postpartum depression
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POSTPARTUM DEPRESSION
BY:
NAME: FARAH HUSNA MOHD FADZIL
NIM: 040100848
DEPARTMENT OF PSYCHIATRY
FACULTY OF MEDICINE
UNIVERSITY OF NORTH SUMATERA
MEDAN
2009
2
CONTENTS
ACKNOWLEDGEMENT…………………………………...4
Chapter 1
1.1 Introduction ………………………………………...5
1.2 Prevalence…………………………...……………....5
Chapter 2
2.1 Definition
2.1.1 Definition of Depression……………………………6
2.1.2 Definition of Postpartum Depression….……………7-8
2.2 Epidemiology ……………………………………….9
2.3 Etiology ……………………………………………..9
Factors that causes depression :
2.3.1 During Pregnancy……………………………………11
2.3.2 After Pregnancy……………………………………...11-12
2.4 Diagnosis …………………………………………….13
2.5 Clinical features ……………………………………..14
2.6 Differential diagnosis………………………………...15
2.7 Prognosis:…………………………..……………..…..16
2.8 Treatment ………………………………….................16
2.8.1 Psychological Treatment………………………………17-18
2.8.2 Medical Treatment……………………………………..18-20
2.9 Complication ………………………………………….20
2.10 Summary………………………………………………21
References …………………………………………………..22
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POSTPARTUM DEPRESSION
This article was written to comply with the conditions of Clinical Postings, Deparment of Psychiatry, Faculty of Medicine USU.
By : Farah Husna Mohd Fadzil (040100848)
Instructor :
Dr. Hj Abdul Rasyid bin Hj. Said Ssp, AMP, M. Med Psyc (HTF)
Prof. Dr. Bahagia Loebis, SpKJ
Prof. Dr. Syamsir BS, SpKJ
Dr. Raharjo S, SpKJ
Dr. Elmeida Effandy, SpKJ
Name of Deparment : Department of Psychiatry FM USU,
Department Of Psychiatry,
Hospital Tuanku Fauziah
Year : 2009
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Acknowledgement
First and foremost I would like to thank the god for setting me up in this
challenging but yet interesting journey of medical education and provide
me the opportunities to excel as a healer.
This journal has materialized only partly due to my efforts. I thanked the
Department of Psychiatry Haji Adam Malik/ FK USU and its dedicated
lecturers for guiding me in completing this journal as a part of my
education. Special thanks is forwarded to the HOD Prof Syamsir BS,
SpKJ, Co-ordinator Dr. Elmeida Effendy SpKJ and our evaluator Prof
Bahagia Loebis SpKJ.
I would also like to extend my gratitude to my parents whom without
them I would never be able to set my foot in the pathway of medicine.
Thanks also to my friends and other contributors for both material and
moral supports.
Hopefully this journal will benefits all those who would like to
understand everything regarding Postpartum Depression.Comments and
critiques are appreciated.
Kangar 29th May 2009
Farah Husna Mohd Fadzil
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Chapter One
Postpartum Depression
1.1 Introduction:
True postnatal depression can be a severe mental illness. However, the massive
hormonal, physical, and emotional effects from childbirth and a new baby are well
known to cause emotional symptoms. It is normal to suffer some level of "baby
blues", and particularly common is some level of crying or distress on the third day
after birth. It's not easy being a mother and first-time mothers often feel
overwhelmed. A new mother feeling down, moody, or a bit "depressed" does not
usually warrant the diagnosis of full postnatal depression. However, persistent
depressive symptoms do need professional medical investigation.
1.2 Prevalence:
The prevalence of Postpartum depression in the general population is 10% among
pregnancies. While the estimation of its occurrence range from 3% to 20% of births.
However, Postpartum depression is a commonly misdiagnosed disorder affecting
10 - 17 percent of women.
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Chapter Two
Discussion
2.1 Definition:
2.1.1 Definition of Depression
Depression can be described as feeling sad, blue, unhappy, miserable, or down in the
dumps. Most of us feel this way at one time or another for short periods. But true
clinical depression is a mood disorder in which feelings of sadness, loss, anger, or
frustration interfere with everyday life for an extended time. Depression can be mild,
moderate, or severe. The degree of depression, which your doctor can determine,
influences how you are treated.
For every woman, having a baby is a challenging time, both physically and
emotionally. It is natural for many new mothers to have mood swings after delivery,
feeling joyful one minute and depressed the next. These feelings are sometimes
known as the "baby blues", and often go away within 10 days of delivery. However,
some women may experience a deep and ongoing depression which lasts much
longer. This is called postpartum depression.
References to postpartum depression date back as far as the 4th century BC. Despite
this early awareness, it has not always been recognized as an illness. As a result,
postpartum depression continues to be under-diagnosed. It is an illness that can be
effectively treated. The sooner the condition is diagnosed, the more effective the
treatment. It is important to recognize and acknowledge the symptoms of postpartum
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depression in yourself or another as soon as possible. This can be difficult, since the
depressive feelings often involve intense and irrational feelings of fear. The mother
may fear she is losing her mind or fear that others may feel she is unfit to be a
mother.
2.1.2 Definition of Postpartum Depression
Postpartum depression is defined by the DSM-IV as the onset of depressive
symptoms within 4 weeks of childbirth. Symptoms are very similar to major
depression, and can also include fluctuations in mood, preoccupation with infant
well-being, as well as at times just the opposite, complete disinterest in the infant
which, if prolonged, may result in failure to thrive syndrome.
A woman with PPD may also have feelings similar to the baby blues -- sadness,
despair, anxiety, irritability -- but she feels them much more strongly than she would
with the baby blues. PPD often keeps her from doing the things she needs to do every
day. When a woman's ability to function is affected, this is a sure sign that she needs
treatment. If a woman does not get treatment for PPD, it can get worse and last for as
long as a year.
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Difference between "baby blues," Postpartum Depression, &
Postpartum Psychosis
Researchers have identified other form of condition related to postpartum depression
which is baby blues and postpartum psychosis.
The baby blues can happen in the days right after childbirth and normally go away
within a few days to a week. A new mother can have sudden mood swings, sadness,
crying spells, loss of appetite, sleeping problems, and feel irritable, restless, anxious,
and lonely. Symptoms are not severe and treatment isn't needed. But there are things
you can do to feel better. Nap when the baby does.
Postpartum depression can happen anytime within the first year after childbirth. A
woman may have a number of symptoms such as sadness, lack of energy, trouble
concentrating, anxiety, and feelings of guilt and worthlessness. The difference
between postpartum depression and the baby blues is that postpartum depression
often affects a woman's well-being and keeps her from functioning well for a longer
period of time. Postpartum depression needs to be treated by a doctor. Counseling,
support groups, and medicines are things that can help.
Postpartum psychosis is rare. It occurs in 1 or 2 out of every 1000 births and usually
begins in the first 6 weeks postpartum. Women who have bipolar disorder or another
psychiatric problem called schizoaffective disorder have a higher risk for developing
postpartum psychosis. Symptoms may include delusions, hallucinations, sleep
disturbances, and obsessive thoughts about the baby. A woman may have rapid mood
swings, from depression to irritability to euphoria
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2.2 Epidemiology:
In developed countries, PPD occurs in about 12% to 13% of postpartum women.
More recently, the rates in the United States have been reported as 10% to20%.
Transculturally, the rates are estimated at 10% to 15%, with a higher rate in
adolescent mothers.Many symptoms are similar to those that naturally follow
childbirth, such as lack of sleep, appetite changes, fatigue, decreased libido, and
mood lability. The exact number of women with depression during this time is
unknown. But researchers believe that depression is one of the most common
complications during and after pregnancy. Often, the depression is not recognized or
treated, because some normal pregnancy changes cause similar symptoms and are
happening at the same time. Tiredness, problems sleeping, stronger emotional
reactions, and changes in body weight may occur during pregnancy and after
pregnancy. But these symptoms may also be signs of depression.
2.3 Etiology:
The exact cause of postpartum depression is not known. One factor may be the
changes in hormone levels that occur during pregnancy and immediately after
childbirth. Also, when the experience of having a child does not match the mother's
expectations, the resultant stress can trigger depression. Studies have also considered
the possible effects of maternal age, expectations of motherhood, birthing practices
and the level of social support for the new mother.There may be a number of reasons
why a woman gets depressed. Hormone changes or a stressful life event, such as a
death in the family, can cause chemical changes in the brain that lead to depression.
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Depression is also an illness that runs in some families. Other times, it's not clear
what causes depression.
There is no one trigger; postpartum depression is believed to result from many
complex factors. It is important, however, to communicate to women with
postpartum depression that they did not bring it upon themselves.
One certain fact is that women who have experienced depression before becoming
pregnant are at higher risk for postpartum depression. Women in this situation should
discuss it with their doctor so that they may receive appropriate treatment, if
required. In addition, an estimated 10% to 35% of women will experience a
recurrence of postpartum depression.
The amount of sick leave taken during pregnancy and the frequency of medical
consultation may also be warning signs. Women who have the most doctor visits
during their pregnancy and who also took the most sick-leave days have been found
to be most likely to develop postpartum depression. The risk increases in women
who have experienced 2 or more abortions, or women who have a history of obstetric
complications.
Other factors which increase the risk of postpartum depression are severe
premenstrual syndrome (PMS), a difficult relationship, lack of a support network,
stressful events during the pregnancy or after delivery.
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Factors that causes Depression During & After Pregnancy
2.3.1 During Pregnancy
During pregnancy, these factors may increase a woman's chance of depression:
History of depression or substance abuse
Family history of mental illness
Little support from family and friends
Anxiety about the fetus
Problems with previous pregnancy or birth
Marital or financial problems
Young age (of mother)
2.3.2 After Pregnancy
Depression after pregnancy is called postpartum depression or peripartum
depression. After pregnancy, hormonal changes in a woman's body may trigger
symptoms of depression. During pregnancy, the amount of two female hormones,
estrogen and progesterone, in a woman's body increases greatly. In the first 24 hours
after childbirth, the amount of these hormones rapidly drops back down to their
normal non-pregnant levels. Researchers think the fast change in hormone levels
may lead to depression, just as smaller changes in hormones can affect a woman's
moods before she gets her menstrual period.
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Occasionally, levels of thyroid hormones may also drop after giving birth. The
thyroid is a small gland in the neck that helps to regulate your metabolism (how your
body uses and stores energy from food). Low thyroid levels can cause symptoms of
depression including depressed mood, decreased interest in things, irritability,
fatigue, difficulty concentrating, sleep problems, and weight gain. A simple blood
test can tell if this condition is causing a woman's depression. If so, thyroid medicine
can be prescribed by a doctor.
Other factors that may contribute to postpartum depression include:
Feeling tired after delivery, broken sleep patterns, and not enough rest often
keeps a new mother from regaining her full strength for weeks.
Feeling overwhelmed with a new, or another, baby to take care of and
doubting your ability to be a good mother.
Feeling stress from changes in work and home routines. Sometimes, women
think they have to be "super mom" or perfect, which is not realistic and can
add stress.
Having feelings of loss—loss of identity of who you are, or were, before
having the baby, loss of control, loss of your pre-pregnancy figure, and
feeling less attractive.
Having less free time and less control over time. Having to stay home indoors
for longer periods of time and having less time to spend with the your partner
and loved ones.
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2.4 Diagnosis:
The criteria used to diagnose depression is the same in postpartum states. In addition
to these criteria, other symptoms may include fear or feelings of guilt about being a
"bad" mother, or possibly extreme fear that some harm will come to the baby. These
thoughts help distinguish postpartum from other kinds of depression.Women with
postpartum major depressive episodes may also have severe anxiety, panic attacks,
spontaneous crying long after the usual duration of "baby blues" (ie, 3-7 days
postpartum), disinterest in the new infant, and insomnia (manifested as difficulty
falling asleep).
When assessing whether a symptom is a sign of depression or a normal postpartum
reaction, the individual's circumstances need to be considered. A woman's level of
exhaustion or irritability may be quite normal when her infant is 2 weeks old and
nursing frequently, but may not be normal when her baby is 4 months old and
sleeping soundly through the night. Sleep deprivation can cause fatigue and poor
concentration, but the degree of these symptoms needs to be carefully assessed.
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2.5 Clinical features:
Any of these symptoms during and after pregnancy that last longer than two weeks
are signs of depression:
Feeling restless or irritable
Feeling sad, hopeless, and overwhelmed
Crying a lot
Having no energy or motivation
Eating too little or too much
Sleeping too little or too much
Trouble focusing, remembering, or making decisions
Feeling worthless and guilty
Loss of interest or pleasure in activities
Withdrawal from friends and family
Having headaches, chest pains, heart palpitations (the heart beating fast and
feeling like it is skipping beats), or hyperventilation (fast and shallow
breathing)
After pregnancy, signs of depression may also include being afraid of hurting the
baby or oneself and not having any interest in the baby.
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2.6 Differential Diagnosis:
The differential diagnosis for postpartum depression should include the following :
1. Postpartum blues ( PPB; no DSM-IV-TR diagnosis )
Note : any depressive syndrome accompanied by psychosis or lasting beyond
2 weeks postpartum ceases qualifying for PPB
2. Postpartum depression (PPD) without psychotic features
3. Postpartum depression with psychotic features
( consider bipolar disorder,depressed )
4. Bipolar I or II disorder,depressed phase.In a sample of 30 women with occult
bipolar disorder, 20 ( 67% ) experienced a postpartum mood episode, almost
exclusively depressive, as the initial presentation of their bipolar disorder
( Chaudron and Pies 2003; Freeman et al. 2002 )
5. Mood disorder due to a general medical condition with major depressive-like
episode or with depressive features.Depressive symptoms have been reported
as the presenting feature in hypothyroidism ( Gunnarsson et al.2001 ),
infection with HIV, and systemic lupus erythematosus ( SLE ).
6. Substance-induced depressive disorder.Effects of prescription drugs,illicit
drugs,alcohol,and over-the-counter and herbal remedies may mimic and
precipitate psychiatric disorders in pregnancy and the postpartum period.
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2.7 Prognosis:
Postpartum depression usually goes away during the months after delivery. Some
women have symptoms for months or years.
If untreated, the illness can cause prolonged misery for the mother and her family.
It can hurt the mother-baby relationship.
It could even be dangerous if the mother considers hurting her child or
herself.
2.8 Treatment:
There are two common types of treatment for depression.
Talk therapy. This involves talking to a therapist, psychologist, or social
worker to learn to change how depression makes you think, feel, and act.
Medical Treatment. Your doctor can give you an antidepressant medicine to
help you. These medicines can help relieve the symptoms of depression.
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2.8.1 Psychological treatments: counseling and support
For a woman with postpartum depression, experts recommend household help and
therapy with a mental health professional. If depression is severe, the experts urge
finding someone to stay with and assist the mother at all times, such as a relative,
friend, or paid helper. Family and friends can offer non-judgmental support,
reassurance, hope, and validation of the new mother’s abilities. Common issues in
psychotherapy for postpartum depression include overwhelming fears about new
responsibilities and guilt over becoming depressed at such a crucial time. Two
techniques that treat depression by putting these problems in perspective are
interpersonal therapy and cognitive-behavioral therapy. It is usually valuable to
include the spouse or other main caretaker in therapy to help him or her understand
the symptoms of depression and cope with the increased stress on the family.
Here are some other helpful tips that can be suggested to the patients:
Try to get as much rest as you can. Try to nap when the baby naps.
Stop putting pressure on yourself to do everything. Do as much as you can
and leave the rest!
Ask for help with household chores and nighttime feedings. Ask your
husband or partner to bring the baby to you so you can breastfeed. If you can,
have a friend, family member, or professional support person help you in the
home for part of the day.
Talk to your husband, partner, family, and friends about how you are feeling.
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Do not spend a lot of time alone. Get dressed and leave the house. Run an
errand or take a short walk.
Spend time alone with your husband or partner.
Talk with other mothers, so you can learn from their experiences.
Join a support group for women with depression. Call a local hotline or look
in your telephone book for information and services.
Don't make any major life changes during pregnancy. Major changes can
cause unneeded stress. Sometimes big changes cannot be avoided. When that
happens, try to arrange support and help in your new situation ahead of time.
2.8.2 Medical Treatment :
Women who are pregnant or breastfeeding should talk with their doctors about the
advantages and risks of taking antidepressant medicines. Some women are concerned
that taking these medicines may harm the baby. A mother's depression can affect her
baby's development, so getting treatment is important for both mother and baby. The
risks of taking medicine have to be weighed against the risks of depression. It is a
decision that women need to discuss carefully with their doctors. Women who decide
to take antidepressant medicines should talk to their doctors about which
antidepressant medicines are safer to take while pregnant or breastfeeding.
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Antidepressant medications
Many different kinds of antidepressants are available with different chemical actions
and side effects. All of them treat depressive symptoms and may be helpful for
postpartum depression.A mother who is breast-feeding, however, may be concerned
about the safety of antidepressant medication for her infant. For postpartum
depression in a breast-feeding mother,the experts recommend medications called
serotonin reuptake inhibitors (SSRIs), which affect the brain chemical
serotonin.Their top choice among these is Zoloft (sertraline), the most widely studied
antidepressant in breast-feeding mothers and their infants. While small amounts enter
breast milk, little or no medication can be detected in infants, and there appear to be
no adverse effects. Paroxetine (Paxil) is also a highly-rated choice.Paroxetine is not
detectable in breast milk or nursing infants.Two other widely used SSRIs, fluoxetine
(Prozac) and citalopram(Celexa), enter breast milk in small amounts but are viewed
as acceptable alternatives. If a mother took fluoxetine or citalopram during her
pregnancy and needs to stay on medication after delivery, experts do not think it is
necessary to change to another drug. Tricyclic antidepressants, an older type of
medication, are also viewed by experts as an appropriate choice for breast-feeding
mothers. Imipramine (Tofranil) and nortriptyline (Pamelor) are 2 examples.
Tricyclics usually cause more side effects in the mother than SSRIs but are
sometimes more effective. If the baby has health problems, the pediatrician can
obtain a blood sample to see if the antidepressant is present in the baby in a
significant amount and might be contributing to the problem.
For an extremely severe type of depression in which the mother has psychotic
symptoms (hallucinations or delusions),it is important to combine the antidepressant
with another kind of medication called an antipsychotic. If the mother is breast-
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feeding, the experts recommend an older type called conventional antipsychotics
(such as Haldol); newer types (atypical antipsychotics such as Risperdal or Zyprexa)
are preferred otherwise, but have not been tested enough in breast-feeding mothers
and their infants.
If a woman has very severe symptoms, such as suicidal or psychotic thoughts, the
doctor may need to put her in the hospital to ensure her safety and that of the baby
while her symptoms are addressed. Electroconvulsive therapy is an alternative to
consider if a mother does not respond to medication or is breast-feeding and wants to
avoid medication.
2.9 Complication:
Postpartum depression,if left untreated, postpartum depression can interfere with
mother-child bonding and cause family distress. Children of mothers who have
untreated postpartum depression are more likely to have behavioral problems, such
as sleeping and eating difficulties, temper tantrums and hyperactivity. Delays in
language development are common as well. Researchers believe that postpartum
depression can affect the infant by causing delays in language development,
problems with emotional bonding to others, behavioral problems, lower activity
levels, sleep problems, and distress. It helps if the father or another caregiver can
assist in meeting the needs of the baby and other children in the family while mom is
depressed.Untreated postpartum depression can last up to a year or longer.
Sometimes untreated postpartum depression becomes a chronic depressive disorder.
Even when treated, postpartum depression increases a woman's risk of future
episodes of major depression.
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2.10 Summary :
Like all forms of depression, postpartum depression creates a cloud of negative
feelings and thoughts over a woman's view of herself, those around her, her situation,
and the future. Under the cloud of depression, a woman might see herself as helpless
or worthless. She might view her situation as overwhelming or hopeless. Things
might seem disappointing, uninteresting, or without meaning. Keep in mind that the
bleak negative perspective is part of depression.
With the right treatment and support, the cloud can be lifted. This can free a woman
to feel like herself again, to regain her perspective and sense of her own strength, her
energy, her joy, and her hope. With those things in place, it's easier to work with
changes, to see solutions to life's challenges, and to enjoy life's pleasures again.
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REFERENCES
1. MedicineNet.Com : postpartum depression
http://www.medicinenet.com/postpartum_depression/article.htm#tocb
2. Manual of Psychiatric Care for the Medically Ill
Postpartum depression: page 133
By Antoinette Ambrosino Wyszynski, Bernard Wyszynski
3. Expert Consensus Guideline Series
Postpartum Depression: A Guide for Patients and Families
By Margaret L. Moline, Ph.D., David A. Kahn, M.D., Ruth W. Ross, M.A.,
Lori L. Altshuler, M.D., and Lee S. Cohen, M.D.
4. "Postpartum Depression - Epidemiology And Course" -
http://family.jrank.org/pages/1293/Postpartum-Depression-Epidemiology-
Course.html
5. Free MD medical interactive library -
http://www.freemd.com/postpartum-depression/outlook.htm
6. Mayoclinic : postpartum depression-complication
http://www.mayoclinic.com/health/postpartumdepression/
7. Postpartum Onset Specifier – with postpartum onset
From DSM-IV : pg 194
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