By Dr. Ihekire Ogemdi.
Six weeks after delivery, a woman passes through a period known as the post-natal (postpartum, puerperal) period. It is a delicate period for the woman and some emotional changes tend to occur.
About 85% of women after delivery will experience one of these disorders. These mood changes include: Postpartum Blues (Baby Blues), Postpartum Depression (PPD), Postpartum Anxiety Disorder (PPAD) and Postpartum Psychosis (PPP).
Majority of post-natal women will experience the mild type which is Postpartum Blues. The severe form of Post-natal mood changes are the Postpartum Anxiety Disorder and Postpartum Psychosis; they rarely occur.
It is very important that families are made aware of these mood disorders that can occur after delivery, know what can cause it, symptoms and what to do to access treatment, because it can be treated.
In African families where they lack awareness, post-natal mood disorders move from bad condition to worse, because they are mostly misconstrued and mismanaged. Families are known to have broken up as a result of this disorder, but that should not be the case because this is a condition that can easily be treated.
Causes may include the following:
Hormonal Factors
The sudden drop in the levels of estrogen, progesterone, and cortisol within 48 hours after delivery can trigger change in some mothers.
Psychosocial Factors
Women who report inadequate social supports, marital discord or dissatisfaction, or recent negative life events are more likely to experience postpartum depression.
Biological Vulnerability
Women with prior history of depression or family history of a mood disorder are at increased risk for postpartum depression. Women with a prior history of postpartum depression or psychosis have up to 90% risk of reoccurrence.
New mothers rarely get adequate rest. In the hospital, they are awakened by nurses and the baby’s feedings. At home, feedings continue every 2 – 4 hours around the clock, along with usual household tasks. When this excessive lack of sleep continues for weeks or months, it can be a major reason for depression.
Mothers who deliver premature babies with birth defect; these concerns can precipitate mood disorder. Expected bay-sex; some mothers unduly expect a particular sex for the baby and get disappointed at delivery.
Other tasks which may pose a stress on a new mother include: establishing successful breast/bottle feeding, coping with sleep, forming an attachment to the child, re-negotiating family relationships and responsibilities, giving up fantasy of what the baby would look like or be like, facing whether one is not and adequate parent.
Types of mood disorders may include:
Postpartum Blues (Baby Blues)
Up to 85% of women experience postpartum affective instability, which rapidly fluctuating moods, tearfulness, irritability, and anxiety are common symptoms.
Symptoms peak on the 4th day after delivery and last for several days, but they are generally time-limited and spontaneously remitted within the first 2 postpartum weeks.
Though symptoms do not interfere with a mother’s ability to function and to care for her child, but women with more severe symptoms or symptoms persisting longer than 2 weeks should be screened for postpartum depression.
‘Baby Blues’ is often described as mild depression interspersed with happier feelings, or as some women state: it is “an emotional roller-coaster”. Onset is usually 2 – 3 days postpartum, with a peak around 7 – 10 days.
Look out for these symptoms: Fatigue/exhaustion, feeling of sadness, crying spells, anxiety, mood swings/irritability, confusion, feeling overwhelmed, inability to cope, over sensitivity, inability to sleep, feelings of loneliness.
Causes of the Baby Blues include biological factors (drop in hormone levels), social/environmental factors (marital stress, lack of support system, low SES), stress and sleep deprivation in addition to the physical aftermath of labour and delivery.
First time moms are at a higher risk of experiencing the ‘Baby Blues’. The Baby Blues typically does not require professional treatment and should subside within two weeks after delivery.
Treatment include validation of the existence of the phenomenon, labelling it as a real but a normal adjustment reaction, most importantly, assistance with self/infant care, and family support.
Postpartum Depression (PPD)
When Baby Blues persist beyond two weeks, it is diagnosed to be Postpartum Depression (PPD) and it is seen in 10% of post-natal women. Onset of PPD can be anytime during the first year after delivery, with the highest incidence of onset between 4 and 8 weeks postpartum. It may last from 3 to 14 months or longer if left untreated.
Though most women recover within a year, the condition may become chronic if it goes untreated. Chronic depression may have significant effects on mother-baby attachment and bonding. Symptoms of PPD include: sadness, frequent crying, insomnia, appetite changes, difficulty concentrating/making decisions, feelings of worthlessness, racing thoughts, agitation and/or persistent anxiety, anger, fear and/or feelings of guilt.
Others are: obsessive thoughts of inadequacy as a person/parent, lack of interest in usual activities, lack of concern about personal appearance, feeling a loss of control, feeling disconnected from the baby, possible suicidal thoughts.
Risk factors for PPD include: first-time motherhood, ambivalence about keeping the pregnancy, history of PPD, bipolar, or another mood disorder, lack of social support, lack of stable relationship with partner and/or with parents, woman’s dissatisfaction with herself, history of infertility, unrealistic expectations of parenthood, recent stressful event, previous aversive reaction to oral contraceptives of severe PMS.
Causes include biological/physiological factors (genetic predisposition, hormone related, severity of physical damage from labour and delivery), environmental factors (stress, feeling alone, lack of support), psychological factors (things that affect a women’s self-esteem and the way she copes with stress), or infant-related factors (infants with difficult temperament or colic, infants born with problems). Most likely is a combination of all these.
Treatment include: individual and/or couple’s therapy, group therapy or support groups, psychological medications, practical assistance with child care/other demands of daily life. If a woman experiences PPD, her chances of PPD with subsequent children are 10 – 50%.
Postpartum Anxiety Disorder (PPAD)
This comes in the form of Postpartum Panic Disorder and Postpartum Obsessive-Compulsive Disorder. The former occurs in less than 5% of postpartum women. Its symptoms are feelings of extreme anxiety and recurring panic attacks, shortness of breath, chest pain, heart palpitations, agitation, and excessive worry or fears.
Three common fears experienced by women with a Postpartum Panic Disorder consist of the fear of dying, fear of loosing control, and/or fear that one is going crazy. A previous history of anxiety or panic disorder and thyroid dysfunction are some of the significant risk factors.
The later on its own occurs in approximately 3 – 5% of childbearing women. Symptoms are presence of both repetitive obsessions (intrusive and persistent thoughts or mental images) and compulsions (repetitive behaviours performed with intention of reducing the obsessions), as well as a sense of horror about these thoughts. The most common obsession is thoughts or mental images of harming or even killing her baby. The most frequent is bathing the baby often or changing the child’s clothes.
This could be as a result of Obsessive-Compulsive Disorder and/or negative feelings about motherhood resulting from unrealistic expectations.
Treatments for both Postpartum Panic and Obsessive-Compulsive Disorders include: individual therapy (cognitive-behavioural is recommended), with psychotropic medications. Also couple’s therapy, group therapy/support group, and practical assistance with child care and/or demands of life.
Postpartum Psychosis
Postpartum Psychosis is the most severe form of postpartum psychiatric illness, which is rare and occurs in approximately 1 – 2 per 1000 women after childbirth. At highest risk are women with a personal history of bipolar disorder or a previous episode of postpartum psychosis.
Postpartum psychosis has a dramatic onset, emerging as early as the first 48 – 72 hours after delivery. In most women, symptoms develop within the first 2 postpartum weeks. This condition resembles a rapidly evolving manic or mixed episode with symptoms such as restlessness and insomnia, irritability, rapidly shifting depressed or elated mood, and disorganized behaviour.
The mother may have delusional beliefs that relate to the infant (e.g. baby is defective or dying, infant is Satan or God), or she may have auditory hallucinations that instruct her to harm herself or her infant. Risks for infanticide and suicide are high among women with untreated postpartum psychosis.
For treatment, the mother should be hospitalized with antipsychotic medication (lithium, when indicated) and temporary removal of infant from mother’s care, also sedatives, electroconvulsive therapy, psychotherapy, and social support. There is a 10% rate of suicide/infanticide associated with this disorder; thus, immediate treatment is imperative.
Women are 20 – 30 times more likely to be hospitalized for psychotic episode in the first 30 days after delivery than any other time in their life. Women with a history of bipolar illness have a 40% chance of developing Postpartum Psychosis after their first child is born.
Almost all women with previous episodes of Postpartum Psychosis will experience repeat episodes in subsequent pregnancies. Preparing for this ahead of time is the key.
The Social Effect of Postpartum Mood Disorders
Lack of understanding of this Postpartum Mood Disorders make the illness worsen from mild form to the severe form because when a woman has PPMD, the husband and the rest of the family are under stress.
PPMD can often lead to divorce as a result of lack of awareness in the family and conversely, marital stress does lead to a woman developing PPMD. Typically, the woman feels very overwhelmed and may feel that her partner is not very helpful, even if he is trying his best to be understanding and/or helpful.
If your wife has PPMD, it is very important that you take time to learn all you can about Postpartum Mood Disorders in order to understand what your wife is experiencing. Let her know that you recognize that she is not making up her symptoms and that this is not her fault. Let her know that you love her, support her, and there for her.
Help with the care of the baby as much as you are able, allowing time for your wife to take naps or sleep during the night. Enlist family, friends and/or the community to help with care of the baby, household, other children and/or meals in order to provide your wife with time to care for herself.
Let her know that you understand she may not be interested in sex and that you love her and enjoy holding her. Be sure to take some time for yourself and encourage your wife to do same. Help her monitor her symptoms and seek out professional help when needed. Remember that this is 100% treatable and she will be well.
