For you, the first visits with a newborn are a busy balancing act of gentle physical exam and empathic parent reassurance and education. It’s difficult to imagine that much else could fit into these visits. But your providing weekly and then monthly checks on a newborn puts you in a unique position to detect postpartum depression in that baby’s mother (as are obstetricians at the 6-week follow up). Postpartum depression is relatively common and very treatable, but it can go untreated because of the silence that is often grounded in shame and stigma. A few days of “baby blues” secondary to being tired and hormonal changes is quite different from persistent postpartum depression. Early detection of postpartum depression and referral to a psychiatrist can relieve extraordinary suffering in a parent and stress in a family, and can protect the critical relationship developing between mother and baby.
Postpartum depression was rarely discussed as recently as 30 years ago; it was not formally recognized by psychiatrists as a distinct illness in the Diagnostic and Statistical Manual of Mental Disorders (DSM) until its fourth edition, released in 1994. It is only slightly more common than depression in nonpregnant women of childbearing age: the Centers for Disease Control and Prevention estimated that depression affects 13% of women in the postpartum period, compared with 11% of age-matched controls. It is, however, more likely to be severe than depression in the nonperipartum woman ( Gen. Hosp. Psychiatry 2004;26:289-95 ).Teenage mothers, women with a personal or family history of depression, women giving birth to twins or triplets, women with a history of miscarriage or stillbirth, and women who experienced premature labor and delivery all appear to be at elevated risk for postpartum depression. While other stressors such as marital conflict, single parenthood, or financial strain are challenging for new mothers, they have not been shown to significantly increase the risk of postpartum depression. It also should be noted that a history of previous deliveries without a postpartum mood disorder is not protective or predictive.
The diagnostic criteria for postpartum depression are the same as for a major depressive episode, except that symptoms start in the 4 weeks after the delivery of a baby (although they may be present during the pregnancy or may not be noted until weeks or months later). This can make it easy to mistake depression for the “baby blues” – a period of weepiness, anxiety, moodiness, and exhaustion that commonly occurs to new mothers. These symptoms affect as many as 75% of mothers in the first few days after delivery and can be very unsettling, but the symptoms always improve within 2 weeks, whereas postpartum depression will persist or worsen. Although it can be severe, postpartum depression will improve with treatment, typically psychotherapy and possibly medication. Without treatment, postpartum depression can persist for months. It may remit spontaneously after a substantial period, but it also may worsen. Untreated postpartum depression can (rarely) deteriorate into postpartum psychosis, which usually requires hospitalization and more significant psychopharmacologic intervention. Failure to detect and treat depression in new mothers can lead to a number of complications for the mother, ranging from difficulty with breastfeeding and forming an attachment with her newborn to an inability to return to work. It also raises the risk for suicide, which accounts for 20% of all deaths in the postpartum population ( Arch. Womens Ment. Health 2005;8:77-87 ).The catastrophe of infanticide is diminishingly rare, but almost always associated with untreated postpartum depression or psychosis.
The complications of untreated depression do not affect only the symptomatic mother. There have been many studies that have demonstrated the negative developmental effects of maternal depression on children of all ages, from infancy through adolescence. Maternal depression in the newborn period can be especially disruptive of development, as it can interfere with healthy attachment and an infant’s development of the fundamentals of self-regulation. Infants of depressed mothers are more likely to be passive, withdrawn, and dysregulated. Cognitive development in infants and toddlers of depressed mothers is frequently delayed. Toddler children of depressed mothers more frequently display internalizing (depressed and anxious) and externalizing (disruptive) behavioral symptoms. Mood, anxiety, conduct disorders, and attention-deficit/hyperactivity disorder are more common in the school-age and adolescent children of depressed mothers than in peers whose mothers are not depressed ( Paediatr. Child Health 2004;9:575-83 ). Clearly, the consequences of untreated depression in a mother on even the youngest children can be profound and persistent. And, most importantly, they are preventable.
Why would new mothers experiencing such uncomfortable symptoms fail to actively seek help? There are many reasons for their silent suffering. Many new mothers assume that their symptoms are the “baby blues,” a normal part of the monumental adjustment from pregnancy to motherhood. When their symptoms fail to improve in the first few weeks as promised by friends or clinicians, they often assume that they are personally inadequate, not up to the task of parenting. Such feelings of worthlessness and guilt are actually common symptoms of depression, and contribute to the shame and silence that accompany depressive disorders. (This is one of the reasons depression is described as an “internalizing” disorder.) These feelings (or symptoms) of guilt often are heightened by popular expectations that new mothers should be experiencing delight and joy in the new child. While all of the attention was on the mother during her pregnancy, the focus of friends, family, and clinicians usually shifts entirely to the infant after delivery. Although the reality of postpartum depression is more comfortably and openly discussed now than a generation ago, these forces continue to compel most women suffering from depression to remain silent.
This is where you are in a unique position to facilitate the recognition and treatment of postpartum depression. While a new mother may have one follow-up visit with her obstetrician, she often will visit you weekly for the first month and monthly for the first 6 months of her infant’s life. These visits are structured around questions about routines of sleeping and eating, the mechanics of breastfeeding, and growing connection with the newborn. You are in a natural position to ask nonjudgmentally about these things, and to follow-up on suggestions that a mother’s sleep, appetite, and energy are problematic with a few screening questions. If it sounds to you like there may be postpartum depression, you are in a powerful position to point out that these feelings do not reflect inadequacy, but rather a common and treatable problem in new mothers. You are uniquely qualified to suggest to the guilt-ridden mother that it is not selfish to seek her own treatment, but it is critical to the healthy development of her newborn and other children, much like the routine airline warning that parents must put on their own oxygen masks before attempting to place the masks on their children. Indeed, the American Academy of Pediatrics recommended in a 2010 report that pediatricians screen new mothers for postpartum depression at the 1-, 2-, and 4-month check-ups of their newborns ( Pediatrics 2010;126:1032 ).
So how best to screen during a busy check-up? The AAP recommends the Edinburgh Postnatal Depression Screen (EPDS), an extensively validated 10-item questionnaire that a mother can fill out in the waiting room. Scoring is relatively fast and a cut-off at or above 10 points suggests a high risk of depression. The AAP also suggests using a “yes” answer to either of the following questions as a positive screen:
1. Over the past 2 weeks have you ever felt down, depressed, or hopeless?
2. Over the past 2 weeks have you felt little interest or pleasure in doing things?
Even without using specific questions or instruments, you can be vigilant for certain red flags. If a new mother reports that she is having difficulty falling asleep (despite the sleep deprivation that usually accompanies life with a newborn); if her appetite is decreasing despite breastfeeding; if she describes intense worries or doubts about the baby or motherhood that have persisted for more than a few days or that interfere with her function; if she reports that she is experiencing no feelings of happiness or pleasure with her infant; or if she describes feelings of hopelessness or recurring thoughts about death and dying, then you should be concerned that she may be suffering from postpartum depression. You might then suggest to the mother that these feelings may reflect postpartum depression, reassuring her that this is a common and treatable condition. When you calmly and comfortably discusses this topic, you provide hope and relief, dissolving some of the stigma that can surround psychiatric illness for mothers.
What to do once you have noted that a new mother may be suffering from postpartum depression? The problem is common enough that you may want to find a psychiatrist with an interest in postpartum depression and develop a collegial working relationship. It can be helpful to find out if the mother has ever seen a psychiatrist or therapist, as this can be an easy and effective referral for a comprehensive evaluation. If she does not already have a mental health provider, referring her to her primary care provider can be an efficient way to access a psychiatric evaluation. Many mothers will want to have more specialized treatment, especially as they consider the safety of medications while breastfeeding. Many academic medical centers will have psychiatrists who specialize in women’s health. Some states have created programs to facilitate access to treatment for mothers, such as Massachusetts Child Psychiatry Access Project (MCPAP) for Moms. There are several national organizations that provide online information about clinicians and other resources, such as Postpartum Support International, the American Psychological Association, and the CDC.
Finally, we have addressed depression in new mothers. But the rates of depression in new fathers also are higher than in age-matched controls. When a father is the primary parent and suggests problems with sleep and mood, asking the same questions, showing concern, and providing referral information can be just as important.
Remember, 13% of new mothers have postpartum depression, and the suffering of parent, family, and newborn is treatable. Unfortunately, many mothers do not get the help they need, as this condition has not been a priority of our health care system. You, the pediatrician or family physician, are in a unique position to make this a priority. You can detect depression in new parents, providing a critical link to treatment and relief for them, and protecting their children from potentially serious and preventable complications.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) program at the Vernon Cancer Center, Newton (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at pdnews@frontlinemedcom.com.
