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Post-Partum Depression

by Professor Philip George, Consultant Psychiatrist

What is Postpartum Depression?

The baby is here. You should feel happy and relieved. Now that there is another little one in your life, your life as a family is complete. You feel fulfilled as a woman now that you have experienced pregnancy and childbirth. There will be joy, excitement and new adventures as you watch your baby grow.

However, all you feel is sadness, anxiety and self-doubt. You worry about whether you are being a good mother and feel intimidated when other mothers give advice on baby care. Deep down, you wonder if there’s something wrong with you because you somehow don’t feel the happiness, fulfilment or excitement other new mothers do.

The good news is that you are not alone. Depressive symptoms after childbirth, commonly known as postpartum depression, are extremely common. In 700 B.C., Hippocrates described the symptoms in great detail.  

Although childbirth is considered a natural process, it is nevertheless a serious physiological and psychological event for mothers. A woman’s mind, body and spirit have just been through 9 months of pregnancy, culminating in the birth. Hence, some women may need more recovery time than others.

After childbirth, the new mother’s body will be all haywire because of the dramatic changes in circulating hormones. She may still be in pain for several weeks but she will also be exhausted, caring for the new baby and breastfeeding. There is so much to do now with a new addition to the family, and she has little time to care for herself.

On top of the physical recovery, a new mother also struggles with changes in her perception of herself, relationship with others and her new role. There are also social changes – income levels, societal status and a loss of freedom. All these snowball into a huge burden which some women find overwhelming, leading to depression.

There are three categories of Postpartum Disorders: Maternity Blues, Postpartum Depression and Psychotic Depression. The first is the mildest category, and most women overcome it successfully soon after childbirth. The latter two warrants more attention. 

Maternity Blues

This is a common condition affecting 50-80% of all new mothers. It usually begins right after birth and can last for up to 14 days. Common symptoms include mood changes, tearfulness, anxiety, irritability and feeling tense.

Maternity blues can be caused by hormonal changes, anxiety about childcare and problems with breastfeeding.  Usually no medication is required; all the mother needs is a lot of reassurance and family support. Practical advice, such as how to bathe baby, breastfeed, change diapers, swaddle or baby massage helps make the new mother feel empowered and confident.

Postpartum Depression

This affects up to 20% of new mothers. This manifests in feelings of sadness, hopelessness, helplessness and worthlessness. New mothers may lose interest in normal passions and feel unable to cope with their new responsibilities due to low energy, low drive, poor attention and concentration.  

Some mothers may feel guilty, inferior or even, suicidal. The feelings are usually worse in the mornings. They may experience a loss of appetite and sleep disturbances. Some present instead with physical symptoms such as bringing their healthy babies to the clinic repeatedly.

Postpartum depression can stem from:

  • Hormonal changes There is a sharp drop in oestrogenand progesterone that are normally increased 10x during pregnancy. There are changes also in plasma cortisol, the stress hormone occurring at this time.

  • Psychosocial factors This can include feelings of inadequacy regarding childbearing

  • Ambivalence towards pregnancy

  • Low self-esteem

  • Interpersonal issues This can include marital relationships or mother-daughter problems

  • Financial problems This can arise from additional expenses

  • Obstetric complications

Interestingly, many women with postpartum depression do not recognize they have an illness, thinking that they are just having the blues. Many associate depression with false notions, such as that it is untreatable and there is a stigma associated with treatment.

If left untreated, postpartum depression can lead to :

  • Disturbed mother-infant relationship

  • Marital tension

  • Psychiatric morbidity in children that manifests at a later stage

  • Vulnerability to future depression

  • Suicide and/or infanticide (killing of baby) 

Treating Postpartum Depression

In managing postpartum depression, the psychiatrist will first investigate social factors and mobilise support. In mild cases, this is often sufficient. The new mother will also be connected to self-help networks and groups for material, emotional and physical help.  Mothers who have had the same experience can share their experiences. 

In more severe cases, antidepressant medication, psychotherapy and/or Electroconvulsive treatment may be recommended, whether independently or in combination. A combination of drug treatments with psycho-social interventions is known to have the best results.

Antidepressants need to be taken for at least 3-4 weeks before any improvement can be seen. Once they feel better, the medication needs to be continued for at least 6- months to prevent a relapse. Mothers who are breastfeeding will need to discuss with the doctor about the safety of the medication.  

Psychotic Depression

Psychotic depression is similar to postpartum depression, but in addition mothers will have delusions (false beliefs) and hallucinations (false perceptions). This includes the feeling that ‘someone’ or ‘something’ is watching or disturbing them. Patients may also show gross abnormalities of speech and behaviour.

Psychotic depression is considered a Psychiatric Emergency and needs inpatient treatment. It is a severe and life-threatening condition, and the patient must be closely monitored for suicide and/or infanticide. Fortunately it is not very common, affecting only 0.2% of new mothers.

Factors that lead to psychotic depression include:

  • Hormonal changes

  • Out of wedlock baby

  • First child

  • Caesarean birth

  • Perinatal death (stillbirth or neonatal death)

  • Psychiatric history

  • Family history of psychiatric illness

Treating Psychotic Depression

It is treated with Electroconvulsive Therapy, or a combination of antipsychotics & antidepressants. Most patients often recover but will need further monitoring as they may cause problems to the family.

Some women may blame the child for their condition, and anger from the family could be projected to the child. On the opposite end of the spectrum, some women become overprotective of the child. Counselling is necessary to handle the topic of future pregnancies. 

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