Dr:Eman Elsheshtawy

Ass. Prof. Psychiatry

Transient

Heightened emotional reactivity

50-85% women experience baby blues

Peaks 3-5 days after delivery

Lasts up to 10-14 days

Considered normal experience of childbirth

Symptoms can be distressing

Usually don’t affect mother’s ability to function and care for child

Characteristics:Mild mood swings Irritability Anxiety Decreased concentration Insomnia Tearfulness Crying spells

Two leading hypothesis:Abrupt hormone withdrawalOvarian steroid receptors in CNS are heavily concentrated in the limbic system

The magnitude of the postpartum drop in estrogens and progesterone correlates with presence of “blues”; absolute levels don’tNeuroactive steroids (pregnanolone, allopregnanolone) decrease postpartum, affecting GABA

Neurobiological systems foster attachment between mammalian mothers & infants

Oxytocin activates limbic structures (e.g. the ACG) that mediate the interface between attention & emotion

Postpartum reactivity may stem from this

With stressors, depression may result

About 10% of women after delivery

Average duration 7 months

¼ still affected at child’s first

birthday

Overlooked and under diagnosed

Female is a 27 year old mother brought into my office as an urgent care appointment. She just had a baby 4 weeks ago after much anticipation. Her husband is an only child and her in-laws filled the nursery with toys and clothes for the baby and are very excited .

She is unable to sleep and eat, extremely doubtful of her ability to do anything.She is preoccupied with the fear that she will harm the baby and intense guilt of her inability to meet the expectations of the family.She has been thinking that how easy it is kill herself than to be this worthless

Depression negatively effects:

Mother’s ability to mother

Mother—infant relationship

Emotional and cognitive

development of the child

Infants perceived to be more bothersome

Make harsh judgments of their infants

Feelings of guilt, resentment, and ambivalence toward child

Loss of affection toward child

Gaze less at their infants

Take longer to respond to infant’s utterances

Show fewer positive facial expressions

Lack awareness of their infants

Negative interactive patterns with infant

Children exposed to maternal psychiatric illness have:

Higher incidence of conduct

disorders

Inappropriate aggression

Cognitive and attention deficits

London study 2001 demonstrated lower IQ’s in 11 year olds whose mothers were depressed at 3 months age

Increased behavior concerns and ADHD (sp. in boys)

Shorter duration of breastfeeding in PPD

Continued breastfeeding in PPD was protective

Patient, society, and physicians dismiss or minimize patients experiences as “normal”

Patient without a primary care physician don’t know who to turn to

Women’s fear and shame about not being a “good mother”

Patients don’t present with CC of depression

Noted in medical history since Hippo crates Recognized in DSM-IV in 1994

Major depression that occurs within 4 weeks of deliveryDefinition used by researchers usually

allows up to 6 months 5 symptoms, every day, at least 2

weeksAND functional impairment

Depressed moodLack of pleasure or interestAppetite disturbance or weight loss*Sleep disturbance*

Physical agitation or psychomotor slowingFatigue, loss of energy*

Feelings of worthlessness or excessive guiltDiminished concentration, or indecisiveness*

Thoughts of death or suicidal ideation ,Thoughts of harming infant

Severe Symptoms:Thoughts of dyingThoughts of suicideWanting to flee or get awayBeing unable to feel love for the babyThoughts of harming the babyThoughts of not being able to protect the

infantHopelessnes

Cause unclear

Rapid decline in reproductive

hormones

Several factors increase risk

Prior episodes depression, anxiety, OCD, bipolar d/o, eating d/oPrior depression = 25% risk PPDPrior PPD = 50% risk recurrent PPD

Stressful life events FHx mood disorders Hx of PMDD Inadequate social support

Education level

Sex of infant

Breastfeeding

Mode of delivery

Planned or unplanned pregnancy

During PregnancyA young and single motherH/O Mental illness or substance abuseFinancial or relationship difficultiesPrevious Pregnancy or postpartum depression

After BirthLabor/Birth ComplicationsLow confidence as a parentProblems with Baby’s HealthLack of supportsMajor Life change at the same time as birth of the baby

2:1,000 birthsPsychiatric emergencyUsually within 3 weeksUsually manifestation of bipolar d/o

70% women experience recurrence in PPP

Severe disturbances Rapidly evolving manic episodes Dramatic presentation Initial signs are restlessness,

irritability, insomnia Infanticide: 4% of untreated PPP Suicide: 5% of untreated PPP

Confusion/disorientationExtreme disorganization of thought Bizarre behaviorUnusual hallucinations Visual, olfactory, or tactile

Delusions (often centered on the infant)

HyperactivityNot feeling need to sleepRapid speechLoss of touch with reality

Inform the publicDepression screening in public health settingsProvide appropriate referralsPartnership with mental health, social service agenciesFollow up care (home visits, support services

“Behind the Smile: My Journey Out of Postpartum Depression”, Marie Osmond

“Down Came the Rain”, Brooke ShieldsAnne Lamott, “Operating Instructions: A Journal of My Son’s First Year”

Depression After Delivery 1-800-944-4PPD( ://http

. .www depressionafterdelivery com)National Women’s Health Information Center (www.4woman.gov)Postpartum Support International 1-805-967-7636