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Understanding Postpartum Depression

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The birth of a baby is the source of many new and exciting experiences for parents and families. However, it can also be a time of significant and at times, indeed overwhelming, challenges for many new mothers. Challenges come not only from learning how to care for a new infant, but also emerge as part of a mother’s physical and mental health. This article will examine a specific aspect of a new mother’s psychological and emotional makeup that can become a great concern as well as a risk to both the new mother and also the newborn infant. Postpartum depression is not simply a reaction to stressful changes or difficultly adjusting to caring for an infant. Although some women may experience what have been referred to as “the baby blues,” this should not be confused with the very serious and damaging impact of postpartum depression.

There is a long history that indicates that many women can be at risk for become depressed following childbirth. Indeed, some reports have suggested that this knowledge can be dated back to Hippocrates’ time. Writing in the Journal of Clinical Psychology, O’Hara notes, “Postpartum depression is a term applied to depressions that are prevalent during the postpartum period, which is increasingly viewed as up to one year after childbirth in research and clinical practice. There is no category of postpartum in the Diagnostic and Statistical Manual (American Psychiatric Association, however, there is a ‘postpartum onset’ specifier… Otherwise the criteria for clinical diagnosis are essentially the same as for major depressive disorder” (O’Hara, 2009, p. 1258).

In their study on postpartum depression, Blackmore and Chaudron write, “Epidemiologic studies demonstrate that women are more likely to be admitted to a psychiatric unit after giving birth than at any other time in their lives” (Blackmore & Chaudron, 2012, p. 133). It is estimated that during 2009 alone, some 537,680 women suffered postpartum as a complication of bearing a child. The likelihood or prevalence of postpartum depression is considered to run between 4.5% to 28%, based on a number of variables. The study that seems to be most widely accepted indicates a prevalence rate of 13% for the occurrence of postpartum depression among new mothers. And yet, even in 2012, postpartum remains both under diagnosed as well as undertreated in the United States.

Why are women not reporting this disorder? Fear of perhaps being seen as an unfit mother might be a root cause for a great deal of cases that go under- or unreported. Blackmore and Chaudron contend, “Women may be reluctant to disclose symptoms for fear of losing their child(ren), stigma, or embarrassment, or they do not realize that the symptoms are pathological” (2012, p. 133). The argument can certainly be raised that health practitioners need to be better attuned to the difficulties of new mothers. Follow-up appointments for both the infant and the mother tend to largely pertain to assessing the physical health of the infant and its mother. Time constraints within the healthcare system often do not allow for careful assessment of a new mother’s emotional status. “Because of the overlap of symptoms in normal postpartum adaptation and postpartum depression, it is often difficult for mothers and providers to identify postpartum depression” (Blackmore & Chaudron, 2012).

An interesting aspect of the issue that has yielded some mixed results is whether the onset of major depression simply happens to coincide with the birth of a child, or rather, if there is a specific causal factor that occurs only with childbirth that causes depression to emerge? Studies thus far have not seemed to provide a consensus as to the cause-effect question. This seems to be yet another reason for healthcare providers and researchers to work on developing and utilizing better methods of screening and identifying mothers who are potentially at risk for postpartum depression.

A study conducted in 2011 focused on a community-based screening initiative that included some 5,169 participants, aged 14 to 49, all of whom were postpartum. The Agency for Healthcare Research and Quality (AHRQ) framework was used to identify mothers who could potentially be included in the study. Additionally, the CARE Intervention for Depressed Mothers and Their Infants, The Mothers Information Tool Brief, and the Edinburgh Postnatal Depression Scale were also implemented in this particular screening initiative. Based on this work, Horowitz, Murphy, Gregory & Wojcik suggest, “Although combinations of risk factors are likely to contribute to any individual woman’s vulnerability to postpartum depression (PPD), accumulating evidence suggests that PPD affects a cross-section of women and that factors such as prenatal depression and history of maternal depression, current stress, poor quality of relationships, young age, very low socioeconomic status or education, and possibly being African American/Black, or an immigrant may be associated with increased PPD risk” (Horowitz et al., 2011).

The symptomatology and subsequent manifestation of behavior and affect are problematic both to the mother as well as her ability to interact with her infant. Mothers have been reported to experience inability or impairment of cognitive processing, the capacity to process and interpret information, expressing affect, and inconsistent ability to engage with their infants in ways that are positive and responsive. The researchers in the Horowitz et al. study questioned the accuracy of the notion that postpartum women are likely to be resistance to screening methods for postpartum depression. The authors suggest, “We can only conclude that failure to provide universal PPD screening for early case identification and mental health treatment referral is due in large measure to a sense of inadequacy on the part of providers, rather than resistance to PPD screening on the part of mothers” (Horowitz et al., 2011). Indeed the researchers hope that their findings, based on such a large sample of 5,000+ mothers, will motivate and encourage primary care providers to make more widespread use of screening methods to identify women who are struggling with PPD.

The growing indication that mothers and children are both likely to suffer from the impact of PPD serves as a reminder that considerable research needs to continue. Moreover, the screening methods that are currently available, in particular the Edinburgh Postnatal Depression Scale, can be instrumental in identifying risk factors in women who may become vulnerable to developing postpartum depression. Postpartum does not simply need to be something that new mothers must endure without benefit of treatment. Mental health treatment can be highly beneficial as a supportive measure for new mothers as they transition into the kind of parents they wish to become.

As mentioned, the negative impact of a mother with PPD is not something from which the infant is often spared. Field contends, "The interaction disturbances of depressed mothers and their infants appear to be universal, across different cultures and socioeconomic status groups, and include less sensitivity of the mothers and responsivity of the infants. Several caregiving activities also appear to be compromised by postpartum depression including feeding practices, most especially breastfeeding, sleep routines and well-child visits, vaccinations, and safety practices" (Field, 2010).

Arguably, many of these activities are those that represent the very core of what is needed in order to successfully parent an infant. Another significant aspect of PPD is clearly recognized in depressed mothers who do not take all proper measures to safeguard the infant. This can reflected in the failure to use an infant care seat, as well as the laundry list of little efforts required to ‘baby-proof’ a house.

The catastrophic results of undiagnosed and untreated postpartum depression have been reported in the news media throughout the years. Perhaps among the most heartbreaking of such reports of that nature is the one about Andrea Yates. Yates drowned her five children a little over a decade ago, while she was very likely in the throes of postpartum psychosis. It should be noted that although some mothers with postpartum depression might have obsessive thoughts about hurting an infant, this rarely occurs. Reports indicate that Yates had been chronically mentally ill, yet undertreated, all the while trying to parent five young children. Unfortunately, the treatment she so desperately needed came after she had killed her kids.

On a much more optimistic note, another noteworthy name that has recently been paired with postpartum depression is actress Brooke Shields. Indeed, Shields wrote about her experiences and has contributed a great deal to increasing awareness of and legitimizing the seriousness of postpartum depression (Lusskin, 2012).

Sources

Blackmore, Emma Robertson and Chaudron, Linda H. (2012). Postpartum Depression: Recognition and Intervention. Journal of Clinical Outcomes Management, Vol. 19, No. 3.http://www.hospitalphysician.com/pdf/jcom_mar12_postpartum.pdf

Field, Tiffany. (2010). Postpartum Depression: Effects on Early Interactions, Parenting, and Safety Practices: A Review. Infant Behav Dev. 33(1). http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2819576/

Horowitz, June Andrews, Murphy, Christine A., Gregory, Katherine E., & Wojcik, Joanne. (2011). A Community-Based Screening Initiative to Identify Mothers at Risk for Postpartum Depression. J. Obstet Gynecol Neonatal Nurs, 40(1): 52-61. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3052285/

Lusskin, Shari. (2010). Beyond the Baby Blues. News & Views: A Publication for the NYU Langone Medical Center Community. November/December. http://newsandviews.med.nyu.edu/beyond-baby-blues

O’Hara, Michael W. (2009). Postpartum Depression: What We Know. Journal of Clinical Psychology, Vol. 65(12), 1258-1269. http://onlinelibrary.wiley.com/doi/10.1002/jclp.20644/pdf

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