BY JENNIFER HEALY, MSN, RNC-OB, CCM
Having a baby is thought to be one of the happiest times in many people’s lives. For many families, that is a true statement. However, this is not always the case. As many as 15% of women are affected by postpartum depression, making it the most common pregnancy complication (Tahirkheli, Cherry, Tackett, McCaffree & Gillaspy, 2014). Postpartum depression is often underdiagnosed and therefore undertreated (Cherry, et al., 2016). The social stigma associated with any mental health concern, including postpartum depression, prevents many mothers from openly communicating with friends, family or their medical provider about their symptoms, preventing them from getting the help they need. It is important, now more than ever, to bring awareness to this pregnancy complication to help patients who suffer from postpartum depression get the treatment they need.
Definition and Symptoms
Postpartum depression can be either a major or minor depressive episode and may occur as early as during pregnancy or any time during the first year postpartum, with most cases identified during the first four weeks (Committee on Obstetric Practice, 2018). A formal diagnosis of postpartum depression requires at least five of the following symptoms to be present most of every day for 2 weeks (Tahirkheli, Cherry, Tackett, McCaffree & Gillaspy, 2014).
Symptoms often include:
- Feeling depressed
- Significantly decreased interest or pleasure in doing most things
- Significant weight change or change in appetite
- Unable to sleep or sleeping too much
- Easily agitated
- Fatigue/ decrease in energy level
- Feeling worthless
- Decreased ability to think or make decisions
- Obsessed with the baby’s health and well-being
(Tahirkheli, Cherry, Tackett, McCaffree & Gillaspy, 2014).
Risk Factors for Developing Postpartum Depression
Many risk factors can predispose a mother to suffering from postpartum depression. It is important for not just doctors but all people working with new mothers to be able to identify these risk factors. Risk factors can be present during the perinatal period and can include:
- History of depression/anxiety prior to pregnancy
- Decreased social support
- Unplanned pregnancy
- Poor relationship/ no relationship with significant other
In addition to the above-mentioned risk factors, there are additional considerations that can lend themselves to a mother developing postpartum depression:
- Traumatic labor/birth experience
- Preterm delivery
- NICU admission
- Breastfeeding difficulties
(Committee on Obstetric Practice, 2018)
Many sociodemographic indicators also have been found to put mothers at increased risk for developing postpartum depression. Patients with lower education levels, lower income and Medicaid insurance are more likely to experience postpartum depression.
Barriers to Diagnosis and Treatment
There remains a social stigma against mental illness, including postpartum depression. Women note feelings of embarrassment and failure to be a good mother among the reasons they do not admit to exhibiting symptoms of postpartum depression (Boyd, Mogul, Newman, & Coyne, 2011). By not feeling able to talk about how they are feeling, these women are often not aware of the different treatment options available or where to seek help. Sometimes, a woman may convince herself that what she is feeling is normal, preventing her from finding help. Support from family and friends can help her normalize what she is feeling and encourage her to reach out for assistance.
The sociodemographic factors, such as living below the poverty line, being a single parent and not completing high school, that place a mother at risk for developing PPD are also barriers to diagnosis and treatment. Financial concerns and lack of insurance can prevent a mother from seeking help. Immigration status has also been found to be a barrier to treatment. Undocumented women often are afraid of being identified and facing any repercussions the government may impose on them. This fear may prevent them from reaching out for resources they need to treat their depression. This population of women is also typically uninsured, making the anticipated cost of care and treatment a barrier to seeking help (Boyd, Mogul, Newman, & Coyne, 2011).
Identifying and Treating
Postpartum depression is very treatable, but when left undiagnosed and untreated, it can lead to serious and potentially life-threatening consequences. Symptoms of postpartum depression are often not quantitative or tangible, often relying on healthcare providers to know what questions to ask their patients in addition to providing standardized screening tools. To decrease the complications associated with postpartum depression, increased screenings need to be implemented along with plans for treatment. In an early effort to identify women at increased risk for depression in the postpartum period, healthcare providers should follow the American College of Obstetricians and Gynecologists recommendation to screen pregnant women during the perinatal period in addition to during postpartum visits (Committee on Obstetric Research, 2018). In the postpartum period, formal screening for postpartum depression is recommended to occur at 1, 2 and 4 months following delivery (Tahirkheli, Cherry, Tackett, McCaffree & Gillaspy, 2014).
The use of screening tools allows for a more structured, systematic method to evaluate women for postpartum depression symptoms. Numerous tools are available to healthcare providers to screen patients for postpartum depression. The most used tool is the Edinburgh Postnatal Depression Scale (EPDS). It is written in more than 50 languages, consists of 10 items and typically takes less than 5 minutes to complete. This screening tool asks the mother to assess her feelings over the past week but does not evaluate the mother’s perception of her ability to be a good mother.
The Postpartum Depression Screening Scale (PDSS) is another screening tool, which provides a more in-depth evaluation on the mother’s perception (Committee on Obstetric Practice, 2018). PPDS is a 35-question questionnaire, which takes longer for the mother to complete. Both screening tools provide self-reported information, so they are only useful if the mother is honest with her results.
There is a myriad of treatment options available for postpartum women, both non-pharmacological and psychopharmacological. Based on the severity of depression symptoms that the mother is experiencing, treatment options may include:
- Journal writing
- Cognitive behavior therapy
- Interpersonal psychotherapy
- Counseling – individual or group
- Antidepressant medications
(Tahirkheli, Cherry, Tackett, McCaffree, & Gillaspy, 2014). These treatment options may be used alone or in conjunction with one another, based on the severity of symptoms.
Women who cite lack of time or available childcare as a barrier to seeking help can utilize telehealth services for help. Telehealth is a wonderful tool available to mothers since they can stay in their own home, don’t need to procure childcare for their infant and can often access services 24/7. There are also hotlines that mothers as well as family members can contact for help.
Impacts on Mother and Family
Postpartum depression is a condition that affects not only the mother but her entire family. Short-term impacts include poor parent-infant bonding, poor infant sleeping patterns and feeding difficulties as well. Infants whose mothers are diagnosed with postpartum depression have been found to be fussier and make fewer positive vocalizations and facial expressions (Tahirkheli, Cherry, Tackett, McCaffree & Gillaspy, 2014).
Children whose parents struggle with untreated postpartum depression can also exhibit long-term difficulties. These children are at increased risk for delayed learning, speech and social skills and may exhibit poor behavior issues (Cherry, et al., 2016). Postpartum depression, when left untreated, can have a negative impact on the relationship between the parents as well.
Postpartum Depression in the NICU Population
Mothers with children admitted to the neonatal intensive care unit (NICU) following delivery are at an even greater risk for suffering postpartum depression. Studies have found that the incidence of postpartum depression is anywhere from 28%-70% for mothers whose babies have been admitted to the NICU (Cherry, et al., 2016). There are numerous circumstances surrounding NICU admissions that are believed to create the higher incidence of postpartum depression in parents. Feelings of stress and uncertainty regarding the prognosis of the baby, helplessness and the inability to interact with their infant, an altered parental experience and poor coping skills are all issues that can create feelings of depression for the parents (Tahirkheli, Cherry, Tackett, McCaffree & Gillaspy, 2014). The physical environment of the NICU can also put added stressors on NICU parents. The sight of their intubated child, the confusing medical terminology used by the NICU staff and even the lights and sounds of the equipment can add fuel to a parent’s already depressive feelings (Tahirkheli, Cherry, Tackett, McCaffree & Gillaspy, 2014).
Because of the higher incidence of postpartum depression among NICU parents, routine screenings should be considered as part of the NICU stay (Cherry, et al., 2016). By waiting for the mother’s recommended OB follow-up appointment to screen, which could be 6 weeks following delivery, crucial time to provide early interventions for the mother may be lost.
Discharge Planning and Follow-up Care
Anyone working with postpartum women needs to be able to not only identify women at risk and recognize and screen for symptoms but also know how to refer women to available services and treatment. As part of discharge planning and follow-up care, it is important to be aware of local community resources available to families to get the care and support they need. Mothers are often provided with a list of local resources at the time of discharge from the hospital; however, they may be feeling overwhelmed with their new role of being a parent and not retain the information that was provided. Resources can include mental health hotlines, primary care physicians, support groups and local support organizations specific for postpartum depression.
Within our society, childbirth is typically considered a happy event. However, not all new mothers respond this way. It is important to dispel the myth that becoming a mother always equates to feeling joyful. All mothers should be given the opportunity and be encouraged to share negative feelings without fear of being judged. Our society continues to make great strides in educating the public about mental health issues and helping to erase the stigma that is attached to them. However, there is still much work to be done to help ensure that mental health issues are not something to be ashamed of by anyone, including new mothers. As professionals caring for postpartum mothers, creating open lines of communication and a trusting relationship can go a long way for a mother who is silently suffering.
Boyd, R. C., Mogul, M., Newman, D., & Coyne, J. C. (2011). Screening and referral for postpartum depression amoung low-income women: A qualitative perspective from community health workers. Depression Research and Tratment.
Cherry, A. S., Blucker, R. T., Thornberry, T. S., Hetherington, C., McGaffree, M., & Gillaspy, S. R. (2016). Posptartum depression secreening in the Neonatal Intensive Care Unit: program development, implementation, and lessons learned. Journal of Multidisciplinary Healthcare, 59-67.
Comittee on Obstetric Practice. (2018). Screening for perinatal depression. Retrieved from The American College of Obstetricians and Gynecologists: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/11/screening-for-perinatal-depression
Tahirkheli, N. N., Cherry, A. S., Tackett, A. P., McCaffree, M., & Gillaspy, S. R. (2014). Postpartum depresson on the neonatal intensive care unit: current perspectives. International Journal of Women’s Health, 975-985.
Jennifer Healy, MSN, RNC-OB, CCM, has 15 years of experience in the specialty of women’s and children’s nursing. Currently, Jennifer is an inpatient acute case manager in the neonatal intensive care setting.
IMAGE CREDIT: ISTOCK.COM/TATYANA ANTUSENOK