NOT ALWAYS
HAPPY
Postpartum depressive
disorders
NOT ALWAYS
HAPPY
Postpartum depressive
disorders
Mental health aspects of women’s
reproductive health. A global
review of the literature (WHO,
2009)
„There is now a consistent
view that psychological
disturbance following childbirth
can be conceptualized as
fittingone of three distinct
conditions, of differing severity:
transient mood disturbance,
depression
and psychotic illness.” (p.15)
Types of postpartum
depressive disorders
Postpartum blues
Postpartum
depression
Postpartum
psychosis
Not listed in DSM-IV
In ICD-10 – no
special category of
depression (only
episodes of
depression, but…
F53.0 - mild disorders
F53.1 severe
disorders
Postpartum blues
2-4 days after delivery
Usually lasts up to 2 weeks
Even in 80-85% of new mothers
Non-Anglophone 13- 50%
France 42%
Jamaica 60%
Arab countries 24%
Symptoms:
Episodes of crying
Emotional lability
Disturbances in sleep and appetite
Postpartum blues – causal
factors
Emotional problems and depression in
pregnancy
Depressive symptoms before pregnancy
Premenstrual syndrome
Depressive symptoms more often in
older and better educated women (only
in normal pregnancy)
Negative mood across time
(Murray & Cooper, 1997)
What is postpartum
depression?
...nonpsychotic
depressive episode
that begins in or
extends into the
postpartum period
Dysphoric mood
sleep, appetite or
psychomotor
disturbance
fatigue
excessive guilt,
suicidal thought
AT LEAST 1 WEEK
„In practice, it is common for any
episode of depression during this
period (1 year after childbirth) to
be regarded as linked to the birth
(Scottish Intercollegiate
Guidelines Network, 2002).” p. 17
Prevalence (how often?)
Oxford, UK - 8,7%
Edinburgh, UK - 9,9%
Iowa, USA - 10,4%
In teenage mothers –
26-32% (Aiken, 2000)
Single, young vs.
older than 30 yrs
Comparisons with
nonchildbearing
women show similar
rates of depression
prevalence!
Postpartum depression -
symptoms
Low mood
Anxiety, being affraid of harming a baby
Guilt feelings
Low evaluation of oneself as the mother
Fatigue, poor concentration
Disturbances in sleep and appetite
Negative mood across time
EPDS scores > 13
,
(A.Mandy 1998)
Timing of onset (when?)
Within 3 months after the delivery
Kumar & Robson (1984) - 3 times as
many new cases as within 6 or 12
months
Watson et al. (1984) - 2/3 of all new
cases diagnosed during 1 postnatal year
Cox (1993) - 50% in the first 5 weeks
O’Hara (1990) - 69% within 3 weeks
Depression in pregnancy and 1st postartum
year (M. Eberhard-Gran et al., 2004 -
Norway)
Mental health aspects of women’s
reproductive health. A global
review of the literature (WHO,
2009)
„Despite the impression of
well-being in pregnancy,
comparable rates of depressive
symptoms have been
found among pregnant and
non-pregnant women. Large
systematic studies have
shown that rates of depression
in late pregnancy are
as high or higher than rates
of postpartum depression
(Zuckerman et al., 1989;
Da Costa et al., 2000; Evans
et al., 2001; Josefsson et al.,2001)” . p. 12
Duration of an episode
Watson et al. (1984)
1/4 subject
3 months+, 1/4
6
months+
Kumar & Robson (1984)
50% 6 months or more
Campbell et al. (1992)
15 weeks or more
Burt & Hendricks (2005) – 4-8 weeks
similar duration in mothers and others
Postpartum depression - causal
factors
Background factors
rarely socioeconomic factors, but…
In some studies depression more oftern in less educated
women (Johnstone et al., 2001; Tammentie et al., 2002)
Single motherhood
Unplanned pregnancy (Beck, 2001)
Biological (Harris, 1989, O’Hara, 1991)
lower level of progesterone – inconclusive
In breast feeding mothers – depression when low level
In bottle feeding mothers – depression when high levels
lower level of estradiol
Causal factors -2
Gynaecological / obstetric
more in women with premenstrual tension
(Dennerstein 1988)
delivery complication - less (Paykel et al.,1980;
Pitt, 1968)
forceps or caesarean section (CS) - more
depression (O’Hara et al., 1991)
more recent studies (Hiltunen et al., 2004) – no
links between CS and depression
When anesthetics were used in labour – less depression
in 1st postpartum week (effect not present in 4th month
follow-up)
abortion or miscarriage - no increased risk
Causal factors - 3
Stressful life events
more stresses - more depression (Hopkins et
al.. 1987)
Poor marital relationships
in pregnancy, postpartum - Gotlib, 1991;
Whiffen, 1988; Rubertsson et al. 2005
Lack of social support
Cutrona, 1984, O’Hara, 1994, Sender, 1999;
Eberhard-Garn et al., 2004
Causal factors - 4
Personal and family psychopatholgy
anxiety in pregnancy (Gotlib, 1991)
previous psychiatric disorders (Marks,
1992)
depressed mothers
Meta-analyses show little or no
association between family
psychopathology and postparum
depression (O’Hara & Swain, 1996)
Causal factors - 5
Psychological constructs
attributional style (Atkinson & Rickel,
1984; Cutrona, 1983; O’Hara et al., 1991)
Low self-esteem (WHO, 2009)
Attributional style can predict the
depressive symptoms NOT the diagnosis
of depression
Causal factors – 6 (Rubertsson
et al., 2005)
Swedish representative sample (N=3293),
tested in pregnancy (16 weeks) and 2
months postpartum
12,3% - high level of depressive symptoms
postpartum
In some women - depression only after delivery
In others - depression both in pregnancy and
postpartum
Causal factors – 7 (Rubertsson
et al., 2005)
Depression before and after delivery in
women who were:
Not employed
Younger than 25 yrs
Without a partner
Low educated
In unplanned pregnancy
Not receiving support from a child’s father and
others
In poor health
Experiencing at least 2 stressful events in the
year before pregnancy
Taking antidepresants before
Causal factors – 8 (Rubertsson
et al., 2005)
Depression after delivery when:
Almost the same characteristics, but the relevant
risk was smaller
Poor child’s health
Frequent crying
Poor weight gain
Two types of etiological factors:
Background and family factors (before &
after)
Child’s health/behaviour (after)
Mental health aspects of women’s
reproductive health. A global
review of the literature (WHO,
2009)
The birth of a daughter was found
to contribute independently to
postpartum depression in women
in India and Pakistan (Patel,
Rodrigues & DeSouza, 2002;
Chandran et al., 2002; Rahman,
Iqbal & Harrington., 2003) p. 14
Depression in men after the
birth of their offspring
Prevalence – 10 – 30% (Soliday et al.,
1999)
Portugal – 5% (WHO, 2009)
Australia – 2,8% (WHO, 2009)
Onset (Ballard et al., 1994)
6 weeks after the delivery
Intensity of symptoms might increase in
next 6 months
Variables related to men’s depressed
mood after the birth of their offspring
(Bielawska-Batorowicz & Kossakowska-Petrycka,
2006)
Depression in women and
difficulties in parental role at 1
year postpartum
(L. Seimyr et al., 2004.)
EPDS
2 mo
EPDS
1 year
Maternal role
1 year
Paternal role
1 year
0,46*
0,07
0,41
*
0,29*
0,1
5*
*p<0,0
5
0,42*
Some consequences
Perception of a baby as more difficult
(Edhborg, 2000)
Increased risk of future depression
over 5-years period
Phillips & O’Hara (1991) - 80% (42%
controls)
Cooper & Murray (1995) - 60% (35%)
Consequences (for mothers)
When postpartum episode is the first
depression then:
episode is of shorter duration
less likely nonpostpartum depression
more likely subsequent postpartum
episode
depression due to biological or
psychological elements of giving birth
Consequences for children
Infants whose mothers were
depressed postpartum show lower
scores in standard cognitive tests
The effect not observed when children
were 4-5 years old
Stronger effects of maternal depression
in disadvantaged families and when
depression lasts longer
Consequences for children -
2
When fathers are depressed
(Ramchandani et al., 2005)
In children:
Emotional and behavioural problems
Hyperactivity
The negative effects of parental
depression more often detected
in male infants
Postpartum psychosis
Prevalance 0,1 – 0,2 %
Tanzania – 0,32% (infections after delivery?)
In first month after delivery
Duration – several weeks (months)
Symptoms
Disorientation, ilusion, delusions, rapid mood
changes, insomnia
Postpartum psychosis considered as the
first episode of bipolar affective disorders
(Burt & Hendricks, 2005)