Health care practitioners find that few medical conditions are subject to more confusion and contradictory interpretation than postpartum depression (PPD). Lack of clarity about its diagnosis, causation and treatment, however, seriously affects the wellbeing of mothers and babies throughout the world, for postpartum depression is of worldwide concern, affecting about 15% of women having babies. In the United States alone, there are over three and a half million women per year giving birth, and over 400,000 of these women will experience postpartum depression. This article does not aim to summarize the broad array of knowledge and research about PPD, but rather to clarify some of the essential facts and concepts.
What is PPD?
Postpartum depression is one of six major categories of postpartum mood disorders: postpartum depression, postpartum obsessive compulsive disorder (including obsessive thought disorder); postpartum panic disorder, postpartum post traumatic stress disorder, postpartum bipolar disorder and postpartum psychosis. "Baby blues", lasting a transient few days to up to two weeks, is not considered a disorder. Fifty to eighty percent of new mothers report these mild "Blues" symptoms of mood swings, crying, and feeling overwhelmed. Confusing PPD with "Baby blues" may lead to absence of treatment for the mother who is suffering. Confusing "Baby blues" with PPD may result in unnecessary treatment for the mother who is experiencing normal hormonal and life adjustment feelings.
Postpartum depression occurs on a continuum of severity, but for ease of rating or classification it is often referred to as having three levels of severity -- mild, moderate, and severe. Symptoms range from mild sadness in the least severe to a complete inability to care for oneself or the baby in the most severe. The most common symptoms include anxiety, lethargy, insomnia, irritability, confusion, frequent crying, decreased libido, eating disorders, obsessive thoughts, guilt feelings, night sweats, feeling overwhelmed, forgetfulness, and hopelessness.
Onset and duration of symptoms
The onset of symptoms occurs any time up to one year postpartum. The duration of the symptoms can be days, weeks, months, or years, depending upon a number of factors. These factors include the severity of the symptoms, the timeliness of the intervention(s), how the individual's body chemistry reacts to a medication (if used), other life stressors, and the strength of the woman's support system (caring family, friends, professionals).
PPD - A Distinct Illness
It is now generally recognized that PPD is a defined disorder and not the same as other conditions that may give rise to similar psychological symptoms. The prevailing view is that, at its core, PPD reflects the mother's physiological changes, particularly shifts in endocrine balance, during the first few weeks after delivery. Psychological and emotional factors, such as poor partner support or over-optimistic expectations of life after hospital discharge are very significant. They can affect the likelihood of onset of the disorder and its severity. Both the central organic factors and contributing psychological elements have to be understood.
One major distinction that postpartum illness has in comparison with other disorders is that it is highly labile both in the array of symptoms and level of severity, with frequent changes. For instance, with a depressive episode in a man who loses his job, the symptoms of depression are fairly constant. In a postpartum depression, however, the woman's symptoms can range from high anxiety one moment to a mild depression the next, and she could even feel relatively normal during another part of the day.
Complexity of the Disorder
Although PPD may appear to the lay observer as if it were the same in every case, it is not. Two new mothers may live next door to each other, both with PPD, but with entirely different causes and requiring different kinds of treatment. One may have had a previous history of depression reactivated by postpartum factors and the other has chronic sleep deprivation plus a poor support system. For each woman there are different pieces to the puzzle. The growing body of research is making it more possible to distinguish among these different elements, to assess accurately the basis of the problem, and therefore to begin the appropriate course of treatment for each individual woman. That is why, when a woman seeks help, she should get a complete well-rounded assessment, covering all aspects of her current life as well as pertinent past psychological and physiological events.
Giving Information to Postpartum Women
When helping depressed postpartum women, health practitioners should neither minimize nor over-dramatize the condition. The women should expect to be told their diagnosis without ambiguity, have it explained matter-of-factly, and the severity level should be estimated as accurately as possible. They should be told that at least the primary cause of the condition is related to the adjustments of body chemistry after delivery, and the process of readjustment may take a while. Each woman and her family members should also be reassured that, especially when treated early, the eventual outcome is expected to be total recovery. All medical therapeutic actions should be explained as efforts to facilitate the body's return to the equilibrium that existed before pregnancy.
Risk factors
Any new mother may get PPD, after any birth, regardless of how uneventful her mental health history or life stressors have been. No one is immune. We do know, however, that a personal and/or family history of depression or anxiety automatically places the woman at high risk for postpartum depression (This includes experiencing symptoms of depression and anxiety during pregnancy). As a result, authorities stress the importance of obtaining a thorough personal and family mental health history while the woman is still pregnant. If she is assessed as being high risk, a plan of action can be devised which could be effective in at least minimizing, if not preventing, a postpartum depression.
There are other accurate predictors of postpartum depression such as sleep deprivation, poor marital relationship, abrupt weaning, isolation, and health problems of the mother or baby. There is misinformation as well about predictors. For instance, the sex of the baby is not a predictor nor is there any evidence that bottle-feeding increases the incidence of PPD. A number of women have reported to me that their various practitioners had told them they were not at high risk of having another PPD after a subsequent delivery. These women were misinformed that it is only after the first child that PPD occurs, since they are new at taking care of babies and adjusting to motherhood. On the contrary, if she has had one postpartum depression the mother is at high risk to have another, since organically she may be "wired" that way. There are health caregivers who may provide incorrectly reassuring information, or who avoid referring to risk factors, on the premise that women may otherwise worry themselves into the disorder. Instead, the failure to deal openly with risk factors is likely to increase the women's susceptibility to severe distress by keeping her unprepared to deal with her situation effectively.
Instruction on these basic points of knowing what information to elicit from their patients and then having a plan of early intervention should be part of the OB/GYN and midwife formal training program. This should include information regarding mental health therapists, medications and herbs which can be used during pregnancy and lactation, other alternative therapies, or at least reference numbers of specialists/agencies who will know.
Terminology Confusion and Its Consequences
Both clinicians and clients can be confused by the official terminology for mood disorders following childbirth. Although postpartum depression is informally referred to frequently as a diagnosis, the term "postpartum depression" is not, regretfully, one of the official diagnostic categories in the DSM IV as of yet. At the end of the section on Mood Disorders there is a Postpartum Onset Specifier (page 386) which unfortunately blends all of the postpartum mood disorders (especially depression, panic, obsessive-compulsive, and psychosis) into one section. The Criteria for Postpartum Onset Specificer (page 387) states that there is no difference in symptomatology between postpartum and nonpostpartum mood disorders. The only difference is that postpartum mood disorders occur "within 4 weeks after delivery of a child". There is not only misinformation in this statement regarding time of onset, but more importantly, the postpartum mood disorders are not considered to warrant their own diagnoses, distinct from nonpostpartum diagnoses, as they should be. The woman who suddenly feels depressed 8 months postpartum is often not diagnosed or misdiagnosed due to this Specifier.
The ambiguities of the Specifier are quite misleading and cause numerous problems. Present terminology confuses not only those responsible for health care, but can enter the criminal justice system and distort the facts. The result is often to sacrifice the rights of women suffering from this condition. A woman, for instance, who has postpartum obsessive thought disorder, might be reported to Child Protective Services if she admits to having thoughts of harming her infant. This agency may remand her to the police if her symptoms are not recognized properly as harmless to her baby. Her baby would then be placed in protective custody. A woman with postpartum psychosis who commits infanticide may find herself in jail rather than in a hospital receiving the medical attention she needs so desperately. The technical terminology used by doctors may also deprive many patients of insurance coverage to which they are entitled.
Additionally, the medical records of women with postpartum depression or other psychiatric illness after childbirth often use different terms to describe and diagnose. The same woman may be described and diagnosed differently numerous times. Psychiatric terminology needs to be established which clearly distinguishes the postpartum women from those with chronic "functional" mental illness. This will let health professionals know that they are dealing with an acute illness which has a particular onset, duration, and termination, and that there are appropriate therapeutic options available. In addition, formally assigning a childbirth-related name to these disorders would have a positive therapeutic effect on the women, since they would understand that their condition is directly related to having had a baby.
Concluding Note
Strengthening the understanding among health care providers of the complex nature of PPD, recognizing that differential diagnosis and various treatment approaches are necessary, and seeking common terminology, will help to minimize, if not eliminate the confusion. Women in individual treatment and their families will benefit, as would the effectiveness of community health education in general.
