Depression, anxiety & mood

What is postpartum depression, and how do I know if I have it?

by Marcy Holmes, Women’s Health Nurse Practitioner

Identifying postpartum depression (PPD) is not always a simple matter. There are so many situations in which women develop symptoms of depression after giving birth, but there are two main distinctions to be made here. In the first, a woman is mildly depressed or even “just” highly stressed before she has her baby, and the hormonal fluctuations of childbirth and the stress of caring for a newborn act as the triggers that put her over the edge into full-blown depression. Categorically speaking, this sort of depression is not PPD in the strictest of definitions — it’s an episode of depression that was present or imminent before the baby’s birth and continues afterward.

In the second situation, a mother’s moods were relatively stable and upbeat prior to giving birth but spiraled downward after birth — often within a matter of days but sometimes over the course of months. In this case, the depression is very clearly connected to postpartum hormone fluctuations.

Exactly how many women experience true postpartum depression is hard to know, since so many women hide their negative feelings both before and after giving birth. Fatigue, problems with sleep, pain, inflammation, and other postpartum issues fog the boundary lines with depression. An estimated 70–85% of mothers report some form of mild “baby blues” within the first few weeks of birth, while a much smaller percentage (10–20%) experience longer-lasting, deeper effects, classified as PPD. A very few women will develop the severest form of postpartum psychiatric illness, known as postpartum psychosis. This is the (fortunately rare) situation when the mother loses touch with reality and can deliberately or inadvertently do things that may harm herself or her child.

Baby blues, PPD, and hormonal imbalance

When we’re trying to distinguish whether a mother is suffering standard, short-term baby blues or a bout of PPD, we start with the following questions:

Identifiers of the baby blues

• Do your emotions seem magnified, with extreme shifts in moodiness, sadness, irritability, or anxiety?
• After delivery, did your emotional symptoms improve within the first two to three postpartum weeks?
• Are your symptoms self-limited? (In other words, they do not interfere with your ability to function and to care for your child or children.)

Typically, more severe symptoms or symptoms persisting longer than two weeks should be screened for PPD. For these women, whose symptoms aren’t short term or are particularly severe, we also ask the following:

Identifiers of postpartum depression

• Do you have a personal history of depression? Have you experienced a previous episode of depression, or felt depressed during your pregnancy?
• How long have you been feeling this way? Typically, PPD develops gradually over the first three postpartum months, but symptoms can also arise very quickly.
• What are your symptoms like? Symptoms may include depressed mood and anhedonia (the inability to experience anything pleasurable), guilt, insomnia, crying easily, fatigue, appetite disturbance, and recurrent thoughts of death or suicide.
• Do you find yourself overly anxious about yourself and your child? Is this something your friends and family have also observed?
• Do you have ambivalent or negative feelings towards your child?
• Are your emotions interfering with your ability to care for yourself or your child?

One of my first questions in assessing a new mother who says she’s depressed is, “How did you feel before you had your baby?” Her answer will give me a clue as to whether the depression is a long-standing issue just coming into the light, or a new problem related to her hormones. And this is important, because often a pre-existing depression will respond to different types of therapy than true PPD. I also often ask women, “How did you feel while you were pregnant?”

One answer that gives us a strong indication of whether the problem is hormone-based is when a new mother struggling with depression tells us that pregnancy was wonderful and the best she has ever felt, and describes a sharp contrast between the euphoria she felt before giving birth and the lows that came afterward. This is usually a signal that her hormones, particularly her progesterone level, are imbalanced (we discuss this further in our article on PPD and hormones).

Any form of depression has both physical and emotional components, and certainly postpartum depression is no exception to this statement. Our fluctuating hormones magnify our emotions after giving birth, and these fluctuations continue for far longer than four weeks (particularly if we breastfeed). This situation is compounded by the fatigue, discomfort, and sleeplessness characteristic of the first days and weeks after childbirth. It can feel especially lonely at night, when we’re often the only one awake to care for our babe (and that’s even true when we have attentive, helpful partners, so it’s all the more difficult for single moms or those whose partners don’t realize their help is needed). If the baby herself isn’t sleeping well (or at all), has health problems, is premature, or is simply prone to fussiness, it takes an even greater toll on Mom. And Mom may already have conflicting emotions about her new role as a mother, particularly if her own mother was distant, absent, or abusive. All of these different factors that go with caring for a new baby contribute to feeling depressed after giving birth.

Yet this is where the “conventional wisdom” about depression becomes a problem. You might be startled to learn that conventional medicine does not diagnose women with “postpartum depression”. Instead, if you look in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders — the “bible” of mental health, commonly known as the DSM-IV — you’ll find that postpartum depression is considered to be a variation of standard depression. The treatment recommendations they have for postpartum depression are the same as they’d offer someone who hadn’t just had a baby — and that includes using drugs such as Prozac or other SSRIs that probably won’t be effective for true PPD. Antidepressants, as we’ve discussed in other articles, often just mask symptoms in women who have issues with hormonal balance.

Treating postpartum depression

One of the drawbacks to the DSM-IV’s perspective is that it discourages research into the causes and treatments of PPD. After all, there’s plenty of research already ongoing into standard depression, so if PPD is “just” depression that happens to occur in a new mom, there’s no real reason to address it separately for one subset of patients. The problem with this logic is that PPD is different from standard depression because the circumstances of women’s bodies and hormonal balance after childbirth are not the same as in non-pregnant women.

The DSM-IV also stipulates that postpartum depression occurs within four weeks of childbirth. Yes, that’s right, four weeks — when your ob-gyn or midwife will have told you to watch for symptoms for as much as a year after giving birth. Clearly, there’s a disconnect between what the psychiatric community thinks is going on and what those of us involved in childbearing have experienced!

When it comes to treatment, this disconnect means that there aren’t very many clinical trials investigating what therapies work well for PPD. Most conventional practitioners will treat it as if it were standard depression, which may not be effective (and that’s leaving aside the fact that drug therapies for depression have unknown effects on nursing babies). But our experience at the clinic has shown that there are ways to address the imbalances of PPD naturally. And most of these therapies are just as effective in helping women long past their PPD experience, but who may still feel “off” even years after childbirth — and they work for menopause too!

A natural approach

For women with PPD, we advocate many natural approaches for returning them to a better mood and hormonal balance, similar to what we suggest with depression, anxiety, PMS/PMDD and perimenopausal symptoms. These include:

• Eat well and be sure to take your prenatal multivitamin and omega-3 essential fatty acids daily (or another high-quality multivitamin formula, such as our Essential Nutrients).
• Try to get as much sleep as you can; it sometimes helps to adjust your sleep schedule to match your baby’s and ask Dad to take one shift at night, feeding your baby formula or pumped milk.
• Ask friends and relatives for help with the baby, and talk to them or a health care professional if you feel depressed right away.
• If you are no longer breastfeeding, consider bioidentical progesterone therapy or herbal supplements to support hormone balance, such as our Herbal Equilibrium formula.
• Get outside in the sunshine daily, and try to get gentle exercise daily as well, keeping in mind that you need to listen to your body as it heals and not over-do it!

(We talk about these more in our discussion of hormones and PPD).

It’s rare that PPD cannot be resolved quickly if the woman gets good nutrition, rest, exercise, emotional support and, if needed, progesterone therapy. We do know, however, that we don’t live in an ideal world and that sometimes women can’t get their needs met easily, particularly given that your little one’s demands often take precedence! But more than anything, it’s important that you let people know how you’re feeling. Don’t let yourself become isolated — reach out to friends, family, or social services if you find you’re overwhelmed by your depressed mood. With time and with help, your struggle with PPD can be resolved.

Related to this article:

References & further reading on postpartum depression

 

Original Publication Date: 07/21/2008
Last Modified: 02/16/2010