Postpartum Depression

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POSTPARTUM DEPRESSION BY:

NAME: FARAH HUSNA MOHD FADZIL NIM: 040100848 DEPARTMENT OF PSYCHIATRY FACULTY OF MEDICINE UNIVERSITY OF NORTH SUMATERA MEDAN 2009

CONTENTS

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ACKNOWLEDGEMENT…………………………………...4 Chapter 1 1.1 Introduction ………………………………………...5 1.2 Prevalence…………………………...……………....5 Chapter 2 2.1 Definition 2.1.1 Definition of Depression……………………………6 2.1.2 Definition of Postpartum Depression….……………7-8 2.2 Epidemiology ……………………………………….9 2.3 Etiology ……………………………………………..9 Factors that causes depression : 2.3.1 During Pregnancy……………………………………11 2.3.2 After Pregnancy……………………………………...11-12 2.4 Diagnosis …………………………………………….13 2.5 Clinical features ……………………………………..14 2.6 Differential diagnosis………………………………...15 2.7 Prognosis:…………………………..……………..…..16 2.8 Treatment ………………………………….................16 2.8.1 Psychological Treatment………………………………17-18 2.8.2 Medical Treatment……………………………………..18-20 2.9 Complication ………………………………………….20 2.10 Summary………………………………………………21 References …………………………………………………..22

POSTPARTUM DEPRESSION

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This article was written to comply with the conditions of Clinical Postings, Deparment of Psychiatry, Faculty of Medicine USU.

By : Farah Husna Mohd Fadzil (040100848)

Instructor : Dr. Hj Abdul Rasyid bin Hj. Said Ssp, AMP, M. Med Psyc (HTF)

Prof. Dr. Bahagia Loebis, SpKJ

Prof. Dr. Syamsir BS, SpKJ

Dr. Raharjo S, SpKJ

Dr. Elmeida Effandy, SpKJ

Name of Deparment

: Department of PsychiatryFM USU, Department Of Psychiatry, Hospital Tuanku Fauziah

Year

: 2009

Acknowledgement

First and foremost I would like to thank the god for setting me up in this challenging but yet interesting journey of medical education and provide me the opportunities to excel as a healer.

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This journal has materialized only partly due to my efforts. I thankedthe Department of Psychiatry Haji Adam Malik/ FK USU and its dedicated lecturers for guiding me in completing this journal as a part of my education. Special thanks is forwarded to the HOD Prof Syamsir BS, SpKJ, Co-ordinator Dr. Elmeida Effendy SpKJ and our evaluator Prof Bahagia Loebis SpKJ. I would also like to extend my gratitude to my parents whom without them I would never be able to set my foot in the pathway of medicine. Thanks also to my friends and other contributors for both material and moral supports. Hopefully this journal will benefits all those who would like to understand everything regarding Postpartum Depression.Comments and critiques are appreciated. Kangar 29th May 2009 Farah Husna Mohd Fadzil

Chapter One

Postpartum Depression 1.1 Introduction: True postnatal depression can be a severe mental illness. However, the massive hormonal, physical, and emotional effects from childbirth and a new baby are well

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known to cause emotional symptoms. It is normal to suffer some level of "baby blues", and particularly common is some level of crying or distress on the third day after birth. It's not easy being a mother and first-time mothers often feel overwhelmed. A new mother feeling down, moody, or a bit "depressed" does not usually warrant the diagnosis of full postnatal depression. However, persistent depressive symptoms do need professional medical investigation.

1.2 Prevalence: The prevalence of Postpartum depression in the general population is 10% among pregnancies. While the estimation of its occurrence range from 3% to 20% of births. However, Postpartum depression is a commonly misdiagnosed disorder affecting 10 - 17 percent of women.

Chapter Two

Discussion 2.1 Definition: 2.1.1 Definition of Depression Depression can be described as feeling sad, blue, unhappy, miserable, or down in the dumps. Most of us feel this way at one time or another for short periods. But true clinical depression is a mood disorder in which feelings of sadness, loss, anger, or frustration interfere with everyday life for an extended time. Depression can be mild,

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moderate, or severe. The degree of depression, which your doctor can determine, influences how you are treated. For every woman, having a baby is a challenging time, both physically and emotionally. It is natural for many new mothers to have mood swings after delivery, feeling joyful one minute and depressed the next. These feelings are sometimes known as the "baby blues", and often go away within 10 days of delivery. However, some women may experience a deep and ongoing depression which lasts much longer. This is called postpartum depression. References to postpartum depression date back as far as the 4th century BC. Despite this early awareness, it has not always been recognized as an illness. As a result, postpartum depression continues to be under-diagnosed. It is an illness that can be effectively treated. The sooner the condition is diagnosed, the more effective the treatment. It is important to recognize and acknowledge the symptoms of postpartum depression in yourself or another as soon as possible. This can be difficult, since the depressive feelings often involve intense and irrational feelings of fear. The mother may fear she is losing her mind or fear that others may feel she is unfit to be a mother.

2.1.2 Definition of Postpartum Depression Postpartum depression is defined by the DSM-IV as the onset of depressive symptoms within 4 weeks of childbirth. Symptoms are very similar to major depression, and can also include fluctuations in mood, preoccupation with infant well-being, as well as at times just the opposite, complete disinterest in the infant which, if prolonged, may result in failure to thrive syndrome. A woman with PPD may also have feelings similar to the baby blues -- sadness, despair, anxiety, irritability -- but she feels them much more strongly than she would with the baby blues. PPD often keeps her from doing the things she needs to do every

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day. When a woman's ability to function is affected, this is a sure sign that she needs treatment. If a woman does not get treatment for PPD, it can get worse and last for as long as a year.

Difference between "baby blues," Postpartum Depression, & Postpartum Psychosis Researchers have identified other form of condition related to postpartum depression which is baby blues and postpartum psychosis. The baby blues can happen in the days right after childbirth and normally go away within a few days to a week. A new mother can have sudden mood swings, sadness, crying spells, loss of appetite, sleeping problems, and feel irritable, restless, anxious, and lonely. Symptoms are not severe and treatment isn't needed. But there are things you can do to feel better. Nap when the baby does. Postpartum depression can happen anytime within the first year after childbirth. A woman may have a number of symptoms such as sadness, lack of energy, trouble concentrating, anxiety, and feelings of guilt and worthlessness. The difference between postpartum depression and the baby blues is that postpartum depression often affects a woman's well-being and keeps her from functioning well for a longer period of time. Postpartum depression needs to be treated by a doctor. Counseling, support groups, and medicines are things that can help. Postpartum psychosis is rare. It occurs in 1 or 2 out of every 1000 births and usually begins in the first 6 weeks postpartum. Women who have bipolar disorder or another psychiatric problem called schizoaffective disorder have a higher risk for developing

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postpartum psychosis. Symptoms may include delusions, hallucinations, sleep disturbances, and obsessive thoughts about the baby. A woman may have rapid mood swings, from depression to irritability to euphoria

2.2 Epidemiology: In developed countries, PPD occurs in about 12% to 13% of postpartum women. More recently, the rates in the United States have been reported as 10% to20%. Transculturally, the rates are estimated at 10% to 15%, with a higher rate in adolescent mothers.Many symptoms are similar to those that naturally follow childbirth, such as lack of sleep, appetite changes, fatigue, decreased libido, and mood lability. The exact number of women with depression during this time is unknown. But researchers believe that depression is one of the most common complications during and after pregnancy. Often, the depression is not recognized or treated, because some normal pregnancy changes cause similar symptoms and are happening at the same time. Tiredness, problems sleeping, stronger emotional reactions, and changes in body weight may occur during pregnancy and after pregnancy. But these symptoms may also be signs of depression.

2.3 Etiology: The exact cause of postpartum depression is not known. One factor may be the changes in hormone levels that occur during pregnancy and immediately after childbirth. Also, when the experience of having a child does not match the mother's expectations, the resultant stress can trigger depression. Studies have also considered the possible effects of maternal age, expectations of motherhood, birthing practices and the level of social support for the new mother.There may be a number of reasons

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why a woman gets depressed. Hormone changes or a stressful life event, such as a death in the family, can cause chemical changes in the brain that lead to depression. Depression is also an illness that runs in some families. Other times, it's not clear what causes depression. There is no one trigger; postpartum depression is believed to result from many complex factors. It is important, however, to communicate to women with postpartum depression that they did not bring it upon themselves. One certain fact is that women who have experienced depression before becoming pregnant are at higher risk for postpartum depression. Women in this situation should discuss it with their doctor so that they may receive appropriate treatment, if required. In addition, an estimated 10% to 35% of women will experience a recurrence of postpartum depression. The amount of sick leave taken during pregnancy and the frequency of medical consultation may also be warning signs. Women who have the most doctor visits during their pregnancy and who also took the most sick-leave days have been found to be most likely to develop postpartum depression. The risk increases in women who have experienced 2 or more abortions, or women who have a history of obstetric complications. Other factors which increase the risk of postpartum depression are severe premenstrual syndrome (PMS), a difficult relationship, lack of a support network, stressful events during the pregnancy or after delivery.

Factors that causes Depression During & After Pregnancy

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2.3.1 During Pregnancy During pregnancy, these factors may increase a woman's chance of depression: •

History of depression or substance abuse

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Family history of mental illness

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Little support from family and friends

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Anxiety about the fetus

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Problems with previous pregnancy or birth

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Marital or financial problems

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Young age (of mother)

2.3.2 After Pregnancy Depression after pregnancy is called postpartum depression or peripartum depression. After pregnancy, hormonal changes in a woman's body may trigger symptoms of depression. During pregnancy, the amount of two female hormones, estrogen and progesterone, in a woman's body increases greatly. In the first 24 hours after childbirth, the amount of these hormones rapidly drops back down to their normal non-pregnant levels. Researchers think the fast change in hormone levels may lead to depression, just as smaller changes in hormones can affect a woman's moods before she gets her menstrual period.

Occasionally, levels of thyroid hormones may also drop after giving birth. The thyroid is a small gland in the neck that helps to regulate your metabolism (how your body uses and stores energy from food). Low thyroid levels can cause symptoms of depression including depressed mood, decreased interest in things, irritability, fatigue, difficulty concentrating, sleep problems, and weight gain. A simple blood

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test can tell if this condition is causing a woman's depression. If so, thyroid medicine can be prescribed by a doctor. Other factors that may contribute to postpartum depression include: •

Feeling tired after delivery, broken sleep patterns, and not enough rest often keeps a new mother from regaining her full strength for weeks.

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Feeling overwhelmed with a new, or another, baby to take care of and doubting your ability to be a good mother.

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Feeling stress from changes in work and home routines. Sometimes, women think they have to be "super mom" or perfect, which is not realistic and can add stress.

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Having feelings of loss—loss of identity of who you are, or were, before having the baby, loss of control, loss of your pre-pregnancy figure, and feeling less attractive.

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Having less free time and less control over time. Having to stay home indoors for longer periods of time and having less time to spend with the your partner and loved ones.

2.4 Diagnosis: The criteria used to diagnose depression is the same in postpartum states. In addition to these criteria, other symptoms may include fear or feelings of guilt about being a "bad" mother, or possibly extreme fear that some harm will come to the baby. These thoughts help distinguish postpartum from other kinds of depression.Women with postpartum major depressive episodes may also have severe anxiety, panic attacks, spontaneous crying long after the usual duration of "baby blues" (ie, 3-7 days

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postpartum), disinterest in the new infant, and insomnia (manifested as difficulty falling asleep). When assessing whether a symptom is a sign of depression or a normal postpartum reaction, the individual's circumstances need to be considered. A woman's level of exhaustion or irritability may be quite normal when her infant is 2 weeks old and nursing frequently, but may not be normal when her baby is 4 months old and sleeping soundly through the night. Sleep deprivation can cause fatigue and poor concentration, but the degree of these symptoms needs to be carefully assessed.

2.5 Clinical features: Any of these symptoms during and after pregnancy that last longer than two weeks are signs of depression: •

Feeling restless or irritable

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Feeling sad, hopeless, and overwhelmed

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Crying a lot

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Having no energy or motivation

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Eating too little or too much

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Sleeping too little or too much

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Trouble focusing, remembering, or making decisions

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Feeling worthless and guilty

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Loss of interest or pleasure in activities

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Withdrawal from friends and family

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Having headaches, chest pains, heart palpitations (the heart beating fast and feeling like it is skipping beats), or hyperventilation (fast and shallow breathing)

After pregnancy, signs of depression may also include being afraid of hurting the baby or oneself and not having any interest in the baby.

2.6 Differential Diagnosis: The differential diagnosis for postpartum depression should include the following : 1. Postpartum blues ( PPB; no DSM-IV-TR diagnosis ) Note : any depressive syndrome accompanied by psychosis or lasting beyond 2 weeks postpartum ceases qualifying for PPB 2. Postpartum depression (PPD) without psychotic features 3. Postpartum depression with psychotic features ( consider bipolar disorder,depressed ) 4. Bipolar I or II disorder,depressed phase.In a sample of 30 women with occult bipolar disorder, 20 ( 67% ) experienced a postpartum mood episode, almost exclusively depressive, as the initial presentation of their bipolar disorder ( Chaudron and Pies 2003; Freeman et al. 2002 ) 5. Mood disorder due to a general medical condition with major depressive-like episode or with depressive features.Depressive symptoms have been reported

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as the presenting feature in hypothyroidism ( Gunnarsson et al.2001 ), infection with HIV, and systemic lupus erythematosus ( SLE ). 6. Substance-induced depressive disorder.Effects of prescription drugs,illicit drugs,alcohol,and over-the-counter and herbal remedies may mimic and precipitate psychiatric disorders in pregnancy and the postpartum period.

2.7 Prognosis: Postpartum depression usually goes away during the months after delivery. Some women have symptoms for months or years. If untreated, the illness can cause prolonged misery for the mother and her family. •

It can hurt the mother-baby relationship.

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It could even be dangerous if the mother considers hurting her child or herself.

2.8 Treatment: There are two common types of treatment for depression. •

Talk therapy. This involves talking to a therapist, psychologist, or social worker to learn to change how depression makes you think, feel, and act.

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Medical Treatment. Your doctor can give you an antidepressant medicine to help you. These medicines can help relieve the symptoms of depression.

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2.8.1 Psychological treatments: counseling and support For a woman with postpartum depression, experts recommend household help and therapy with a mental health professional. If depression is severe, the experts urge finding someone to stay with and assist the mother at all times, such as a relative, friend, or paid helper. Family and friends can offer non-judgmental support, reassurance, hope, and validation of the new mother’s abilities. Common issues in psychotherapy for postpartum depression include overwhelming fears about new responsibilities and guilt over becoming depressed at such a crucial time. Two techniques that treat depression by putting these problems in perspective are interpersonal therapy and cognitive-behavioral therapy. It is usually valuable to include the spouse or other main caretaker in therapy to help him or her understand the symptoms of depression and cope with the increased stress on the family. Here are some other helpful tips that can be suggested to the patients: •

Try to get as much rest as you can. Try to nap when the baby naps.

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Stop putting pressure on yourself to do everything. Do as much as you can and leave the rest!

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Ask for help with household chores and nighttime feedings. Ask your husband or partner to bring the baby to you so you can breastfeed. If you can, have a friend, family member, or professional support person help you in the home for part of the day.

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Talk to your husband, partner, family, and friends about how you are feeling.

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Do not spend a lot of time alone. Get dressed and leave the house. Run an errand or take a short walk.

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Spend time alone with your husband or partner.

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Talk with other mothers, so you can learn from their experiences.

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Join a support group for women with depression. Call a local hotline or look in your telephone book for information and services.

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Don't make any major life changes during pregnancy. Major changes can cause unneeded stress. Sometimes big changes cannot be avoided. When that happens, try to arrange support and help in your new situation ahead of time.

2.8.2 Medical Treatment : Women who are pregnant or breastfeeding should talk with their doctors about the advantages and risks of taking antidepressant medicines. Some women are concerned that taking these medicines may harm the baby. A mother's depression can affect her baby's development, so getting treatment is important for both mother and baby. The risks of taking medicine have to be weighed against the risks of depression. It is a decision that women need to discuss carefully with their doctors. Women who decide to take antidepressant medicines should talk to their doctors about which antidepressant medicines are safer to take while pregnant or breastfeeding.

Antidepressant medications Many different kinds of antidepressants are available with different chemical actions and side effects. All of them treat depressive symptoms and may be helpful for postpartum depression.A mother who is breast-feeding, however, may be concerned about the safety of antidepressant medication for her infant. For postpartum depression in a breast-feeding mother,the experts recommend medications called serotonin reuptake inhibitors (SSRIs), which affect the brain chemical

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serotonin.Their top choice among these is Zoloft (sertraline), the most widely studied antidepressant in breast-feeding mothers and their infants. While small amounts enter breast milk, little or no medication can be detected in infants, and there appear to be no adverse effects. Paroxetine (Paxil) is also a highly-rated choice.Paroxetine is not detectable in breast milk or nursing infants.Two other widely used SSRIs, fluoxetine (Prozac) and citalopram(Celexa), enter breast milk in small amounts but are viewed as acceptable alternatives. If a mother took fluoxetine or citalopram during her pregnancy and needs to stay on medication after delivery, experts do not think it is necessary to change to another drug. Tricyclic antidepressants, an older type of medication, are also viewed by experts as an appropriate choice for breast-feeding mothers. Imipramine (Tofranil) and nortriptyline (Pamelor) are 2 examples. Tricyclics usually cause more side effects in the mother than SSRIs but are sometimes more effective. If the baby has health problems, the pediatrician can obtain a blood sample to see if the antidepressant is present in the baby in a significant amount and might be contributing to the problem. For an extremely severe type of depression in which the mother has psychotic symptoms (hallucinations or delusions),it is important to combine the antidepressant with another kind of medication called an antipsychotic. If the mother is breastfeeding, the experts recommend an older type called conventional antipsychotics (such as Haldol); newer types (atypical antipsychotics such as Risperdal or Zyprexa) are preferred otherwise, but have not been tested enough in breast-feeding mothers and their infants. If a woman has very severe symptoms, such as suicidal or psychotic thoughts, the doctor may need to put her in the hospital to ensure her safety and that of the baby while her symptoms are addressed. Electroconvulsive therapy is an alternative to consider if a mother does not respond to medication or is breast-feeding and wants to avoid medication.

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2.9 Complication: Postpartum depression,if left untreated, postpartum depression can interfere with mother-child bonding and cause family distress. Children of mothers who have untreated postpartum depression are more likely to have behavioral problems, such as sleeping and eating difficulties, temper tantrums and hyperactivity. Delays in language development are common as well. Researchers believe that postpartum depression can affect the infant by causing delays in language development, problems with emotional bonding to others, behavioral problems, lower activity levels, sleep problems, and distress. It helps if the father or another caregiver can assist in meeting the needs of the baby and other children in the family while mom is depressed.Untreated postpartum depression can last up to a year or longer. Sometimes untreated postpartum depression becomes a chronic depressive disorder. Even when treated, postpartum depression increases a woman's risk of future episodes of major depression.

2.10 Summary : Like all forms of depression, postpartum depression creates a cloud of negative feelings and thoughts over a woman's view of herself, those around her, her situation, and the future. Under the cloud of depression, a woman might see herself as helpless or worthless. She might view her situation as overwhelming or hopeless. Things might seem disappointing, uninteresting, or without meaning. Keep in mind that the bleak negative perspective is part of depression. With the right treatment and support, the cloud can be lifted. This can free a woman to feel like herself again, to regain her perspective and sense of her own strength, her energy, her joy, and her hope. With those things in place, it's easier to work with changes, to see solutions to life's challenges, and to enjoy life's pleasures again.

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REFERENCES 1. MedicineNet.Com : postpartum depression http://www.medicinenet.com/postpartum_depression/article.htm#tocb

2. Manual of Psychiatric Care for the Medically Ill Postpartum depression: page 133 By Antoinette Ambrosino Wyszynski, Bernard Wyszynski 3. Expert Consensus Guideline Series Postpartum Depression: A Guide for Patients and Families By Margaret L. Moline, Ph.D., David A. Kahn, M.D., Ruth W. Ross, M.A., Lori L. Altshuler, M.D., and Lee S. Cohen, M.D.

4. "Postpartum Depression - Epidemiology And Course" http://family.jrank.org/pages/1293/Postpartum-Depression-EpidemiologyCourse.html 5. Free MD medical interactive library http://www.freemd.com/postpartum-depression/outlook.htm

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6. Mayoclinic : postpartum depression-complication http://www.mayoclinic.com/health/postpartumdepression/ 7. Postpartum Onset Specifier – with postpartum onset From DSM-IV : pg 194