Pregnancy and the arrival of a new baby is usually a joyous time for the new parents and their families. Months of planning, preparation for the new baby, and delivery can cause quite a bit of physical and emotional stress in the new mother. Because this is such an exciting time for new parents, new moms and their doctors focus on the immediate questions about the new baby such as feeding issues, vaccinations, developmental questions, safety, and minor infections. Pediatricians and Obstetricians often forget to ask the new moms about their emotional health. The incidence of major and minor depression varies between 6.5%-12.9% in the first year after the birth of a child. Every year there are more than 400,000 infants born to mothers who are depressed; this makes perinatal depression the most undiagnosed obstretric complication in America.
The symptoms of depression during the postpartum period ranges from “maternity blues” to postpartum depression and postpartum psychosis. Maternity blues can affect 60-80% of new mothers and occurs within a few days after delivery. Symptoms include crying, worrying, sadness, anxiety, and mood swings. These symptoms usually resolve on their own within 2 weeks and do not impair normal activities. The only treatment required is reassurance and emotional support from the family.
Postpartum depression occurs in up to 20% of mothers after birth. The symptoms meet the DSM-IV criteria for depression. In general, major depression is diagnosed when a person has at least 5 of 9 following symptoms for at least 2 weeks, occurs most days, and is changes her level of functioning. Also the depessed symptoms are not related to medications, medical condition, normal grief or loss.
a. Depressed mood.
b. A significantly reduced level of interest or pleasure in most or all activities.
c. A considerable loss or gain of weight (e.g., 5% or more change of weight in a month when not dieting). This may also be an increase or decrease in appetite.
d. Difficulty falling or staying asleep (insomnia), or sleeping more than usual (hypersomnia).
e. Behavior that is agitated or slowed down. Others should be able to observe this.
f. Feeling fatigued, or diminished energy.
g. Thoughts of worthlessness or extreme guilt (not about being ill).
h. Ability to think, concentrate, or make decisions is reduced.
i. Frequent thoughts of death or suicide (with or without a specific plan), or attempt of suicide.
Postpartum psychosis affects about 1 to 3 mothers per 1000 deliveries and usually happen within the first 4 weeks after delivery. These mothers are severely affected and may have paranoiea, mood shifts, hallucinations, delusions, and suicidal and homicidal thoughts. This is a very serious problem and will require hospitalization and immediate medical treatment. Mothers with a history of bipolar disorder are at higher risk of developing post partum psychosis.
Postpartum depression affects the mother-baby bonding which leads to an environment that can affect the baby’s development. Early brain development is highly sensitive to the enviroment; brain cell migration and connections are affected by environment and genetics. MRI scans have changes in the brain in children who lived in neglectful environments. Infants also show impaired social interaction and developmental delays. If there is no early intervention, the baby becomes less and less responsive to treatment. Studies have shown that maternal deperession can negatively affect intelligence, social and emotional development, and behavior of a child. Language development depends on the number of words spoken, playing, and cuddling with the infant; these behaviors are less likely to occur in a family of a depressed mother. Research has shown infants as young as 2 month of age looks at the depressed mother less often and have a lower activity. Parenting skills are also affected which can lead to poor attention to and judgment about supervision of safety and health issues. Early and continued treatment of the mother’s depression has shown improved functioning in the mother and child.
Many experts believe that the Primary Care Physician (PCP) is key in screening and identifying depression. Unfortunately not all Pediatricians or Obstetricians are trained to screen for postpartum depression. A recent study from the University of Pittsburgh followed 731 families to see the effect of intervention for maternal depression on the behaviors for children between 3 and 4 years of age. The researchers concluded that reductions of maternal depression improved the children’s behavioral problems. Many Pediatricians agreed that they should be screening for maternal depression but they were concerned about their lack of training in the screening process and treatment of maternal depression and the lack of resources to refer those mothers who were identified to have depression. To address this issue, The Parental Well-Being Project of Dartmouth Medical School used a simple 2- question screen. It was found to be effective in screening for depression but only used in 67% of well-child visits. Although the PCP may not be able to address the mother’s depression, the PCP may have a role in supporting the mother and facilitating her access to resources.
The American Academy of Pediatrics endorses the Bright Futures program. This program has guidelines that include screening for depression. Useful tools for depression screening are the Edinburgh Postnatal Depression Scale and the 2-Question screen. It is recommended that the screening is done at the 1-, 2-, 4-, and 6-month visits. The Edinburgh scale is a 10 question screen and a score of > 10 indicates a risk for depression and an affirmative response for Question 10 (suicidality indicator) constitutes a postive screen.
The 2-question screen is:
Over the past 2 weeks:
1. Have you ever felt down, depressed, or hopeless?
2. Have you felt little interest or pleasure in doing things? One yes is a positive screening result.
The key to treatment is to realize that(1) the mother is not alone in having postpartum depression, (2) she is not to blame (hormonal changes are a big part), and (3) she will get better. Treatment should include addressing the mother-child relationship. If the mother does not get adequate treatment this will affect attachment issues, growth, abuse/neglect, and developmental delay. New mothers should actively discuss their feelings with their Obstetrician and Pediatricians. There are many resources available to new mothers such as What to Expect When You're Expecting and Postpartum Depression For Dummies.