postpartum depression

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1 POSTPARTUM DEPRESSION BY: NAME: FARAH HUSNA MOHD FADZIL NIM: 040100848 DEPARTMENT OF PSYCHIATRY FACULTY OF MEDICINE UNIVERSITY OF NORTH SUMATERA MEDAN

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Page 1: Postpartum Depression

1

POSTPARTUM DEPRESSION

BY:

NAME: FARAH HUSNA MOHD FADZIL

NIM: 040100848

DEPARTMENT OF PSYCHIATRY

FACULTY OF MEDICINE

UNIVERSITY OF NORTH SUMATERA

MEDAN

2009

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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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