Postpartum Depression
Paths to Recovery

Expectant mothers look forward to bringing home their new bundle of joy after nine months of waiting and careful planning. It should be the happiest time in a new mother’s life. Sadly, this is also the time when women are at greatest risk for developing symptoms of depression.

"Vanessa"’ represents one such mother who returned home from the hospital with her newborn. After delivery, she felt overwhelmed and emotional. She could not stop crying over little things, had lost her appetite, and had trouble sleeping even when the baby was asleep. She became exhausted and didn’t feel like she could handle taking care of her baby. The “Best Wishes” greeting card describing “Joy in your Beautiful Child” seemed like a cruel joke. She felt guilty about feeling so sad and crying all the time when she had such a beautiful baby. To avoid having to hide her tears, she was isolating herself from family and friends and not returning phone calls. She thought, “No one understands! Why is this happening?”

On her routine postpartum follow up visit, Vanessa was lucky to see a medical professional who was experienced with the diagnosis and treatment of postpartum depression. The clinician routinely screened for postpartum depression 4-6 weeks postpartum. Depression is more common than other complications of pregnancy such as preterm delivery, gestational diabetes and high blood pressure. If left untreated, it can have a devastating impact. Vanessa was asked about her symptoms and filled out the Edinburgh Postnatal Depression Scale, a tool to diagnose depression in new mothers. Her reported symptoms and screen results showed symptoms of depression.

These symptoms can interfere with a woman’s ability to care for her newborn and, if left untreated, can continue on average for seven months. In addition to the miserable symptoms of feeling depressed, women with postpartum depression can have difficulty attending to their baby, maintaining their home, and returning to work. Since the baby depends on the mother, who is usually the primary caregiver, to provide love and attention, the stressful symptoms of depression can affect the emotional connection the baby needs for proper development. The general rule in treating mothers and babies is, “When moms do well, babies do well”, but Vanessa was not doing well.

Vanessa was diagnosed with postpartum depression. Her doctor ordered blood tests to screen for medical contributions to her mood symptoms. The loss of blood at delivery and the increased nutritional requirements during pregnancy and lactation increase the risk for anemia, causing fatigue. The thyroid is the ‘thermostat’ for the body. Too much thyroid hormone may cause anxiety and weight loss, too little may result in fatigue and weight gain. Vanessa was relieved when her labs returned normal but wondered how her mood symptoms could be treated. Her provider reviewed the following treatment options.

Psychotherapy or ‘talk therapy’ involves meeting with a skilled clinician who will problem solve around life stressors and offer supportive counseling. Cognitive exercises, insights, and homework assignments could help Vanessa cope with negative thoughts and improve her depressive symptoms.

Antidepressant medication is recommended for women with postpartum depression but treatment is often delayed due to concern of medication effects on the breastfed newborn. Recently, the American College of Obstetrics and Gynecology (ACOG) reiterated that breastfeeding has clear short and long-term benefits for mother and infant, and most psychotropic medications are transferred through breast milk at very low levels and are unlikely to affect the baby. Because women who have recently given birth are often sensitive to side effects of medications, the doctor should begin the medication at half the normal recommended dose and increase it to the effective dose. At least six months of treatment is recommended in order to avoid relapse into depression.

From years of experience, Vanessa’s provider knows women appreciate consideration of these other treatments. Light therapy provides bright light exposure for 30-60 minutes in the early morning and is an effective treatment for major depressive disorders, including non seasonal affective disorder (winter depression). Adjunctive use of exercise, particularly aerobic exercise, provides benefit for depressive symptoms. The American College of Obstetrics and Gynecology recommends 30 minutes of moderate exercise for most days for pregnant women without medical contraindications.

Regardless of the treatment approach, we recommend close follow-up of women with postpartum depression and would expect improvement in the Edinburgh Postnatal Depression Scale with effective therapy. Vanessa also needed a crisis plan for her mood symptoms. Just like her doctor might have given emergency instructions if she had increasing abdominal pain or fever after delivery, she should also know what to do if her mood symptoms worsened. This plan included calling her treatment team, available crisis clinic hotlines, going to the closest emergency department, or calling 911.

Thanks to early diagnosis and treatment, Vanessa recovered and is enjoying her family life. Vanessa was fortunate to have such a knowledgeable treatment team who took the time to screen, diagnose, and provide treatment recommendations for this very common problem in new mothers. Sadly, many women who read this story may have difficulty finding help. If you are suffering from postpartum depression, don’t wait. Get help now so you can join Vanessa on the path to recovery.

Editorial provided by Christopher S. Famy, MD of Women’s Behavioral HealthCARE and the University of Pittsburgh. (PD1111)

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