NOT ALWAYS
HAPPY

Postpartum depressive
disorders

Mental health aspects of women’s
reproductive health. A global
review of the literature (WHO,
2009)

„There is now a consistent
view that psychological
disturbance following childbirth
can be conceptualized as
fittingone of three distinct
conditions, of differing severity:
transient mood disturbance,
depression
and psychotic illness.” (p.15)

Types of postpartum
depressive disorders



Postpartum blues



Postpartum

depression



Postpartum

psychosis



Not listed in DSM-IV



In ICD-10 – no

special category of

depression (only

episodes of

depression, but…



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



Non-Anglophone 13- 50%



France 42%



Jamaica 60%



Arab countries 24%



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

„In practice, it is common for any
episode of depression during this
period (1 year after childbirth) to
be regarded as linked to the birth
(Scottish Intercollegiate
Guidelines Network, 2002).” p. 17

Prevalence (how often?)



Oxford, UK - 8,7%



Edinburgh, UK - 9,9%



Iowa, USA - 10,4%



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



Single, young vs.
older than 30 yrs



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)

Mental health aspects of women’s
reproductive health. A global
review of the literature (WHO,
2009)

„Despite the impression of
well-being in pregnancy,
comparable rates of depressive
symptoms have been
found among pregnant and
non-pregnant women. Large
systematic studies have
shown that rates of depression
in late pregnancy are
as high or higher than rates
of postpartum depression
(Zuckerman et al., 1989;
Da Costa et al., 2000; Evans
et al., 2001; Josefsson et al.,2001)” . p. 12

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)



Low self-esteem (WHO, 2009)



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)

Mental health aspects of women’s
reproductive health. A global
review of the literature (WHO,
2009)

The birth of a daughter was found
to contribute independently to
postpartum depression in women
in India and Pakistan (Patel,
Rodrigues & DeSouza, 2002;
Chandran et al., 2002; Rahman,
Iqbal & Harrington., 2003) p. 14

Depression in men after the
birth of their offspring



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

1999)



Portugal – 5% (WHO, 2009)



Australia – 2,8% (WHO, 2009)



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 %



Tanzania – 0,32% (infections after delivery?)



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)