Ask Dr. Pat

Dr. Pat Consults: New Mothers and Postpartum Depression—When It’s More Than Baby Blues

Treatment options vary with the severity of the depression. For women with mild to moderate depression— individuals who have symptoms of depression, but are still able to make it through their day and not having thoughts of suicide—psychotherapy is considered first-line treatment.  Evidence shows that a number of different types of therapy, including cognitive behavioral therapy and interpersonal therapy, are very effective. Some new mothers also find less structured counseling to be helpful, as well as programs that emphasize partner and peer support. In addition to individualized therapy, many new mothers find parenting support classes helpful, giving them the opportunity to share their experiences with other women.

When depression is moderate to severe and the new mother is not breastfeeding, antidepressant medications are a good choice. For women who are breastfeeding, consideration must be taken before starting an antidepressant, since they are all passed through the breast milk, although concentrations vary. Fortunately, studies of women who use antidepressants while breastfeeding have been reassuring, with levels of medication typically being low or undetectable in infants and with very few reports of negative consequences.   While some have proposed that the pumping and discarding of the breast milk at times when concentrations are thought to peak could reduce infant exposure, there is little data to support this. Careful consultation with a psychiatrist experienced in this area can help with the decision-making process.

Other non-pharmacological options that have been proposed include light therapy, omega-3 fatty acids, massage, and acupuncture. At this point, the jury is still out on these interventions, with some small promising trials, but overall mixed results. However, some women find them helpful—and, given their fairly benign side effects, they are worth further investigation.

For women like you who have experienced postpartum depression before, there is increased risk or recurrence, and thus efforts have been made to study the role of prevention.  A number of interventions have been found to decrease rates of developing depression among those at risk. Many of these focus on increased psychosocial supports, such as visits by a home nurse, interpersonal or cognitive behavioral therapy, or phone calls from peers, all of which have been shown to be effective.  For some who suffered a particularly severe episode, starting an antidepressant prior to the onset of symptoms may be worth considering.  In sum, if you have experienced postpartum depression in the past, it is a good idea to discuss your options with your obstetrician and a mental health provider.

In a discussion of postpartum depression, it is important to also mention postpartum psychosis. Unlike postpartum depression, which effects 1 in 8 women, postpartum psychosis is much less common, affecting fewer than 2 in 1,000 women during the postpartum period, but can be dangerous to both mother and baby. In postpartum psychosis, symptoms typically develop within the first two weeks, and include severe mood swings along with erratic behavior, delusions, and hallucinations. Delusions tend to center around the new child. This merits further discussion: While most new mothers have a certain level of anxiety and worry, the delusions of postpartum psychosis are out of touch with reality. There can be auditory hallucinations commanding the mother to harm herself or the baby. Postpartum psychosis is considered an emergency and requires psychiatric intervention to protect both mother and child. This is a treatable condition, and with careful intervention, both mother and baby can do well once the crisis has passed.

Thank you for writing your letter. There is still a degree of shame surrounding emotional issues that can arise during pregnancy and childbirth, and it is important that we talk about them, for support and treatment are critical to ensuring a healthy mother and a healthy baby. I would encourage you to have a conversation with Emily about your own experience, to let her know that you are an understanding ear and someone she can turn to if things get rough. Also, this gives her the opportunity to discuss her family history of mental health with her obstetrician. Just because you had this experience does not mean that she will too; although genetics plays a role, it is only one of many factors.   I hope that sharing this with her—and then her sharing it with her physician—helps to alleviate some of the burden you are currently carrying, enabling you to enjoy this special time with you daughter and grandchild-to-be.

Megan Riddle, M.D., Ph.D.



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