Facts of Life Vol. 9 No. 11

Facts of Life:
Issue Briefings for Health Reporters
Vol. 9, No. 11
November 2004

In a culture where giving birth is often believed to be the most joyful moment in life, many women instead feel tired, sad, anxious, distracted and depressed after the baby is born. Three out of four women experience the “baby blues,” a condition that can come and go within a week or two. Less common — but more serious — is postpartum depression, which can last six to nine months if untreated. [1]

Health care providers detect fewer than half of postpartum depression cases in new mothers, says Linda Chaudron, M.D., a psychiatrist at the University of Rochester. Some women may feel ashamed or embarrassed to discuss such feelings. Busy physicians may not ask about or pick up signs of depression. Postpartum depression may have negative effects on a baby’s development.

A recent systematic review of 15 randomized controlled trials, which included 7,697 women, concluded that psychosocial and psychological interventions provided no clear benefit in preventing postpartum depression. Only one study of women visited by public health nurses or midwives demonstrated any reduced risk of postpartum depression. [2] Prevention of the condition has proved elusive, so early detection, diagnosis and treatment are essential. Effective treatments include psycho-therapy and antidepressant drugs.

Postpartum depression affects about 15 percent of women. It may begin before giving birth or up to four to six months later.

“There are many possible origins but little research data,” says Linda Chaudron, M.D., of the University of Rochester. “The cause may have something to do with the normal drop in estrogen and progestin that occurs in women after giving birth but there’s also evidence implicating the thyroid, as well as marital conflict, stressful life circumstances like poverty and lack of social support.”

There are longer-term effects, too, Chaudron says. Women who have post-partum depression once are more likely to experience it again. Sometimes the condition is so overwhelming that a woman decides not to have another child. Children of depressed mothers may have more cognitive, social and behavioral problems, or fail to bond well if the mother is withdrawn or overanxious. [10]

Experts say early detection is key. “Rather than sifting through all new mothers to find those in need of prevention, we need early identification and early intervention,” says Michael O’Hara, Ph.D., of the University of Iowa.

Chaudron argues that women and their health care providers need more education to raise awareness of postpartum depression. Most women only see their obstetricians once after giving birth, so Chaudron suggests that pediatricians be trained to screen new mothers for depression and then refer them to primary care doctors or psychiatrists for treatment and follow-up. [12]

“ I’m attracted to using pediatricians as sentinels to pick up signs of depression in new mothers, but pediatricians don’t like the idea,” O’Hara says. “They face pressures to move patients through the system and don’t want to slow down and spend time talking to their patient’s mother. Then there’s the matter of responsibility: If a doctor asks, he has to follow through. That means setting up a good pathway to care.”

Treatment requires consideration of individual circumstances. The question of whether to take medication is simpler in cases of high or low severity but becomes more complicated in the middle, O’Hara says. Patient preference is important. Does a nursing woman want to take medications? Will her insurance cover treatment? Does she prefer psychotherapy?

There’s not enough data to rule out effects of antidepressants on newborns, but research increasingly indicates that some drugs don’t affect the child’s safety.

“On the other hand, the absence of treatment carries great risks,” O’Hara says.

Experts agree that more research needs to be done on the effects of mental health in pregnancy and on screening women following birth, and more randomized controlled trials are needed of medications and psychotherapy together, both pre- and postpartum.

Expert Sources:

(2) Dennis C-L, Creedy D. Psychosocial and psychological intervention for preventing postpartum depression. Cochrane Library. 2004.

(3) Hendrick V. Treatment of postnatal depression. BMJ. 2003 Nov 1;327(7422):1003-4

(4) Hendrick V, Altshuler L, Strouse T, Grosser S. Postpartum and nonpostpartum depression: differences in presentation and response to pharmacologic treatment. Depress Anxiety. 2000;11(2):66-72.

(5) Gorman LL, O’Hara MW, Figueiredo B, Hayes S, Jacquemain F, Kammerer MH, Klier CM, Rosi S, Seneviratne G, Sutter-Dallay AL; TCS-PND Group. Adaptation of the structured clinical interview for DSM-IV disorders for assessing depression in women during pregnancy and post-partum across countries and cultures. Br J Psychiatry Suppl. 2004 Feb;46:s17-23.

(6) O’Hara MW, Stuart S, Gorman LL, Wenzel A. Efficacy of interpersonal psychotherapy for postpartum depression. Arch Gen Psychiatry. 2000 Nov;57(11):1039-45

(7) Nulman I, Rovet J, Stewart DE, Wolpin J, Pace-Asciak P, Shuhaiber S, Koren G. Child development following exposure to tricyclic antidepressants or fluoxetine throughout fetal life: a prospective, controlled study. Am J Psychiatry. 2002 Nov;159(11):1889-95.

(8) National Women’s Health Information Center. U.S. Department of Health and Human Services. http://www.4woman.gov/faq/postpartum.pdf (Accessed November 3, 2004)

(9) Murray L, Cooper PJ, Wilson A, Romaniuk H. Controlled trial of the short- and long-term effect of psychological treatment of post-partum depression: 2. Impact on the mother-child relationship and child outcome. Br J Psychiatry. 2003 May;182:420-7.

(10) Chaudron LH. Postpartum depression: what pediatricians need to know. Pediatr Rev. 2003 May;24(5):154-61.

(11) Dennis C-L, Creedy D. Psychosocial and psychological intervention for preventing postpartum depression. Cochrane Library. 2004.

(12) Chaudron LH, Szilagyi PG, Kitzman HJ, Wadkins HI, Conwell Y. Detection of postpartum depressive symptoms by screening at well-child visits. Pediatrics. 2004 Mar;113(3 Pt 1):551-8.

(13) Epperson CN. Postpartum major depression: detection and treatment Am Fam Physician. 1999 Apr 15;59(8):2247-54, 2259-60.

The Center for the Advancement of Health is an independent nonprofit organization that promotes greater recognition of how psychological, social, behavioral, economic and environmental factors influence health and illness. The Center advocates the highest quality research and communicates it to the medical community and the public. The fundamental aim of the Center is to translate into policy and practice the growing body of evidence that can lead to the improvement and maintenance of the health of individuals and the public. The Center was founded by the John D. and Catherine T. MacArthur Foundation and the Nathan Cummings Foundation, which continue to provide core funding. Funding for this series was provided by the Robert Wood Johnson Foundation.

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