Postpartum and Its Mental Health Problems
Sophie Grigoriadis
No time in a women’s life is as likely to be filled with as much change as the postpartum period. Changes in all aspects of a woman’s life (biologic, psychological, as well as sociocultural) during the first year following childbirth define the postpartum period. Although the addition of a new family member is usually a time of joy and excitement, for many women the postpartum time is not the period of well-being depicted by women’s and parenting magazines. Instead, it is a high-risk period for significant psychiatric illness.
Many adaptations need to occur following childbirth. Following labor, the physiologic changes of pregnancy resolve during the early postpartum period. Changes in body shape require increased attention to diet and exercise with consideration for the needs of lactation if nursing. Over and above the medical complications that may occur during the early and late postpartum period, maternal sleep deprivation is common and can lead to exhaustion. The infant is completely dependent on the caregiver around the clock and the immediate postpartum time is centered on the infant’s needs, which pose physical as well as psychological demands. Both mother and infant need to learn the skills involved in breast-feeding, an intense physical connection between mother and infant. Pain during feedings (from irritated nipples or mastitis) can create heightened anxiety and interfere with the process and the formation of the maternal-infant bond. Feeding difficulties can heighten insecurities the mother may have regarding the adequacy of
care she is providing. Over time, the new mother becomes increasingly attuned to her infant’s cues and usually comes to terms with her new maternal role and identity. As her infant develops, the challenge of parental adjustment impacts on both the mother and her relationship with her partner. Although the presence of the child solidifies the family unit, the mother’s time for herself is reduced as are time for the couple and for socialization. The many challenges can lead to a resurfacing of old conflicts between partners or to the development of new ones. Housing and economic difficulties can negatively affect the developing relationship with the infant further. Economic necessity or career aspirations may require the mother’s return to work and decisions on how to coordinate child care and previous working commitments (1). In Western societies, where women are usually expected to be the primary caregiver for their infants following childbirth, an emotionally and instrumentally supportive relationship between the partners can help moderate stress on the mother. In non-Western societies, traditional rituals enable the mother to receive much needed family and community support following childbirth—a potentially protective factor (2). The physical changes and the combination of new and multiple demands in all aspects of life postpartum can be overwhelming to many women, and some develop psychiatric illness for the first time; others experience a recurrence of illness.
care she is providing. Over time, the new mother becomes increasingly attuned to her infant’s cues and usually comes to terms with her new maternal role and identity. As her infant develops, the challenge of parental adjustment impacts on both the mother and her relationship with her partner. Although the presence of the child solidifies the family unit, the mother’s time for herself is reduced as are time for the couple and for socialization. The many challenges can lead to a resurfacing of old conflicts between partners or to the development of new ones. Housing and economic difficulties can negatively affect the developing relationship with the infant further. Economic necessity or career aspirations may require the mother’s return to work and decisions on how to coordinate child care and previous working commitments (1). In Western societies, where women are usually expected to be the primary caregiver for their infants following childbirth, an emotionally and instrumentally supportive relationship between the partners can help moderate stress on the mother. In non-Western societies, traditional rituals enable the mother to receive much needed family and community support following childbirth—a potentially protective factor (2). The physical changes and the combination of new and multiple demands in all aspects of life postpartum can be overwhelming to many women, and some develop psychiatric illness for the first time; others experience a recurrence of illness.
POSTPARTUM PSYCHIATRIC DISORDERS
Postpartum psychiatric disorders are characterized by the onset of emotional symptoms during the weeks or months that follow childbirth. These mood and anxiety disorders have been described since antiquity, but they continue to be poorly recognized, undertreated, and underresearched. Recently, there has been a growth of interest, but the length of time characterizing the postpartum period has not been consistently agreed upon. Although this categorization is not reflected in the nosology of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR), most researchers categorize the mood disturbances of this period into postpartum blues, postpartum depression (PPD), and postpartum psychosis. Panic disorder or postpartum obsessive compulsive disorder typify the anxiety disorders of this period. Debate has ensued over whether the disorders manifesting during the postpartum time are distinct from the mood and anxiety disorders that manifest at other times of the life cycle (3). Given that research in postpartum psychiatric illness has only recently begun to gain momentum, the relationship and potential overlap between the categories remains to be adequately delineated and are still empirical. Moreover, at the early onset of symptoms, many clinicians find it difficult to differentiate between normal postpartum emotional adjustment and postpartum psychiatric illness.
POSTPARTUM MOOD DISORDERS
Etiology
The temporal association between childbirth and psychiatric illness reinforced the hypothesis that the etiology of postpartum disturbance rests in a biologic aberration. Early theories examined the “withdrawal phenomenon” related to the rapid shift in the hormonal environment and the consequences on the activity of neurotransmitter or circadian systems. Gonadal steroids such as estrogen and progesterone, cortisol and the hypothalamic-pituitary-adrenal (HPA) axis, androgens, thyroid hormones, polypeptide hormones, mineralocorticoids, inhibin, β-endorphins, and gonadotropins
have been examined as potential etiologic factors in postpartum mood disorders (4). However, studies investigating potential biologic aberrations have been negative, inconsistent, or not replicated. Nonetheless, there may be endocrinologic changes that are causally linked to postpartum mood disorders in a vulnerable subgroup of women who may be specifically sensitive to changing titers of reproductive hormones. In a key biologic study, Bloch and colleagues pharmacologically simulated pregnancy, parturition, and the postpartum period and found that women with a history of PPD developed significant mood symptoms during the hormonal add back and withdrawal periods; none of the control women developed symptoms (5). These investigators suggest that women with a history of PPD are differentially sensitive to the mood-destabilizing effects of the marked changes in gonadal steroid levels. It has also been suggested that estrogen plays a role in the regulation of circadian rhythms and may, in part, contribute to sleep loss. Sleep loss in turn has been suspected to have an etiologic role in the onset of postpartum psychosis in susceptible women (6). The mechanism of these changes remains to be determined.
have been examined as potential etiologic factors in postpartum mood disorders (4). However, studies investigating potential biologic aberrations have been negative, inconsistent, or not replicated. Nonetheless, there may be endocrinologic changes that are causally linked to postpartum mood disorders in a vulnerable subgroup of women who may be specifically sensitive to changing titers of reproductive hormones. In a key biologic study, Bloch and colleagues pharmacologically simulated pregnancy, parturition, and the postpartum period and found that women with a history of PPD developed significant mood symptoms during the hormonal add back and withdrawal periods; none of the control women developed symptoms (5). These investigators suggest that women with a history of PPD are differentially sensitive to the mood-destabilizing effects of the marked changes in gonadal steroid levels. It has also been suggested that estrogen plays a role in the regulation of circadian rhythms and may, in part, contribute to sleep loss. Sleep loss in turn has been suspected to have an etiologic role in the onset of postpartum psychosis in susceptible women (6). The mechanism of these changes remains to be determined.
A positive personal or family history of a mood disorder has been well associated with all types of postpartum psychiatric illness in retrospective, cross-sectional, and prospective studies (7). Recurrence of a postpartum episode is common; rates as high as 70% for postpartum psychosis and up to 50% for postpartum depression have been reported. From 20% to 50% of women with bipolar disorder experience a relapse during the postpartum time. Women with a history of major depression are also at risk for relapse during the postpartum, especially those with severe and recurrent illness, and rates as high as 30% have been reported (8). (See also Chapter 19.) The development of depressive symptoms during pregnancy increases the likelihood of postpartum depression regardless of history for major depression (9). Although there is a subpopulation of women who develop their index episode during the postpartum time (up to 50%) and subsequently experience psychiatric illness only following future childbirths, the majority of women go on to develop nonpuerperal episodes (8).
Attempts to delineate risk factors for vulnerability to psychiatric disturbance during the postpartum time (for example, age, marital status, parity, educational level, and socioeconomic factors) have been inconsistent and weak (8). Primiparous women may be at higher risk for postpartum psychosis than multiparous women, and obstetric complications (cesarean section, perinatal death) may also increase the risk for postpartum psychosis; replication of these findings is needed. Moreover, the impact of psychosocial factors in the development of postpartum psychiatric illness can be significant. High levels of marital conflict or dissatisfaction, low levels of social and spousal support, and increased number of life events during pregnancy have consistently been reported by women with postpartum affective illness (10). Studies attempting to link personality traits and coping styles with the risk of illness during the postpartum have not produced consistent findings. It is likely that many risk factors act synergistically to predispose women to postpartum affective disorders or increase the likelihood of the development of such disorders.
Most of the research in postpartum mood disorders has been done on PPD. Robertson and colleagues identified risk factors for PPD following their comprehensive review of the literature and grouped the factors as strong to moderate, moderate, small, and no effect (11). Strong to moderate risk factors include depression and anxiety during pregnancy, stressful recent life events, lack of social support, and a previous history of depression. Moderate factors include high levels
of stress related to child care, low self-esteem, neuroticism, and difficult infant temperament. Small factors include obstetric and pregnancy complications, cognitive attributions, quality of relationship with partner, and socioeconomic status. Ethnicity, maternal age, level of education, parity, and gender of child (within Western societies) were found to have no effect. These authors concluded that the identified risk factors for postpartum depression are methodologically robust, replicated within numerous studies across sample populations, and well established.
of stress related to child care, low self-esteem, neuroticism, and difficult infant temperament. Small factors include obstetric and pregnancy complications, cognitive attributions, quality of relationship with partner, and socioeconomic status. Ethnicity, maternal age, level of education, parity, and gender of child (within Western societies) were found to have no effect. These authors concluded that the identified risk factors for postpartum depression are methodologically robust, replicated within numerous studies across sample populations, and well established.
Postpartum Blues
Postpartum blues is a mild, transitory mood state characterized by rapid mood shifts, mild depression, irritability, anxiety, tearfulness, fatigue, insomnia, poor appetite, headaches, poor concentration, and confusion (7). Symptoms generally begin within the first week postpartum, last a few hours up to two weeks, and resolve spontaneously without sequelae. The mother’s functioning is only minimally affected, and if treatment is necessary, it is limited to support and reassurance. Given that the incidence has been reported to range from 26% to 85% of new mothers, it has been debated whether postpartum blues constitute a normal variant of maternal behavior rather than a psychiatric disorder (7). It may be of value to identify women experiencing these symptoms because as many as 25% will develop PPD during the first postnatal year (9).
Postpartum Depression
Postpartum depression (PPD) is estimated to occur in 10% to 15% of women, and prevalence ranges from 5% to over 20% have been reported (9). This wide variation reflects the fact that the disorder has been poorly characterized and unreliably diagnosed. This is due in part to the poorly defined diagnostic criteria and conflicting definitions of the postpartum period. Most experts currently do not support the notion that PPD is phenomenologically distinct from major depression that occurs at other life stages. PPD is now included in the DSM-IV-TR as a major depressive disorder with postpartum onset, beginning within the first four weeks after delivery. Historically, the clinical course of PPD was not well characterized; it was thought to begin insidiously after the second or third week postpartum, most patients developing symptoms within six weeks. The severity of the disorder is variable, ranging from mild dysphoria to melancholia to psychotic depression. Commonly, women are tearful, report mood lability, obsessional thinking (especially with regard to the infant’s health), feelings of hopelessness, somatic complaints (especially fatigue), anorexia, sleep disturbance, poor concentration and memory, and feelings of guilt and inadequacy. Clearly some of the symptoms, such as alterations in sleep pattern, energy, libido, appetite, and body weight, are common during the postpartum period; their overlap with the symptoms of depression as well as with medical disorders common during the postpartum time often renders accurate diagnosis difficult. The duration of postpartum illness is variable, depending on the severity of the illness, with most episodes lasting no more than three months (12); however, some residual depressive symptoms are common up to one year following delivery (13). Women with a previous history of major depression may have more severe and prolonged illness. With treatment, the prognosis is good. The outcome may be better for those women who receive treatment early (8).
Few treatment studies have been conducted in women with PPD. There is one randomized controlled trial (RCT) comparing fluoxetine to a hybrid cognitive-behavioral counseling approach, one open-label trial of sertraline, one open-label trial of venlafaxine, a fluoxetine case series, and one retrospective chart review of several antidepressants and the most recent RCT which compares paroxetine to paroxetine plus cognitive-behavioral therapy combination therapy in postpartum women with depression and comorbid anxiety disorder (14,15,16,17,18,18A). The limited information about antidepressant treatment for PPD often leads clinicians at present to extrapolate from studies of nonpostpartum samples; such extrapolation may not be appropriate. Many women with PPD breast-feed, and the amount of antidepressant entering breast milk must be given special consideration. Hendrick and colleagues also argue that women with PPD recover more slowly and may not have the same response profile as women with depression not related to childbearing (18). Therefore, not only are trials needed to compare the efficacy of various treatments in postpartum women with special considerations for lactation, but studies addressing response profiles such as rapidity of response in the management of PPD would also advance the field. The evidence for estrogen as a treatment is also still at the initial stages (19,20). Although Gregoire and colleagues demonstrated a positive response to estrogen that was sustained at three-month follow-up and there was no evidence of endometrial hyperplasia, over one third of the women in that study were also using an antidepressant (20). As a result, the evidence from this study may support estrogen as an adjunctive treatment, not necessarily as a primary treatment. Other interventions being investigated for the treatment of PPD include bright light therapy (21) as well as sleep interventions (22). It is difficult to compare the efficacy of these studies because of differing diagnostic criteria, rating scales used, and sample populations. Moreover, many of the results are still preliminary and require replication with larger samples. However, double-blind placebo-controlled crossover trials of pharmacologic interventions cannot be easily designed because postpartum psychiatric illness can be such a risk to the mother, her infant, and the family that it may be unethical to include a placebo arm.
The best evidence for psychotherapy as an effective treatment for postpartum depression is for interpersonal psychotherapy (IPT); the evidence comes from three studies, two open trials, and a wait list controlled trial (23,24,25). Although IPT reduces depressive symptoms and improves social adjustment, it also involves a time commitment by the new mother and may not be appropriate as stand-alone treatment for women with severe depressive symptoms. Cognitive-behavioral therapy (CBT) (14,18A, 26,27), counseling by health nurses (28) or health visitors (29), peer support (30,31,32), and partner support (33) have been shown to be helpful, although randomized controlled trials with larger sample sizes need to be conducted. If breast-feeding, some women avoid drugs despite the severity of their depressive symptoms. This is because the long-term effects of antidepressants on breast-fed infants are unknown. Studies comparing different treatment modalities to determine which treatments are most suited to certain clinical presentations would significantly advance the field, because it is unlikely that one treatment would be the first choice for all patients.
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