POSTPARTUM DEPRESSION

What Is Postpartum Depression?

There are three forms of postpartum depression, which vary greatly in terms of severity, duration, and impairment. The least severe (and most common) type is known as the "baby blues." This is a mild syndrome occurring in up to 80 percent of new mothers. It usually starts within the first few days following childbirth and may last from a few hours to several days. Although distressing, the symptoms (which generally include episodes of crying, mood swings, and worry) do not cause significant impairment for the mother. On the other hand, "postpartum psychosis" is a rare yet very severe psychiatric illness. In such cases, the symptoms, which include mood disturbances along with hallucinations or delusions, cause major impairment in the new mother's ability to function. This illness usually requires that the mother be hospitalized.

The third type of depression, known as "postpartum depression," occurs in approximately 15 to 20 percent of women following childbirth. It is a psychiatric syndrome, defined by the Diagnostic and Statistical Manual of Mental Disorders: DSM-IV as dysphoric mood (or loss of pleasure or interest in usual activities), coupled with symptoms such as sleep and appetite changes, cognitive disturbances, loss of energy, and/or recurrent thoughts of death, which co-occur for at least a two-week period. These symptoms cause significant distress and/or impairment in the new mother's functioning. It is important to note that these are the same symptoms used to diagnose a major depression at anytime during a person's life. The depressive syndrome is labeled a postpartum depression if the symptoms begin within the first three months following childbirth. On average, postpartum depression lasts for about four months, although it can vary considerably in length.

What Causes Postpartum Depression?

Depression during the postpartum period can best be considered an accident of timing; research has suggested that the rates, antecedents, course, and quality of depression during the postpartum period are similar to episodes experienced at other times in a woman's life. Although some research has suggested that negative life events during pregnancy and following delivery (such as financial difficulties, unemployment, and poor marital adjustment) may be associated with the onset of postpartum depression in new mothers, research in the late 1990s identified a previous instance of major depression as the most salient risk factor for postpartum depression.

What Are the Consequences of Postpartum Depression?

There has been an abundance of research on the influence of maternal depression in general on child outcome. This is for good reason—such research generally supports the notion that parental psychological distress (such as depression) is related to the development of negative parent-child interaction and family relationship patterns, which are associated with poor child outcomes. Depressed mothers as a group provide more negative self-reports regarding various aspects of family life, including dissatisfaction in relationships with their spouses and children, as well as stress and uncertainty regarding their own role as parents. Maternal depression has also been associated with disruptions in family unit functioning.

Not only are mothers affected by postpartum depression, the children of depressed mothers also exhibit a variety of impairments in social, psychological, and emotional functioning. More specifically, maternal depression during the postpartum period has been associated with problems for infants such as increased levels of distress/irritability, protest, withdrawal, and avoidance of social interaction. Maternal postpartum depression has been related to insecure parent-infant attachment in some studies but not others. Researchers need to provide a better understanding of how the timing, chronicity, and intensity of the mother's depression are related to the infant's development. In general, even though maternal depression in the postpartum period has been found to be problematic for mothers and infants, it is important to keep in mind that depressed mothers "don't always look as bad as they feel" (according to researchers Karen Frankel and Robert Harmon) and that they likely have the ability in most cases to provide "good enough" parenting to their young children.

Are Interventions Effective in Treating Postpartum Depression?

There have been two main approaches for treating postpartum depression, neither of which has had much empirical testing. The first strategy is to focus directly on the individual woman, with the main goal of reducing her depressive symptoms. As discussed above, postpartum depression is by definition a major depression that occurs during the postpartum period. There is ample evidence to suggest that major depression can effectively be treated with psychopharmacological intervention (i.e., antidepressant medication). Mothers (and physicians) are generally reluctant, however, to use medication during the postpartum period given potential complications associated with breast-feeding. Alternatively, individual psychotherapy has been used to help improve the moods of depressed women. For example, Michael O'Hara and his colleagues reported in 2000 that interpersonal psychotherapy (IPT) was an effective treatment for reducing depressive symptoms, and improving social adjustment, in women with postpartum depression. Initially, IPT involves identifying depression as a medical disorder that occurs within an interpersonal context. The next stage of treatment focuses on current interpersonal challenges identified by the patient (i.e., difficulties with a partner or extended family, role transitions, and/or losses related to the birth). The final stage of treatment consists of reinforcing the patient's competence related to symptom reduction, as well as future-oriented problem solving related to the potential recurrence of depressive symptoms.

The second general strategy for treatment is to focus on maladaptive relationship patterns or parenting practices that are often associated with maternal postpartum depression, in order to improve and enhance parent-infant interactions. There are a number of techniques that have been examined, including relationship-based intervention conducted in the family's home, interaction guidance, and touch or massage therapy for infants. Although these approaches vary in technique, all are generally designed to enhance maternal sensitivity, responsivity to infant cues, and positive parent-infant interaction. Primary outcomes are examined in terms of improvement in factors such as infant regulatory capacities, social-emotional development, and parent-infant attachment. In addition, reduction in maternal depressive symptoms is usually reported, although this is not the direct focus of the intervention. Overall, improvements are noted, although minimal information is available to determine the duration or the specific effects.

Summary

There are several important points to consider in regard to postpartum depression. First, postpartum depression has been linked to adverse infant and family outcomes. Postpartum depression has been associated with problematic infant development, poor parent-child interactions, and unhealthy family functioning. Recent research has suggested that it is the quality of family functioning that is the key to promoting positive child outcomes.

Second, the best intervention for postpartum depression is early identification. Women at risk for postpartum depression can be identified early (even during pregnancy) by determining whether the woman has a history of depression. Past history of depression is one of the most consistent findings for the prediction of postpartum depression.

Third, once the risk for maternal depression has been identified, steps can begin immediately to prevent adverse outcomes for mother and child. Early identification of depression is most critical—that is, before the baby is born. Even prior to the onset of full-blown disorder, services can be put in place to facilitate parenting competence, enhance parent-child relationship quality, and/or reduce intensity of depressive symptoms by connecting mothers with appropriate community services.

Finally, interventions are effective in ameliorating symptoms of postpartum depression. Much research has focused on the treatment of mothers' depressive symptoms. Treatment strategies for post-partum depression also need to include family development plans that account for each family's unique strengths and needs, an emphasis on strengthening family relationships by highlighting the role of fathers and other important caregivers, and the promotion of positive parenting and parental competence. Without question, giving support to families who are experiencing significant risks such as maternal depression is ultimately in the best interest of children.

See also: BIRTH; PARENTING; PREGNANCY

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Susan Dickstein