental health history. Patients tend to benefit when the health care provider takes into account their client's entire life and background. This includes, but is not limited to, the person's gender, sexual orientation, cultural, religious, ethnic background, and socioeconomic status. The health care professional will also either perform a physical examination or request that the individual's primary care doctor perform one. The medical examination will usually include lab tests to evaluate the person's general health and as part of screening the individual for medical conditions that might contribute to mental health symptoms.

Postpartum depression must be distinguished from what is commonly called the "baby blues," which tend to occur in most new mothers. In the brief mood problem of baby blues, symptoms like crying, sadness, irritability, anxiety, and confusion can occur. In contrast to the symptoms of PPD, the symptoms of the baby blues tend to peak around the fourth day after delivery, resolve by the 10th day and do not tend to affect the individual's ability to function.

Postpartum psychosis is a psychiatric emergency that requires immediate intervention because of the danger that the sufferer might kill their baby or themselves. Postpartum psychosis usually begins within the first two weeks after delivery. Symptoms of this disorder tend to involve extremely disorganized thinking, bizarre behavior, unusual hallucinations, and delusions. Postpartum psychosis is often a symptom of bipolar disorder, also called manic depression.

Quick GuidePostpartum Depression: Symptoms, Causes, and More in Pictures

Postpartum Depression: Symptoms, Causes, and More in Pictures

What are the treatments for postpartum depression?

Educational programs and support groups

Treatment of postpartum depression in men and women is similar. Both mothers and fathers with this condition have been found to greatly benefit from being educated about the illness, as well as from the support of other parents who have been in this position.

Psychotherapies

Psychotherapy ("talk therapy") involves working with a trained therapist to determine methods to solve problems and cope with all forms of depression, including postpartum depression. It can be a powerful intervention and may produce, positive biochemical changes in the brain. This is a particularly important alternative to treatment with medication in women who are breastfeeding. In general, these therapies take weeks to months to complete. More intense counseling may be needed for longer when treating very severe depression or other psychiatric symptoms.

Interpersonal therapy (IPT): This helps to alleviate depressive symptoms and helps the person with PPD develop more effective skills for coping with social and interpersonal relationships. IPT employs two strategies to achieve these goals.

  • The first is education about the nature of depression. The therapist will emphasize that depression is a common illness and that most people can expect to get better with treatment.
  • The second is defining specific problems (such as child care pressures or interpersonal conflicts). After the problems are defined, the therapist is able to help set realistic goals for solving these problems. Together, the individual with PPD and his or her therapist will use various treatment techniques to reach these goals.

Cognitive behavioral therapy (CBT): This helps to alleviate depression and reduce the likelihood it will return by helping the PPD sufferer change his or her way of thinking. In CBT, the therapist uses three techniques to accomplish these goals.

  • Didactic component: This phase helps to set up positive expectations for therapy and promote cooperation.
  • Cognitive component: This helps to identify the thoughts and assumptions that influence behaviors, particularly those that may predispose the person with PPD to being depressed.
  • Behavioral component: This employs behavior-modification techniques to teach the individual with PPD more effective strategies for dealing with problems.

Medications

Medication therapy for postpartum depression usually involves the use of an antidepressant medication. The major types of antidepressant medication are the selective serotonin reuptake inhibitors (SSRIs), serotonin/norepinephrine/dopamine reuptake inhibitors (NSRIs), the tricyclic antidepressants (TCAs), and the monoamine oxidase inhibitors (MAOIs). SSRI medications affect levels of serotonin in the brain. For many prescribing doctors, these medications are the first choice because of the high level of effectiveness and general safety of this group. Examples of antidepressants are listed here. The generic name is first, with the brand name in parentheses.

SNRIs and NDRs:

TCAs are sometimes prescribed in severe cases of depression or when SSRIs or SNRIs are ineffective. These medications affect a number of brain chemicals (neurotransmitters), especially epinephrine and norepinephrine (also called adrenaline and noradrenaline, respectively). Examples include

About two-thirds of people who take antidepressant medications improve. It may take anywhere from one to six weeks of taking medication at its effective dose to notice mood improvement. It is, therefore, important not to stop taking the medication because benefits may not be seen immediately. The MAOIs are not often used since the introduction of the SSRIs. Because of the possibility of interactions, the MAOIs may not be taken with many other types of medication, and some types of foods that are high in tyramine (like aged cheeses, wines, and cured meats) must be avoided as well. Examples of MAOIs include phenelzine (Nardil) and tranylcypromine (Parnate). Atypical neuroleptic medications are often prescribed in addition to a mood-stabilizer medication in people with postpartum psychosis. Examples of atypical neuroleptics include

Non-neuroleptic mood-stabilizer medications are also sometimes used with a neuroleptic medication to treat people with postpartum psychosis because bipolar disorder may also be present in some patients. Examples of non-neuroleptic mood stabilizers include

What is the prognosis of postpartum depression?

Women who have suffered from postpartum depression are much more likely to have depression again sometime in the future. They are also at risk for being the victim of emotional, physical, or sexual abuse, as well as for developing tobacco or other substance abuse. Children of mothers with PPD are at risk for medical emotional challenges as a result of problematic relationships with their mother and of receiving compromised care from their mother.

Is it possible to prevent postpartum depression?

Intensive nursing intervention in the form of visits to new mothers by a nurse can help prevent the development of postpartum depression.

Where can people get more information about postpartum depression?

Jennifer Mudd Houghtaling Postpartum Depression Foundation

200 E. Delaware Apt. 3D
Chicago, IL 60611
Phone: 312-867-7239
Email: info@ppdchicago.org

Kids Health -- Postpartum Depression and Caring for Your Baby
http://kidshealth.org/parent/emotions/feelings/ppd.html

Postpartum Education for Parents
http://www.sbpep.org

Postpartum Progress
http://postpartumprogress.com

Womenshealth.gov helpline (English and Spanish)
Phone: 800-994-9662
TDD: 888-220-5446
Hours: Monday through Friday, 9 a.m. to 6 p.m., EST. (closed on federal holidays)

Quick GuidePostpartum Depression: Symptoms, Causes, and More in Pictures

Postpartum Depression: Symptoms, Causes, and More in Pictures

Where can people get support for postpartum depression?

Baby Blues Connection
http://www.babybluesconnection.org
Toll free: 866-616-3752

Online Postpartum Depression Support Group
http://www.ppdsupportpage.com

Postpartum Dads
Email: info@postpartumdads.org

Postpartum Education for Parents
PO Box 261
Santa Barbara, CA 93116
Email: pepboard@sbpep.org
PEP Warmline: 805-564-3888
Our free 24-hour service provides confidential one-on-one support from trained volunteers who are parents just like you.

Postpartum Stress Center
http://www.postpartumstress.com

Postpartum Support International
Email: psioffice@postpartum.net
800-944-4773
503-894-9453

What research is being done on postpartum depression?

The current research on postpartum depression includes an increased focus on this condition in men, as well as potential natural remedies based on surges in certain brain chemicals associated with the postpartum period.

REFERENCES:

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision 2013; Washington, D.C.

Baker FM, Bell CC. Issues in the psychiatric treatment of African Americans. Psychiatric Services 1999 March; 50: 362-368.

Beck CT, Gable RK. Further validation of the postpartum depression screening scale. Nursing Research 2001; 50(3): 155-164.

Cormin EJ, Kohen R, Jarrett M, Stafford B. The heritability of postpartum depression. Biological Research for Nursing 2010 July; 12: 173-183.

Dennis CL. Psychosocial and psychological interventions for prevention of postnatal depression: systematic review. British Journal of Medicine 2005 July; 331(7507): 15.

Fitelson, E., S. Kim, A.S. Baker, and K. Leight. "Treatment of postpartum depression: clinical, psychological and pharmacological options." International Journal of Women's Health 3 (2011): 1-14.

Freeman MP, Markowitz JC, Rosenbaum JF, et al. Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Third Edition; American Psychiatric Association October 2010.

Kessler CF, Gilman CP. Charlotte Perkins Gilman: her Progress Toward Utopia with Selected Writings

Kim P, Swain JE. Sad dads: paternal postpartum depression. Psychiatry 2007 February; 4(2): 35-47.

Lin KM, Cheung F. Mental health issues for Asian Americans. Psychiatric Services 1999 June; 50: 774-780.

Marin H. Hispanics and psychiatric medications: An overview. Psychiatric Times 2003 October; 20(10).

Meyer IH. Prejudice, social stress and mental health in lesbian, gay and bisexual populations: conceptual issues and research evidence. Psychological Bulletin 2003; 129(5): 674-697.

O'Hara MW, Stuart S, Gorman LL, Wenzel A. Efficacy of interpersonal psychotherapy for postpartum depression. Archives of General Psychiatry 2000; 57: 1039-1045.

Paulson JF, Dauber S, Leiferman JA. Individual and combined effects of postpartum depression in mothers and fathers on parenting behavior. Pediatrics 2006 August; 118(2): 659-668.

Sacher J, Wilson AA, Houle S, et al. Elevated brain monoamine oxidase A binding in the early postpartum period. Archives of General Psychiatry 2010 May; 67(5): 468-474.

Sit D, Rothschild AJ, Wisner KL. A review of postpartum psychosis. Journal of Women's Health 2006; 15(4).

Spinelli MG. Maternal infanticide associated with mental illness: prevention and the promise of saved lives. American Journal of Psychiatry 2004 September; 161: 1548-1557.

Stevens LM, Lynm C, Glass RM. Postpartum depression. Journal of the American Medical Association 2010; 304(15): 1736.

Wisner KL, Parry BL, Piontek CM. Postpartum depression. New England Journal of Medicine 2002 July; 347(3).

Last Editorial Review: 3/23/2017

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Reviewed on 3/23/2017
References
REFERENCES:

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision 2013; Washington, D.C.

Baker FM, Bell CC. Issues in the psychiatric treatment of African Americans. Psychiatric Services 1999 March; 50: 362-368.

Beck CT, Gable RK. Further validation of the postpartum depression screening scale. Nursing Research 2001; 50(3): 155-164.

Cormin EJ, Kohen R, Jarrett M, Stafford B. The heritability of postpartum depression. Biological Research for Nursing 2010 July; 12: 173-183.

Dennis CL. Psychosocial and psychological interventions for prevention of postnatal depression: systematic review. British Journal of Medicine 2005 July; 331(7507): 15.

Fitelson, E., S. Kim, A.S. Baker, and K. Leight. "Treatment of postpartum depression: clinical, psychological and pharmacological options." International Journal of Women's Health 3 (2011): 1-14.

Freeman MP, Markowitz JC, Rosenbaum JF, et al. Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Third Edition; American Psychiatric Association October 2010.

Kessler CF, Gilman CP. Charlotte Perkins Gilman: her Progress Toward Utopia with Selected Writings

Kim P, Swain JE. Sad dads: paternal postpartum depression. Psychiatry 2007 February; 4(2): 35-47.

Lin KM, Cheung F. Mental health issues for Asian Americans. Psychiatric Services 1999 June; 50: 774-780.

Marin H. Hispanics and psychiatric medications: An overview. Psychiatric Times 2003 October; 20(10).

Meyer IH. Prejudice, social stress and mental health in lesbian, gay and bisexual populations: conceptual issues and research evidence. Psychological Bulletin 2003; 129(5): 674-697.

O'Hara MW, Stuart S, Gorman LL, Wenzel A. Efficacy of interpersonal psychotherapy for postpartum depression. Archives of General Psychiatry 2000; 57: 1039-1045.

Paulson JF, Dauber S, Leiferman JA. Individual and combined effects of postpartum depression in mothers and fathers on parenting behavior. Pediatrics 2006 August; 118(2): 659-668.

Sacher J, Wilson AA, Houle S, et al. Elevated brain monoamine oxidase A binding in the early postpartum period. Archives of General Psychiatry 2010 May; 67(5): 468-474.

Sit D, Rothschild AJ, Wisner KL. A review of postpartum psychosis. Journal of Women's Health 2006; 15(4).

Spinelli MG. Maternal infanticide associated with mental illness: prevention and the promise of saved lives. American Journal of Psychiatry 2004 September; 161: 1548-1557.

Stevens LM, Lynm C, Glass RM. Postpartum depression. Journal of the American Medical Association 2010; 304(15): 1736.

Wisner KL, Parry BL, Piontek CM. Postpartum depression. New England Journal of Medicine 2002 July; 347(3).

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