Postpartum depression: Beyond the 'Baby Blues'

Nov 18 2004

In a culture where giving birth is often believed to be the most joyful moment in life, many women instead feel tired, sad, anxious, distracted and depressed after the baby is born.

Three out of four women experience the "baby blues," a condition that can come and go within a week or two. Less common - but more serious - is postpartum depression, which can last six to nine months if untreated.

Diagnosing the Problem

Health care providers detect fewer than half of postpartum depression cases in new mothers, says Linda Chaudron, M.D., a psychiatrist at the University of Rochester. Some women may feel ashamed or embarrassed to discuss such feelings. Busy physicians may not ask about or pick up signs of depression. Postpartum depression may have negative effects on a baby's development.

Prevention and Treatment

A recent systematic review of 15 randomized controlled trials, which included 7,697 women, concluded that psychosocial and psychological interventions provided no clear benefit in preventing postpartum depression. Only one study of women visited by public health nurses or midwives demonstrated any reduced risk of postpartum depression. Prevention of the condition has proved elusive, so early detection, diagnosis and treatment are essential. Effective treatments include psycho-therapy and antidepressant drugs.

The Facts:

• Postnatal depression is treatable using antidepressants and psychotherapy, but more effective screening and additional research assessing treatment and prevention methods are essential.

• Women with postpartum depression often display more anxiety than women with other types of depression, take longer to respond to medication and require more than one antidepressant.

• Postpartum depression and its severity may vary depending on social or cultural settings. One study of 296 women in eight countries revealed varying postpartum depression rates six months after delivery, ranging from 2.1 percent to 31.6 percent.

• Postpartum depression should not be confused with the more serious postpartum psychosis, occurring in less than 0.2 percent of mothers and characterized by hallucinations and delusions. Such women may be threats to themselves or to their babies, and require immediate hospitalization.

• Interpersonal therapy, focusing on the patient's relationships with other people, appears effective in reducing postpartum depression. This and other types of psychotherapy may be appropriate for breastfeeding women concerned about taking antidepressant medications.

• A trial testing several kinds of counseling or therapy against routine primary care found short-term benefits to mothers and children but no effects on children's cognitive development or on their emotional and behavioral problems at age 5.

• Exposure to some antidepressant drugs in utero does not appear to adversely affect thinking, language development or the temperament of preschool and early-school children. In contrast, a mother's depression is associated

  with reduced cognitive and language achievement by their children.

• Whether nursing women should use antidepressant medications is open to debate. In women with severe postpartum depression, "the benefits of taking an antidepressant will probably outweigh the risks of infant psychotropic exposure." The ultimate decision on using medication should follow a discussion among the woman, her doctor and her husband/partner regarding potential risks and benefits.

Catching the Problem Early

Postpartum depression affects about 15 percent of women. It may begin before giving birth or up to four to six months later.

"There are many possible origins but little research data," says Linda Chaudron, M.D., of the University of Rochester. "The cause may have something to do with the normal drop in estrogen and progestin that occurs in women after giving birth but there's also evidence implicating the thyroid, as well as marital conflict, stressful life circumstances like poverty and lack of social support."

There are longer-term effects, too, Chaudron says. Women who have post-partum depression once are more likely to experience it again. Sometimes the condition is so overwhelming that a woman decides not to have another child. Children of depressed mothers may have more cognitive, social and behavioral problems, or fail to bond well if the mother is withdrawn or overanxious.

Experts say early detection is key. "Rather than sifting through all new mothers to find those in need of prevention, we need early identification and early intervention," says Michael O'Hara, Ph.D., of the University of Iowa.

Chaudron argues that women and their health care providers need more education to raise awareness of postpartum depression. Most women only see their obstetricians once after giving birth, so Chaudron suggests that pediatricians be trained to screen new mothers for depression and then refer them to primary care doctors or psychiatrists for treatment and follow-up.

"I'm attracted to using pediatricians as sentinels to pick up signs of depression in new mothers, but pediatricians don't like the idea," O'Hara says. "They face pressures to move patients through the system and don't want to slow down and spend time talking to their patient's mother. Then there's the matter of responsibility: If a doctor asks, he has to follow through. That means setting up a good pathway to care."

Treatment requires consideration of individual circumstances. The question of whether to take medication is simpler in cases of high or low severity but becomes more complicated in the middle, O'Hara says. Patient preference is important. Does a nursing woman want to take medications? Will her insurance cover treatment? Does she prefer psychotherapy?

There's not enough data to rule out effects of antidepressants on newborns, but research increasingly indicates that some drugs don't affect the child's safety.

"On the other hand, the absence of treatment carries great risks," O'Hara says.

Experts agree that more research needs to be done on the effects of mental health in pregnancy and on screening women following birth, and more randomized controlled trials are needed of medications and psychotherapy together, both pre- and postpartum.

Facts of Life

Published by the Health Behavior News Service
Kristina Campbell, Editor

The Health Behavior News Service provides journalists with information, interviews and commentary about an expanded view of health. It is operated by the independent, nonprofit Center for the Advancement of Health, an organization striving to ensure that evidence of how social, behavioral and economic factors affect health is used in efforts to prevent, treat and manage disease. The Center is funded by the John D. and Catherine T. MacArthur Foundation and The Annenberg Foundation.