Pregnancy glow-

postnatal shadows.

Exploring the impact of postnatal depression

Tamryn Coats

2016

Postnatal Depression

Baby blues vs PNDFeelings of sadness, tearfulness or just feeling ‘down’, irritability and mood swings shortly after birth affects up to 80% of new moms. These are termed the’ baby blues’.

However, when these feelings persist for longer than 3 to 4 weeks, a diagnosis of post-natal depression can be considered. Diagnosable up to the first year postpartum.

Just moms?• International statistics suggest PND affects approximately 5% - 10% of

fathers.

• The most significant determinant of paternal postnatal depression is having a

depressed partner.

• Fathers whose partners are depressed are 2.5 times more at risk for

developing depression themselves

Symptom Criteria

• Feelings of worthlessness / guilt

• Lack of concentration

• Perpetuating feelings of sadness

• Loss of interest or pleasure in doing things

• Social withdrawal (often related to guilt)

• Feelings of anger and irritability/ Tearfulness

• Emotional numbing / loss of affect

• Changes in eating and sleeping patterns

• Suicidal ideation/ attempts ““I overdosed some pills; sometimes I would drink jik” (Case 1).”

Postpartum psychosis: restlessness, irritability, reduced sleep, mood swings, disorientation, confusion, disorganised behaviour, delusional beliefs often about the infant, and auditory hallucinations that commands to harm herself or the baby.

• 1-2 in every 1000 first time mothers

• Occurs generally 2-3 days pp

• Risk: prior mood episodes, history of psychosis, Bipolar

30-50% chance of reoccurrence with each subsequent delivery

How is it measured?

• Edinburgh postnatal depression scale: quick tool, commonly utilized, perinatal indication of risk postpartum (score of 13 or more)

• Responses related to the past 7 days eg. I have been able to laugh and see the funny side in things. Diagnosable for 1 year post partum

• In conjunction with clinical interview/ assessment

Moms with untreated PND are 38% risk of chronic depression

What does this look like in‘real life’?

I felt so alone

Everyone said this would be the happiest time of my life. But It wasn’t at all

I felt guilty and had no one to talk to. No one speaks about it.

I felt like I was a failure at being a woman

I wondered what was wrong with me

It would start crying and I would just watch it cry…I felt so powerless

Lived experiences

It just didn’t feel like it was my baby

I just wanted someone to take the baby away from me

What does this look like in ‘real life’?

• Mom is unable to bond authentically with her baby

• Baby is referred to as ‘it’ or ‘baby’

• When a baby is crying or in distress mom becomes very overwhelmed or completely unresponsive

• Mom is unable to pick up her baby / avoids physical contact with her baby.

• 2 responses: over stimulating or avoidant: Interactions tend to be more negative (poking, rough) than positive. Mom unable to read babies cues

• Mom is less likely to talk to and engage affectionately with her baby (less smiling)

• Mom responds differently to others (anger, tearfulness etc)

• Mom may be aggressive / abusive towards her baby. Harsher forms of punishment

“Yes. I do beat them up. When I am angry I would also start to shout at them. Like I would yell and force them to sleep. When they don’t sleep and start to cry I will slap them.” (Case 4).

• Mom may have thoughts of harming her baby (41% of depressed moms vs. 7% control mothers)

• Mom is neglectful towards her baby – care practices, safety, routines” “Sometimes when I have to make her take a bath or wash her nappies I would feel too lazy to do anything and I would leave everything as it is”. (Case 5).”

Still face experimentDr. Edward Tronick

Impact on the baby

Baby learns that the world is unresponsive, unreliable and scary.

Attachment disorders begin to develop; developmental milestones delayed.

Mom is not able to mediate the world for the baby, contain the

baby’s distress or interpret emotions

for the baby

Baby feels confused,

scared, vulnerable

Overwhelmed by stimuli or emotion

Infant Outcomes

• Low birth weight

• Delayed initiation of breastfeeding

• Stunting (milestones)

• Malnutrition

• Gastro-intestinal problems

• Non-completion of immunisations

• Increased ICU admissions

• Crying and irritability

• Fearfulness

• Higher mortality

• Reduced emotional expression

Child Outcomes

• Impaired motor skills

• Impaired language development

• Weaker adaptation to stress

• Recognition and memory

processes affected

• Lower frustration threshold

• Hyperactivity and attention deficit

• Inconsolability / anxiety

symptoms

• Malnourishment

• Development of asthma in later

childhood

• Internalizing behaviour e.g.

emotional withdrawal

• Externalising behaviour e.g.

aggression / oppositional

behaviours

Adolescence

Outcomes

•Anxiety disorders

and depression

•Shyness

•Unsocial

behaviour

•Conduct disorder

•Attention deficit

disorder

•Substance abuse

•Suicidality

•Increased risk of

HIV infection,

abuse and

unintended

pregnancy

Contextual risk factors

• Social stressors: Truama, Low social support systems (unsupprotive families), Domestic/ partner violence

• Socio-economic stressors (unemployment, poverty, living off a grant)

• Unplanned or unwanted pregnancy

• Pregnancy during adolescence

• Single parenting

• Stressful lifestyles (including career intensive women)

• Unrealistic expectations of parenthood

• Traumatic birthing process

• Previous episodes of depression, or a history of anxiety disorders or substance abuse *not restricted to the first child

- Depression during pregnancy (60-70% relapse rate postpartum)

Bringing it closer to home

• International statistics suggest that approximately 13% of moms will suffer from PND.

• Research from the Perinatal Mental Health Project in the Western Cape suggests PND can reach levels of between 30 and 50% in specific populations within South Africa.

• Consider the South African context: low income country, high violence rates, HIV status, high domestic partner violence, unemployment, patriarchy

50 000 new cases of PND per year in South Africa

Treatment

ReferencesThe knock on effects of postnatal depression. Joanne Zagnoev

Perceptions of postanatal depression and health care needs in a South African sample: the “mental” in maternal health care. Kathree, T; Selohilwe, O; Bhana, A; Petersen,I. 2014. BMC Womens Health vol.14:140.

Maternal mental illness and child outcomes. Perinatal mentl health project. . UCT

Dr. Janine Pingo. Perinatal depression Presentation. 14 April 2016. Akeso Kenilworth Clinic.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.

NHCM Foundation Issue brief, June 2010

Evaluating the clinical effectiveness of a specialized perinatal psychoatry inpatient unit. Meltzer-Brody, S et all. 2013. Springer

The cost of perinatal depression in Australia. Final Report. October 2012. Deloitte & PANDA

The prevalence and clinical presentation of antenatal presentation of antenatal depression in rural South Africa. Rochat, J; Tomlinson, M; Barnighausen, T; Newell, M & Stein, A. 2011. Journal of affective disorders.