NOT ALWAYS
HAPPY

Postpartum depressive
disorders

Types of postpartum
depressive disorders



Postpartum blues



Postpartum
depression



Postpartum
psychosis



Not listed in DSM-
IV



In ICD-10



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



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

Prevalence (how often?)



Oxford, UK - 8,7%



Edinburgh, UK - 9,9%



Iowa, USA - 10,4%



In teenage mothers – 26-32% (Aiken,
2000)



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)

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)



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)

Depression in men after the
birth of their offspring



Prevalence – 10 – 30% (Soliday et al.,
1999)



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 %



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)