Depression in New Mothers

Causes, Consequences and Treatment Alternatives

Kathleen Kendall-Tackett, Kathleen A Kendall-Tackett

• Publisher: Routledge
• Year: 2016
• eBook ISBN: 9781317310297
• Edition: 3
• Topic: Medicine
• Subtopic: Health Care Delivery

Depression is the most common complication of childbirth and results in adverse health outcomes for both mother and child. It is vital, therefore, that health professionals be ready to help women who have depression, anxiety, or posttraumatic stress disorder in the perinatal period.

Now in its third edition, Depression in New Mothers provides a comprehensive approach to treating postpartum depression in an easy-to-use format. It reviews the research and brings together the evidence-base for understanding the causes and for assessing the different treatment options, including those that are safe for breastfeeding mothers. It incorporates research from psychoneuroimmunology and includes chapters on:

• 
  
  

• assessing depression

• 
  
  

• mother-infant sleep

• 
  
  

• traumatic birth experiences

• 
  
  

• infant temperament, illness, and prematurity

• 
  
  

• childhood abuse and partner violence

• 
  
  

• psychotherapy

• 
  
  

• complementary and integrative therapies

• 
  
  

• community support for new mothers

• 
  
  

• antidepressant medication

• 
  
  

• suicide and infanticide.

This most recent edition incorporates new research findings from around the world on risk factors, the use of antidepressants, the impact of breastfeeding, and complementary and integrative therapies as well as updated research into racial/ethnic minority differences. Rich with case illustrations and invaluable in treating mothers in need of help, this practical, evidence-based guide dispels the myths that hinder effective treatment and presents up-to-date information on the impact of maternal depression on the mother and their infants alike.

Symptoms, incidence, and consequences

DOI: 10.4324/9781315651521-1

Depression in new mothers

Myth vs. reality

DOI: 10.4324/9781315651521-2

Depression is among the most disabling disorders for women in their childbearing years. For women aged 15 to 44 years around the world it is second only to HIV/AIDS in terms of total disability. Moreover, in the United States, depression is the leading cause of non-obstetric hospitalization among women aged 18 to 44 years.

(Michael O’Hara, 2009, p. 1258)

Depression is one of the most common complications of childbirth, and one of the most disabling. Yet people often do not recognize it when they see it. Postpartum depression isolates mothers when they most need the help of others. Mothers may be ashamed to admit that life with a new baby is not always bliss. They may assume that everyone has made a smoother transition to motherhood than they have. They may be truly embarrassed that they are not able to “cope” better, as Beck (2006) describes:

Postpartum depression is a serious mood disorder that can cripple a woman’s first months as a new mother. I have described it as “a thief that steals motherhood.” Without appropriate clinical intervention, postpartum depression can have long-ranging implications for both mother and child.

(p. 40)

Myths about postpartum depression

Misperceptions abound regarding depression in new mothers. Unfortunately, myths and misperceptions can keep mothers from receiving the attention they need. Here are some of the most common.

Myth #1: Depression in new mothers is not serious

Some people still trivialize depression in new mothers. What they fail to understand is that depression can cause serious, if not life-threatening, consequences for mothers and babies.

Myth #2: Postpartum depression is caused by shifts in estrogen and progesterone

This description of depression still exists despite the fact that many studies contradict it. Unfortunately, this hypothesis can distract us from the real underlying causes of depression, and can also lead to ineffective, and even harmful, treatment practices.

Myth #3: Postpartum depression is more common in white middle-class women

Revelations of postpartum depression by such well-known women as Brooke Shields, Marie Osmond, and the late Princess Diana, have been undeniably helpful in that they have increased awareness. The downside, however, is that they have inadvertently reinforced the notion that postpartum depression is a condition of privilege. The reality is that postpartum depression affects women in many different cultures, and across all income levels. In fact, lower-income and racial/ethnic-minority women are often at higher risk.

Myth #4: We don't really know what causes postpartum depression

Yes, we do. The causes of depression vary from woman to woman. But we have identified the major risk factors for depression.

Myth #5: Postpartum depression will go away on its own

Unfortunately, untreated postpartum depression can last for months—or longer. Zelkowitz and Milet (2001) identified 48 couples where one or both partners had postpartum mental illness. Four months later, 54 percent of the mothers, and 60 percent of their partners, still had psychiatric diagnoses. In another study, mothers were assessed at 2, 3, 6, and 12 months postpartum. Mothers who were depressed at 2 months continued to be depressed at each subsequent assessment point throughout the first year (Beeghly et al., 2002).

Myth #6: Women with postpartum depression cannot breastfeed

Sadly, when women seek help for depression, many are told to wean. For some mothers, weaning is no problem. But for others, weaning is experienced as a significant loss. The good news is that exclusive breastfeeding actually protects mothers’ mental health. Supporting breastfeeding can help her recover, and almost all treatment options are compatible with breastfeeding.

Myth #7: Women should avoid nighttime breastfeeding to prevent depression

There is no evidence that supports this myth, and the advice that follows is totally impractical, and may actually undermine mothers’ mental health. Several recent, large research studies have demonstrated that exclusively breastfeeding mothers get more sleep than their mixed- or formula-feeding counterparts. Once mothers start supplementing, they actually get less sleep. I will describe these studies in Chapter 7.

Symptoms of depression

Postpartum depression can manifest in a wide variety of symptoms. These include moods of sadness, anhedonia (the inability to experience pleasure), low self-esteem, apathy and social withdrawal, excessive emotional sensitivity, pessimistic thinking, irritability, sleep disturbance, appetite disturbance, impaired concentration, and agitation (Preston & Johnson, 2009). They may feel mentally foggy, anxious, angry, or guilty. They may believe that their lives will never be normal again (Beck, 2002). For some women, it may be more acceptable to talk about physical ailments, rather than depression, so they may present with pain, fatigue, and sleep and appetite disturbances (Alexander, 2007). Missing their postpartum appointment may also indicate possible depression. A study from Brazil of 516 postpartum women found that 22 percent of women who came to their postpartum appointment screened positive for depression compared to 33 percent of women who missed or rescheduled their appointment (Lobato, Brunner, Dias, Moraes, & Reichenheim, 2012).

Donna describes how her symptoms came on suddenly after the birth of her daughter.

I never really went into labor. They did three inductions … I knew I was going to have a C-section … When they said it was a girl, I just went numb. I just didn’t feel like I had a given birth. I felt disconnected from my body. I was up for 24 hours. I was crying hysterically. She wanted to eat a lot. I never was able to breastfeed. I was in the hospital crying. I didn’t feel like her mother. I was very disconnected. I was freaking out. My friends kept telling me that it was the baby blues.

Women in non-Western cultures may describe the symptoms of postpartum depression in quite different terms. For example, in a qualitative study of 12 women from Ghana, the predominant symptom of depression was described as “thinking too much” (Scorza, Owusu-Agyei, Asampong, & Wainberg, 2015). The thoughts these women describe could be rumination, a classic symptom of depression. They could also be related to posttraumatic stress disorder (PTSD).

I don’t sleep at night or in the day because the eyes cannot close while the mind is still thinking.

You sleep small, and when those thoughts come into your mind, you cannot sleep anymore.

Mothers, and their partners and mothers (serving as key informants), described the mothers’ symptoms including body pain, trouble eating and sleeping, low milk supply, intrusive thoughts, social withdrawal, sadness, and tearfulness (Scorza et al., 2015). Seven of the 12 women believed that their condition would kill either them or their babies, and 5 of the 12 had suicidal thoughts. Contributing factors included financial problems, family stress and lack of support, and problems between women and their partners.

Diagnostic criteria for major depressive disorder

While many mothers may exhibit symptoms of depression, major depression is a more serious manifestation of depressive symptoms that has specific diagnostic criteria in the Diagnostic and Statistical Manual-5 (DSM-5). For a diagnosis of major depression, patients must have at least five of the following symptoms during the same two-week period:

1. Depressed mood
2. Markedly diminished interest or pleasure in all or almost all activities
3. Significant (> 5 percent body weight) weight loss or gain
4. Decrease or increase in appetite
5. Insomnia or hypersomnia
6. Psychomotor agitation or retardation
7. Fatigue or loss of energy
8. Feelings of worthlessness or inappropriate guilt
9. Diminished concentration or indecisiveness
10. Recurrent thoughts of death or suicide.

The above symptoms should not be due to psychosis, and the woman should never have had a manic or hypomanic episode. Further, the woman’s symptoms should not be due to physical illness, alcohol, medication or illegal drugs, or normal bereavement. In addition, these symptoms must represent a change in previous functioning, and must include at least depressed mood and anhedonia. These symptoms can be by subjective report or observation of others, and must occur nearly every day (American Psychiatric Association, 2013).

Is postpartum depression a distinct condition?

Professionals frequently raise the question of whether postpartum depression is distinct from depression that occurs outside the puerperium. Some have argued that puerperal and non-puerperal mental illnesses are similar in terms of their symptomatology and factors predicting onset, and that the only distinguishing characteristic of puerperal mental illness is onset and triggers that are specific to new motherhood (e.g. infant characteristics, sleep deprivation, and birth experience).

At the present time, there is no specific diagnostic category for postpartum illness in the DSM-5. The specifier “with peripartum onset” can be added to a current or recent depressive, manic, or hypomanic episode in major depressive disorder, bipolar disorder I or II if the episode happens during pregnancy and up to 4 weeks postpartum (American Psychiatric Association, 2013; Sharma & Mazmanian, 2014).

Critics of this new diagnostic category note that they are unable to include anxiety disorders, obsessive–compulsive disorder (OCD), or PTSD under the peripartum specifier, even though the DSM acknowledges that anxiety and panic attacks can co-occur with perinatal depression. In addition, 4 weeks postpartum is far too short a time period for this diagnosis in that depression can happen any time in the first year (Sharma & Mazmanian, 2014). The DSM-5 also cites the incidence of depression as 3–6 percent—far below the actual number of even the most conservative estimate.

MRI studies of depression

Beginning in the 1990s, the number of studies that compared anatomical brain variations between depressed and non-depressed people dramatically increased. The brains of depressed people had reduced volume of structures that process emotions including the prefrontal cortex, orbitofrontal cortex, cingulum, hippocampus, and striatum. The white matter also had notable abnormalities in depressed people. Perhaps the most important contribution to magnetic resonance imaging (MRI) research of depression is “blood oxygen level dependent” (BOLD), which shows levels of hemodynamic response to stimuli. In functional MRI studies, people with depression often show significant decrease in activation of key structures, such as the medial prefrontal cortex and amygdala (Fiorelli et al., 2015 ).

To consider the issue of whether postpartum depression was a distinct condition, Fiorelli and colleagues (2015) reviewed the literature on postpartum/postnatal depression and MRI/neuroimaging. They identified 11 studies. These studies examined women’s reactions to threatening words or negative facial expressions. Depressed women had reduced activation in the amygdala and dorsomedial prefrontal cortex. Another study found that the depressed women did not show a difference in activation when hearing their own infants’ cries vs. those of other infants. Fiorelli et al. noted that the MRI studies of postpartum depression replicated those of major depressive disorder, and concluded that the data did not support a distinct neurobiological profile for postpartum depression. They did also note, however, the relative dearth of MRI studies on perinatal depression (11 studies) compared to studies of major depressive disorder (over 1,000). With an increase in MRI studies, a distinct profile may still be identified.

Incidence and prevalence of depression in new mothers

Incidence of postpartum depression ranges quite a bit depending on the population studied and how depression is defined. The typical range is 12–25 percent of new mothers, with rates in some high-risk groups being as high as 40 percent or more. A study of 86,957 mothers and fathers in the US found that they are at highest risk for depression in the first year postpartum (Dave, Petersen, Sherr, & Nazareth, 2010). By the time their children are 12 years old, 39 percent of mothers and 21 percent of fathers have been depressed.

Studies that report higher percentages of depressed mothers may have included both major depression and depressive symptoms in their totals. Similarly, the percentage will be higher if major and minor depression are included in the “depressed” group. Below is a summary of studies from around the world.

US studies of postpartum depression

The Childbirth Connections’ Listening to Mothers’ Survey II included a nationally representative sample of 1,573 mothers in the US found that one in three mothers reported depressive symptoms in the past two weeks: 34 percent reported feeling down, depressed, or hopeless, and 36 percent reported anhedonia (little interest or pleasure in doing things) (Declercq, Sakala, Corry, & Applebaum, 2008). In a large US population study, 14,093 women, ages 18–50, were interviewed about past pregnancy status (Vesga-Lopez et al., 2008). Women who were currently pregnant women had the lowest risk of mood disorders. Postpartum women had significantly higher rates of major depression compared with non-postpartum women. Risk factors for psychiatric disorders in pregnant and postpartum women included age, marital status, health status, stressful live events, and history of trauma.

The Centers for Disease Control published prevalence data on postpartum depressive symptoms in 17 US states (Ce...

Table of contents

• Cover Page
• Half Title Page
• Title Page
• Copyright Page
• Table Of Contents
• Foreword
• Preface
• Part I Symptoms, incidence, and consequences
• Part II Risk factors: inflammation and psychoneuroimmunology
• Part III Treatment options
• References
• Index