Read an Excerpt
Overcoming Postpartum Depression and Anxiety
By Linda Sebastian
Addicus Books, Inc.Copyright © 2016 Linda Sebastian, A.R.N.P.
All rights reserved.
Postpartum Disorders: An Overview
I was so excited about having baby. We had waited four years after we were married and saved our money, so I didn't have to go back to work. I worried about the baby having all its parts or being healthy, but I didn't worry about me. When I couldn't stop crying after I got home with the baby, I was so scared and thought I was a terrible mother. No one told me this might happen.
Annette, 32-year-old mother
Annette's anticipation of the birth of her child is common. Most women expect an uneventful pregnancy and delivery. If anything, women usually worry more about the health of their babies than about their own health. For the majority of women, this time in their lives is, indeed, a time of health, happiness, and well-being. However, many women experience problems with depression and anxiety both during their pregnancy and after delivery.
Because so many woman are not aware of potential emotional complications after childbirth, those who do have these problems often feel alone and isolated. This can have devastating consequences for the woman and her baby, and their relationship. Often, women assume that if they are depressed or anxious after the birth of a baby, it means they are not good mothers.
Starting the Journey of Discovery
If you are pregnant or a new mother, it is important that you and your family learn about symptoms that describe what you may be experiencing emotionally. For some women, it is a relief to know that there are medical reasons why they may feel anxious or depressed. You will also realize that you are not alone. Hundreds of thousands of other woman experience overwhelming and frightening feelings before, during, or after their pregnancies. This book is intended to explain the basics of postpartum depression and to provide guidance to help you cope and recover.
What Is Postpartum Depression?
Postpartum depression is a mood disorder that occurs in mothers after the birth of their babies. Sometimes, the depression starts during delivery, but for many women, the first weeks after delivery marks the beginning of a depression. Between 10 and 20 percent of women who have a baby will have some form of psychiatric symptoms, including depression. Postpartum depression is a term that includes a spectrum of problems, including postpartum blues on the mild end of the spectrum to the more severe end of the spectrum that includes postpartum depression (a major depression), postpartum anxiety, and post-partum psychosis. We'll examine an overview of each of these conditions in this chapter.
There is a strong connection between anxiety and depression. Just as most women who suffer from major depression also have some anxiety, women with anxiety disorders often experience some depression. Usually these problems occur together. In fact, one study found that a previous history of an anxiety disorder was a bigger risk factor for postpartum disorders than a previous episode of depression. Anxiety disorders are covered separately in chapter 4 to help you clearly understand the symptoms.
Because postpartum mood and anxiety disorders have different symptoms, different treatments, and possibly different causes, each one will be discussed separately in this book. Bear in mind, however, that sometimes the problems overlap and may be difficult to distinguish from one another. For example, in the second or third week postpartum, it may be difficult to tell if you are experiencing postpartum blues or postpartum depression. For this reason, it is important to consult a mental health professional as soon as you notice problems.
The term postpartum depression is often used to describe any psychiatric problem a pregnant or postpartum woman (one who has given birth) may have, even though actual depression may not be one of her symptoms. The unclear terms used for the various disorders adds to the confusion for much of the public as well as for some professionals. This means that women with depression or anxiety are often overlooked or are not seen as having significant problems. Clinicians know that anxiety disorders are common for pregnant and postpartum women; however, because these problems are not always recognized, some new mothers often go untreated.
In this book, I will use the specific terms postpartum blues, postpartum depression, postpartum psychosis, and post-partum anxiety. However, for the sake of clarity I will often use the more general term postpartum depression even though that term may not be the official clinical term for the problem being discussed.
Today, clinicians and researchers are beginning to use a new term — perinatal psychiatric disorders. (Perinatal refers to the time just before or after the birth of a baby.) This term represents the understanding that many of the problems with mood and anxiety we see in the postpartum period actually begin during pregnancy. Perinatal psychiatry is a subspecialty in the field of psychiatry that began emerging in the early 1990s.
Types of Postpartum Disorders
Let's examine the various types of postpartum disorders to better understand the levels of depression a woman may experience. Each of these conditions will be examined more thoroughly in later chapters.
The term baby blues refers to a brief time of temporary tearfulness, mood swings, fatigue, and perhaps irritability that typically lasts only one to two weeks after childbirth. This is common after giving birth and bringing a baby home. The baby blues usually resolve without treatment. But while they last, it is upsetting for the new mother and her family.
Postpartum depression refers to a state of major depression in which one's mood is marked by feelings of guilt, sadness, lack of enjoyment, fatigue, and problems in concentration. More severe symptoms may include thoughts of harming yourself or your baby.
This mood disorder is characterized by fluctuating moods. There are episodes of depression at times and then there may be periods of excessive energy and grandiose thinking. Other symptoms of bipolar disorder may include irritability, impulsivity, and poor judgment.
Several kinds of [anxiety disorders can occur during and after pregnancy. Anxiety disorders include a spectrum of fearful states. These disorders range from excessive and uncontrollable worry in generalized anxiety disorder, to symptoms such as a racing heart, shortness of breath, and episodes of fear in panic attacks.
Psychosis is a state of confusion, agitation, being out of touch with reality, and having delusions (false beliefs) and/or hallucinations (seeing things or hearing things that are non-existent). For example, a new mother may hear voices telling her to kill her baby; or the voices may convince her that the baby is possessed or is a demon. Postpartum psychosis is considered a psychiatric emergency because of the risk of harm to the baby and the mother. This condition usually develops within the first few days after delivery.
Post-Traumatic Stress Disorder
Post-traumatic stress disorder (PTSD) is a specific kind of anxiety disorder marked by re-experiencing a trauma such as a health scare for the pregnant mother or her fears about the health of the fetus. She may also have nightmares and wish to avoid any situations that provoke unwanted thoughts or feelings. With post-traumatic stress disorder, these symptoms do not lessen in intensity over time. It is becoming apparent that this condition is more common than was previously known, and can have long-lasting consequences for the mother and baby.
Obsessive-Compulsive Disorder (OCD)
This disorder is often overlooked but is actually quite common in the postpartum period. Obsessions are repetitive intrusive thoughts, and compulsions are repetitive behaviors that are accompanied by feelings of guilt and shame. A woman suffering from OCD is unable to stop the thoughts and behaviors and sometimes has difficulty taking care of her baby.
Causes of Postpartum Disorders
Clinicians and researchers still do not know why some women will have psychiatric problems during pregnancy and after delivery while others will not. There is ongoing research about genetic predisposition and the role of stress, but not all women are affected in the same way. Many people assume hormones are the culprit. However, all women experience the same hormonal shifts during pregnancy and after delivery, but not all women get depressed or anxious.
Causes of specific postpartum disorders will be discussed in more depth in later chapters. Although the causes of these disorders are not completely clear, there is considerable research about the risk factors that may predict who will develop problems.
Each disorder described in this book has a unique set of symptoms that are used for reaching a diagnosis; the symptoms for each type of disorder will be explained in subsequent chapters.
Risk Factors for Postpartum Disorders
Even though clinicians and researchers are unable to pinpoint an exact cause of every case of postpartum disorder, they have been able to identify factors that are known to put women as risk for postpartum problems.
Previous Episode of Depression or Anxiety
If a woman has previously suffered depression after childbirth or has had other episodes of depression or anxiety in her lifetime, she is among those most likely to develop problems with the birth of a child and perhaps during pregnancy. She is also at risk if she has experienced severe postpartum blues or has had mood changes related to her menstrual cycle.
Researchers in Italy conducted a fairly large study of 600 pregnant women to see if panic disorder (a specific type of anxiety marked by episodes of panic or fear of death) was a strong predictor of postpartum depression. They found that of all the anxiety disorders, panic disorder or even a family history of panic disorder was a strong predictor of mood disorders after the birth of a baby.
Major Stress Resulting from Change
Another risk factor is major stress or change during pregnancy. Even a positive change such as a move to a new house may place more emotional burden on a pregnant woman. Other stressors, such as a death in the family, conflict with a spouse or partner, and even financial stress, can have an adverse effect on the new mother.
A Mother's Health Concerns for Herself or Her Baby
Problems with the mother's health during pregnancy and delivery are a significant risk factor for postpartum problems. These problems range from a mother's fears of elevated blood pressure to concerns about becoming anemic. (If you're anemic during pregnancy, your red blood cells may not be delivering enough oxygen to your tissues and the baby.) Other stressors a pregnant woman may find herself facing are concerns about the health of the baby before and during delivery. For example, during delivery, a newborn's heart rate is constantly monitored; if there are irregularities in the baby's heart rate, it is an issue that will be of concern to medical staff. If there has been a "scare" during delivery, it is not uncommon for a new mother to have nightmares about the baby having health problems even after the baby has arrived and is doing well.
Lack of Emotional Support
A non-supportive spouse or partner may make the new mother at more risk for developing depression. If family members are not supportive or helpful, the new mother may feel isolated. Also, the time at home after a baby is born may lead a new mother to be more socially isolated, especially if she worked outside the home before delivery. Further, if the new mother is not well acquainted with neighbors, she'll lack close-by emotional support.
Childhood Abuse and Trauma
Two significant risk factors for depression in general, not only during pregnancy and postpartum, are childhood abuse and trauma. Sexual abuse, physical abuse, neglect, and overwhelming traumatic experiences such as the loss of a parent or sibling place women at risk for depression and anxiety even without the added stress of pregnancy and motherhood. Previous abuse and trauma that has not been addressed may become more prominent during this time of major change in a woman's life as she becomes a new mother.
According to studies in multiple cultures, a premature birth increases the risk for postpartum depression significantly. Premature birth, also known as preterm birth, occurs when a baby is born before thirty-seven weeks of pregnancy. Preterm birth is the greatest contributor to infant death.
Preterm birth in the United States occurs in one out of ten deliveries — about 10 percent. It is much higher in some countries, such as Pakistan, where the preterm birth rate is as high as 15 percent, and it is lower in Europe, at 6 percent.
Previous Pregnancy Loss
Although a previous pregnancy loss is known to be a risk factor for developing symptoms of postpartum disorders, the impact on women who have experienced more than one pregnancy loss seems to be even greater. According to some researchers, recurrent pregnancy loss can adversely affect up to 3 percent of women wanting to have a child.
Thirty-seven studies looked at intimate partner violence as a risk factor for postpartum disorders. Researchers found that exposure to partner violence increased the risk for major depression in women two- to threefold. And the increase for post-partum depression was one and one-half- to twofold. Spouse or partner abuse is a risk factor for a woman to experience depression at any stage of life, so this is not a surprising finding.
Other Risk Factors
A longtime nurse researcher in the field of perinatal psychiatry, Cheryl Beck, Ph.D., conducted an analysis of eighty-four studies to further examine risk factors. In addition to the risk factors mentioned above, Dr. Beck discovered that an unplanned pregnancy may put a woman at risk for mood changes. Dr. Beck also found infant temperament, such as a difficult-to-soothe baby, may be a major stressor for the mother. Poor-quality child care, or the lack of child care, can negatively impact the mother's mental health. Marital status, such as being unmarried even if the relationship is stable, may influence a women's mood or anxiety during pregnancy or after delivery.
Predicting Who's at Risk
It is helpful to detect problems with mood or anxiety as early as possible in order to begin treatment or perhaps provide resources to help prevent problems. If women, their families, and clinicians know the risk factors and address the problems early in the pregnancy, they can attempt to lessen the severity of or even possibly prevent the illness.
Being aware of risk factors is important because of the frequency of postpartum psychiatric problems. Sixty to 80 percent of all women who bear children experience milder problems such as postpartum blues, and about 10 to 20 percent will develop major depression or severe anxiety. Only 1 percent develop the more severe psychotic depression.
To detect women at risk for postpartum depression and anxiety, and refer them to appropriate psychiatric professionals, obstetricians and nurse midwives will ask pregnant women a few questions about their mental health history. Questions about the stress levels in the woman's life — especially about the quality of her marital relationship — are just as important as questions about physical symptoms. Lisa's story attests to this:
I was told I was at risk and was referred to a therapist in my third trimester. I was so relieved to have someone recognize that I needed psychological help as well as monitoring of my pregnancy. Things went much better because I had emotional help and support.
One tool that has been used for many years by clinicians and researchers for screening for postpartum disorders is the Edinburgh Postnatal Depression Scale, shown below.
You may wish to answer the questions and then follow the scoring directions at the end of the questionnaire. Important note: this questionnaire is a screening tool only. Do not use it to diagnose yourself. It is an indicator of depression and does not detect anxiety. Answer the questions based on how you have felt the past week.
Excerpted from Overcoming Postpartum Depression and Anxiety by Linda Sebastian. Copyright © 2016 Linda Sebastian, A.R.N.P.. Excerpted by permission of Addicus Books, Inc..
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