Post Partum DepressionRegardless of how much a pregnancy is planned for and wanted, he new mother faces an increased risk (from 10-15%) for postpartum Depression. Fearing the stigma of mental illness, feeling guilty for being "weak" or an inadequate mother, or not knowing what to expect, help explain a new mother's reluctance to seek help for depression. The family physician is ideally placed to assess for changes in mood during follow up visits with the infant, and to provide treatment and aftercare, being familiar with the family and the community resources. Although some women report depression beginning in hospital after delivery, more often symptoms begin gradually over the first two to three months postpartum. In addition to the fatigue, disrupted sleep and weight loss expected, other symptoms are similar to a non-puerperal depression. There may be depressed mood, tearfulness, irritability, lack of pleasure, decreased motivation and even suicidal ideation. Anxiety may be a prominent feature. Approximately half of women with postpartum depression have obsessions, including recurrent intrusive thoughts and/or images that they might harm their infants by such means as drowning, smothering or throwing the baby. These obsessions are distinguished from psychotic delusions by being ego-dystonic, unwanted and distressing without significant risk of harming the baby, but they are very anxiety provoking for the mother. The family doctor will want the new mother's partner as an ally to provide help with childcare, to monitor the situation and to encourage medications if needed. A CBC and TSH help to rule out medical problems that could be confused with or aggravate depression, as hypothyroidism is very common during the post partum period. For mild to moderate postpartum depression, studies have demonstrated the effectiveness of interpersonal therapy and cognitive behavioral therapy. Where these options are not available, or for more severe depression, conventional antidepressants in standard doses are effective and well tolerated. Seratonin Reuptake Inhibitors are the most commonly used antidepressants and also are effective in managing anxiety. All psychotropic medications are secreted in breast milk, but the SSRIs are present in relatively low amounts and are rarely associated with significant complications for full term healthy infants. The best studied are Fluoxitine, Sertraline and Paroxetine in lactating women. Extra support is beneficial and extra sleep is essential, which occasionally necessitates the cessation of nursing. Follow-up of infants exposed to SSRIs has been conducted and it appears that cognitive and behavioral development is not adversely affected in follow-up studies of up to seven years. The antidepressant should be continued for nine to twelve months after response, and premature discontinuation may lead to relapse or early recurrence. Before starting the antidepressant it is wise to ask the woman if she has ever experienced elevated mood, decreased need for sleep and extra energy, that could suggest a bipolar disorder and the possibility of rapid cycling, if an antidepressant is used without a mood stabilizer. Recurrence rate for postpartum depression are in the range of 30-50% for the next pregnancy. It is advisable to ensure psycho/social support and close monitoring for patients at risk, and consideration may be given to prophylactic antidepressant use immediately postpartum for women who have experienced severe illness. Untreated postpartum depression can evolve into chronic dysthymia and a more difficult to treat illness. There is growing evidence of the impact of untreated maternal depression on the child, with higher rates of behavioral problems and cognitive deficits. Frisk factors for postpartum depression include significant antenatal depression or anxiety; psycho/social stress, such as marital discord or lack of support; a family history of affective disorder or a past history of depression or postpartum depression. Women who suddenly discontinue their antidepressants when the pregnancy is discovered can actually increase their risk of relapse of depression during the pregnancy to approximately 50%. Postpartum Depression is vastly under recognized and treated, resulting in long-term disruption of marital and extended family relationships, as well as bonding difficulties with the children. Without the awareness of and routine screening for postpartum depression, there is the potential for unnecessary suffering for the new mother, child and close family members. Thanks to Dr. Aruna Gottamukkala for reviewing the draft copy of this article. Dr. Gottamukkala is the Chair of the Department of Psychiatry at St. Martha's Regional Hospital in Antigonish Nova Scotia. References:
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