Know the many faces of postpartum depression

The cause of postpartum depression (PPD) is unknown, but several factors are thought to contribute to it. Biological factors include hormonal changes and sleep deprivation, and psychosocial factors include changes in social roles, marital issues, family structure, and the changing patterns of daily life, says Madelaine M. Wohlreich, MD, associate professor of psychiatry in the department of psychiatry and behavioral sciences at Emory University School of Medicine in Atlanta. Perhaps the most significant risk factor is a prior history of a psychiatric disorder, she adds.

There are actually four manifestations of postpartum mood disorders, says Wohlreich, who believes all maternity patients should be considered at risk for them. Categorized by severity, here are the four types:

• The "baby blues," which affects up to 80% of all new mothers, is characterized by frequent bouts of crying over a one- to two-day period shortly after the baby’s birth.

Postpartum depression, which affects about 10% of new mothers, is characterized by persistent low moods, decreased appetite, irritability, sleeplessness, and hopelessness, among other symptoms of general depression.

Anxiety disorders are accompanied by palpitations, sweating, dizziness, and shortness of breath.

Postpartum psychosis is a rare occurrence characterized by a loss of contact with reality.

(For more details about these types of mood disorders, see chart, "Common Postpartum Emotional Disorders," inserted in this issue.)

To determine whether normal postpartum occurrences such as weight and sleep loss are actually signs of PPD, Wohlreich finds it helpful to ask about the woman’s sleeping patterns. If she can sleep when the baby is sleeping, she’s probably not suffering from depression, but if she feels "wired" all the time and unable to sleep, it’s best to probe a little deeper.

Linda Sebastian, MSN, director of the women’s program at the Meninger Clinic in Topeka, KS, agrees. She says direct questions about the patient’s mood are the most helpful, such as:

• How have your moods been?

• Have you had episodes of crying?

• Have you had episodes of anxiety or panic?

• Have you felt as if you wanted to hurt yourself or the baby?

Hostile fantasies or thoughts of harming the infant are surprisingly common for women suffering from PPD, Wohlreich says, adding that these thoughts are rarely acted upon but cause tremendous guilt.

Sebastian, who is working on a layperson’s book about PPD, advises health care providers to stress that these feelings don’t mean women are bad mothers or don’t love their babies.

Women with severe emotional distress can benefit from antidepressant therapy, but they would have to stop breast-feeding before taking the drugs, Wohlreich says. Low levels of the medication can be found in breast milk, and safe levels haven’t been determined for infants. She suggests negotiating a "waiting period," perhaps two weeks, during which time if her mood hasn’t improved, she’d begin the drug treatment.

"When it is explained to the patient that her full emotional function is now more crucial to her baby than breast milk, most patients will agree to terminate breast-feeding in order to initiate necessary medication," Wohlreich explains.