Postpartum Counseling – Postpartum Mental Health

(Updated July 2013)

Postpartum mood disorders pose health risks for mother and infant and impair family relationships,¹ yet mental health assessments often are not incorporated into postpartum care. Screening and counseling for disorders such as postpartum depression (PPD), anxiety, and obsessive-compulsive disorder (OCD) can prevent potentially serious consequences. Delay in receiving adequate treatment is associated with an increased duration (and perhaps severity) of PPD.² Clinicians must be proactive in identifying women at risk and providing appropriate counseling, referral, or both.

Postpartum mood disorders are usually grouped into the following categories:

• Baby blues
• Postpartum depression (PPD)
• Postpartum psychosis (PPP)³
• Postpartum anxiety (panic disorder, social phobia, generalized anxiety)⁴
• Postpartum obsessive-compulsive disorder (OCD)⁴

Baby blues refers to commonly occurring mood swings or mild feelings of sadness after childbirth. Also called postpartum reactivity, these feelings usually peak approximately three to five days postpartum and disappear within a couple of weeks after the baby is born.⁵ Postpartum depression, a far more serious disorder, usually develops within the first three months postpartum but may develop any time during the first year and includes symptoms such as low mood, sleep disturbance, and poor functioning.⁶ PPD affects up to 20 percent of postpartum women.^7,8 Potential for the development of postpartum psychosis is highest within the first few weeks after childbirth. Onset is sudden and characterized by hallucinations, delusions, agitation, and other psychotic symptoms. Incidence is estimated at one to three per 1,000 postpartum women.⁹

Postpartum anxiety and OCD are less well-recognized disorders and may occur on their own or in conjunction with depression. Anxiety affects 5 to 20 percent of new mothers; onset can be sudden or gradual.¹⁰ The woman may worry excessively or feel anxious, have a short temper, feel irritable and sad, or experience unusual symptoms of anxiety. Roughly 3 to 5 percent of postpartum women experience obsessive symptoms—intrusive, repetitive, and persistent thoughts or mental pictures (often about harming their baby), as well as behaviors targeted to reducing anxiety. Clinicians should maintain a heightened alertness for the range of possible symptoms that may indicate a mental health problem in a postpartum woman so that early treatment can be initiated.¹¹

Risk factors. Hormonal changes are theorized to be a causative factor in postpartum mood disorders, and such changes may affect women predisposed to the development of mood disorders most.^12,13 The stress of dealing with a newborn, lack of sleep, and nutritional deficiencies may exacerbate the problem.¹⁴ Other factors known to put women at risk for the development of serious postpartum mood changes should be assessed by the clinician periodically during pregnancy, after delivery, and at the time of the postpartum followup visit.¹⁵ These risk factors include a personal or family history of depression, anxiety, bipolar disorder, or other mental illness. Stress, marital conflict, single status, young age, lack of social support, low self-esteem, infant temperament, unplanned pregnancy, unplanned cesarean birth, pre-term labor and delivery, perinatal complications, and fatigue also may signal vulnerability.^16-19

Some women may experience depressive or anxiety-related symptoms when they breastfeed or encounter difficulties with the breastfeeding experience. Similarly, when a woman stops breastfeeding, she may experience these symptoms, likely because of significant hormonal shifts. Many women also may feel sadness and a sense of loss after they stop nursing.

Screening. Both provider-administered and patient self-report assessment tools have been recommended to identify women at risk for PPD. The Postpartum Depression Predictors Inventory (PDPIRevised) provides a guide for interviewing a patient at any point between the preconception and postpartum periods.¹⁵ It includes questions related to 13 predictors of PPD and assists the clinician in identifying issues for discussion and possible intervention.

Two well-tested, self-administered screening tools are available. The Edinburgh Postnatal Depression Scale (EPDS) assesses depressive mood in the past seven days based on patient responses to 10 questions related to mood, anxiety, guilt, and suicidal ideation.¹⁵ The Postpartum Depression Screening Scale (PDSS) comprises 35 items that cover seven dimensions: sleeping/eating disturbances, anxiety/ insecurity, emotional lability, mental confusion, loss of self, guilt/ shame, and suicidal thoughts.²⁰ Although the EPDS has fewer items than the PDSS, either can be completed by the patient within five to 10 minutes. The short-form Depression Anxiety Stress Scales (DASS-21) also can be used to diagnose depression or anxiety in postpartum women.²¹

Caring for the patient at risk. The way a health care provider manages postpartum mood disorders will depend on that practitioner’s level of comfort and expertise in dealing with mental and emotional problems, as well as the perception of the seriousness of the woman’s problem.

If a patient appears at risk for serious depression or postpartum-related anxiety, the primary care provider can:

• Acknowledge concern to the patient
• Reassure her that treatment is available, that it is NOT her fault, and that you—her health care provider—are there for her
• Encourage her to discuss how she is feeling
• Help her identify support systems and, if she consents, enlist their support
• Offer breastfeeding education and support, behavioral counseling, and ongoing reinforcement

Even women who exhibit no signs of depression, anxiety, or maladjustment at the time of the postpartum follow-up visit need to be educated about the ongoing risk of mood disorders beyond the initial month or two following childbirth. Hormonal shifts that can trigger mood swings or depression may occur at any time during the first year postpartum.¹²

Review some of the steps that the woman can take to help ward off depression or anxiety and promote general health:

• Get enough rest
• Call on family and friends for help
• Eat a well-balanced diet
• Get regular exercise
• Consider joining a mothers’ or postpartum support group
• Delay going back to work for at least six weeks postpartum²³

Treatment options. Treatments for postpartum mood disorders include psychological and pharmacological therapy. Research demonstrates that both individual and group counseling as well as cognitive-behavioral therapy can be effective. Selective serotonin reuptake inhibitors and tricyclic antidepressants are effective in treating postpartum depression and anxiety, and current research suggests little if any adverse effect on the infants of nursing mothers who take these drugs.^24-26 Carbamazepine, sodium valproate, and short-acting benzodiazepines also appear to be relatively safe during breastfeeding.²⁴ Further research is needed to clarify the risks of these drugs for newborns.

Close follow-up and an interdisciplinary approach are keys in the care of the woman experiencing mood disorders during the postpartum period.

References

1. Beck CT. Postpartum Depression: it isn’t just the blues. Am J Nurs 2006;106(5):40-50.
2. Beck CT. Theoretical perspectives of postpartum depression and their treatment implications. Am J Matern Child Nurs 2002;27(5):282-7.
3. American College of Obstetricians and Gynecologists. News Release: Answers to common questions about postpartum depression. 2002.
4. Rapkin AJ, Mikacich JA, Moatakef-Imani B, Rasgon N. The clinical nature and formal diagnosis of premenstrual, postpartum, and perimenopausal affective disorders. Curr Psychiatry Rep 2002;4(6):419-28.
5. Kennedy HP, Beck CT, Driscoll JW. Postpartum depression. J Midwifery & Women’s Health 2002 Sep-Oct;47(5):391.
6. Halbreich U, Karkun S. Cross-cultural and society diversity of prevalence of postpartum depression and depressive symptoms. J Affect Dis 2006;91(2-3):97-111.
7. Flores DL, Hendrick VC. Etiology and treatment of postpartum depression. Curr Psychiatry Rep 2002;4(6):461-6.
8. Milgrom J, Negri LM, Gemmill AW, McNeil M, Martin PR. A randomized controlled trial of psychological interventions for postnatal depression. Br J Clin Psychol 2005;44(Pt 4):529-42.
9. Indiana Perinatal Network. Postpartum depression consensus statement. Indianapolis, IN. October 2002.
10. Bennett SS, Indman P. Beyond the Blues—A Guide to Understanding and Treating Prenatal and Postpartum Depression. San Jose, CA: Moodswings Press; 2003. Available from: http://www.beyondtheblues.com. [Accessed July 14, 2003.]
11. Beck CT, Indman P. The many faces of postpartum depression. J Obstet Gynecol Neonatal Nurs 2005;34(5):569-76.
12. Parry BL, Newton RP. Chronobiological basis of female-specific mood disorders. Neuropsychopharmacology 2001;25(5 Suppl):S102-8.
13. Bloch M, Schmidt PJ, Danaceau M, Murphy J, Nieman L, Rubinow DR. Effects of gonadal steroids in women with a history of postpartum depression. Am J Psychiatry 2000;157(6):924-30.
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16. Cutrona C, Troutman BR. Social support, infant temperament, and parenting selfefficacy: a mediational model of postpartum depression. Child Dev 1986;57(6):1507-18.
17. Bozoky I, Corwin EJ. Fatigue as a predictor of postpartum depression. J Obstet Gynecol Neonatal Nurs 2002;31(4):436-43.
18. Britton JR. Pre-discharge anxiety among mothers of well newborns: prevalence and correlates. Acta Paediatr 2005;94:1771-76.
19. Zelkowitz P, Papageorgiou A. Maternal anxiety: an emerging prognostic factor in neonatology. Acta Paediatr 2005;94:1704-5.
20. Beck CT, Gable RK. Postpartum Depression Screening Scale: development and psychometric testing. Nurs Res 2000;49(5):272-82.
21. Miller RL, Pallant JF, Negri LM. Anxiety and stress in the postpartum: is there more to postnatal distress than depression? BMC Psychiatry 200612;6:28.
22. McGovern P, Dowd B, Gjerdingen D, Gross CR, Kenney S, Ukestad L, et al. Postpartum health of employed mothers 5 weeks after childbirth. Ann Fam Med 2006;4(2):159-67.
23. Dennis CL. Psychosocial and psychological interventions for prevention and postnatal depression: systematic review. BMJ 20052;331(7507):15.
24. Austin MP, Mitchell PB. Use of psychotropic medications in breast-feeding women: acute and prophylactic treatment. Aust NZ J Psychiatry 1998;32(6):778-84.
25. Gupta S, Masand PS, Rangwani, S. Selective serotonin reuptake inhibitors in pregnancy and lactation. Obstet Gynecol Surv 1998;53(12):733-6.
26. Epperson CN, Jatlow PI, Czarkowski K, Anderson GM. Maternal fluoxetine treatment in the postpartum period: effects on platelet serotonin and plasma drug levels in breastfeeding mother-infant pairs. Pediatrics 2003;112(5):e425.