Postpartum depression
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مها
postnatal depression ,is a form of which can affect women, and less frequently men, after
childbirth .Studies report prevalence rates among women from 5% to 25%, but methodological
differences among the studies make the actual prevalence rate unclear. Among men, in
particular new fathers, the incidence of postpartum depression has been estimated to be
between 1.2% and 25.5%.
Postpartum depression occurs in women after they have carried a child, usually in the first few
months, and may last up to several months or even a year.Symptoms include sadness, fatigue,
changes in sleeping and eating patterns, reduced libido, crying episodes, anxiety, and
irritability. It is sometimes assumed that postpartum depression is caused by a lack of vitamins
but studies tend to show that more likely causes are the significant changes in a woman's
hormones during pregnancy .On the other hand, hormonal treatment has not helped postpartum
depression victims. Many women recover because of a support group or counseling
Symptoms
• Sadness
• Hopelessness
• Low self-esteem
• Guilt
• A feeling of being overwhelmed
• Sleep and eating disturbances
• Inability to be comfortable
• Exhaustion
• Emptiness
• anhedonia
• Social withdrawal
• Low or no energy
• Becoming easily
• Feeling inadequate in taking care of the baby
• Impaired speech and writing
• Spells of anger towards others
• Increased anxiety or panic attacks
• Decreased sex drive
• One method of detecting Postnatal Depression (PND) is the use of Edinburgh Postnatal
Depression Scale. If the new mother scores more than 13, she is likely to develop PND
Risk factors
While not all causes of PPD are known, a number of factors have been identified as predictors
of PPD :
• A history of depression
• Cigarette smoking
• Low self esteem.
• Childcare stress
• Prenatal depression during pregnancy
• Prenatal anxiety
• Low social support
• Poor marital relationship
• Infant temperament problem to
Post partum blue-risk factors
• Unplanned/unwanted pregnancy
• single mother
• low socioeconomical class
Of these, three factors - formula feeding, a history of depression, and cigarette
smoking - have been shown to be additive effects
• with PPD., high levels of prenatal depression are associated with high levels of postnatal
depression, low levels of prenatal depression are associated with low levels of postnatal
depression But this does not mean the prenatal depression causes postnatal depression—they
might both be caused by some third factor. In contrast, some factors, such as lack of social
support,
• postpartum depression. (The causal role of social support in PPD is strongly suggested by
several studies)
Effect on mother baby relationship
• Postpartum depression may lead mothers to be inconsistent with childcare .Women diagnosed
with postpartum depression often focus more on the negative events of childcare, resulting in
poor coping strategies.)
There are four groups of coping methods, each divided into a different style of coping
subgroups .Avoidance coping is one of the most common strategies used). It consists of denial
and behavioral disengagement subgroups (for example, an avoidant mother might not respond
to her baby crying). This strategy however, does not resolve any problems and ends up
negatively impacting the mother’s mood
Coping strategy
• Four coping strategies
1. Avoidance coping
denial ,behavioral disengagement
2. Problem-focused coping
:
active coping, planning, positive reframing
3. Support seeking coping
:
emotional support, instrumental support
4. Venting coping
:
venting ,self-blame
Treatment
• Women need to be taken seriously when symptoms occur. This is a two-fold practice: First, the
postpartum woman will want to trust her intuition about how she is feeling and believe that her
symptoms are real enough to tell her significant other, a close friend, and/or her medical
practitioner; erring on the side of caution will go a long way in the treatment of PPD
the people in whom she confides must take her symptoms seriously as well, aiding her with
treatment and support. Partners, friends and physicians may notice changes in a postpartum
mother that she may not. Knowing that PPD is treatable with a variety of methods can make
persistence in seeking treatment
• Medical evaluation to rule out physiological problems
• Cognitive behavioral therapy a form of psychotherapy
• Possible medication
• Support groups
• Home visits/Home visitors
• Healthy diet
• Consistent/healthy sleep patterns
• An experienced medical professional will work with a postpartum mother to develop a
treatment plan that is right for her. This plan may include any combination of the above
options, and might include some discussion or feedback from/with a partner. If a woman
suffering from PPD does not feel she is being taken seriously or is being recommended a
treatment plan she does not feel comfortable with, she will want to seek a second opinion.
• Confirms that postpartum depressed mothers’ symptoms promptly improved at similar rates
when treated with cognitive behavioral therapy or the antidepressant fluoxetine .A group of 61
depressed mothers completed a 12-week treatment program with or without the antidepressant
plus one session versus six sessions of counseling.‖ Improvement followed after ―one to four
weeks of either treatment. The findings of Appleby et al.’s study conclusively showed that
combining counseling with drug therapy did not add to the improvement of just drug therapy or
just counseling.This suggests that counseling is equally as effective a treatment for PPD as
medication, and that the
Post partum psychosis
• First recognized as a disorder in 1850, postpartum psychosis is a very serious mental condition
that requires immediate medical attention. Interestingly, studies on the rates of the disorder
have shown that the number of women experiencing postpartum psychosis haven’t changed
since the mid 1800s.
• affects between one and two women per 1,000 women who have given birth .
• Unfortunately, though many women with the disorder realize something is wrong with them,
fewer than 20% actually speak to their healthcare provider. Sadder still is the fact that often
postpartum psychosis is misdiagnosed or thought to be postpartum depression ,thereby
preventing a woman from receiving the appropriate medical attention that she needs.
Women who do receive proper treatment often respond well but usually experience postpartum
depression before completely recovering. However, without treatment, the psychosis can lead
to tragic consequences. Postpartum psychosis has a 5% suicide rate and a 4% infanticide rate
Signs
• Although the onset of symptoms can occur at anytime within the first three months after giving
birth, women who have postpartum psychosis usually develop symptoms within the first two to
three weeks after delivery. Postpartum psychosis symptoms usually appear quite suddenly; in
80% of cases, the psychosis occurs three to 14 days after a symptom-free period .
• Hallucinations
• Delusions
• Illogical thoughts
• Insomnia
• Refusing to eat
• Extreme feelings of anxiety and agitation
• Periods of delirium or mania
• Suicidal or homicidal thoughts
Symptoms
• Hallucinations
• Delusions
• Periods of delirium or mania
• Thoughts of harming the baby or oneself
• Irrational feelings of guilt
• Refusing to eat
• Thought insertion - the notion that other beings or forces (God, aliens, the CIA, etc.) can put
thoughts or ideas into one's mind
• Insomnia - although studies are beginning to show that insomnia may be a cause rather than an
effect
• Reluctance to tell anyone about the symptoms
risk factors
1-Women with a personal history of psychosis,
2-bipolar disorder .
3-women with history of schizophrenia or psychosis-
4-women with family history of psychosis, bipolar disorder or schizophrenia
5- women who have had a past incidence of postpartum psychosis are between 20% and 50%
more likely of experiencing it again in a future pregnancy
Causes
1- changing hormones being at the top of their list.
2- lack of social and emotional support;
3-a low sense of self-esteem
4- feeling isolated and alone;
5-having financial problems;
6- undergoing a major life change such as moving or starting a new job
7- previously diagnosed bipolar disorder or schizophrenia,
8- family history of one of these conditions.
9-postpartum depression or psychosis have a 20-50% chance of having it again at future births
Treatment options
• The use of lithium carbonate for prophylaxis of postpartum psychosis in such women remains
controversial. Given the apparent safety of lithium prophylaxis relative to the dangers of
postpartum affective psychosis,
• ECT is indicated specially if there is compelling suicidal and infanticide tendencies sometimes
it is the first line of treatment
Treatment
1-Family support
2- educating the family, It is important that the affected individual not be labeled a bad mother .
3-Anti-psychotic medications do pass into the mother's breast milk. Subsequently if the mother
has been breastfeeding and continues to do so, the baby needs to be monitored for drowsiness
or lethargic behavior, and prescribing the least amount of anti-psychotic medication in order
for symptom reduction to occur is also crucial .
Severe agitation and delusions may require rapid tranquilization by neuroleptic
(antipsychotic) drugs, but they should be used with caution
4-Electro-convulsive (electroshock) treatment is highly effective
5-stabilizing drugs such as lithium are also useful in treatment .
6-hospitalization is disruptive to the family, and it is possible to treat moderately severe cases
at home, where the sufferer can maintain her role as a mother and build up her relationship
with the newborn. This requires the presence, round the clock, of competent adults (such as the
baby's maternal grandmother), and frequent visits by professional staff if in the hospital
\Note :Postpartum psychosis is one of the serious emergency in psychiatry
• there are advantages in conjoint mother and baby admission. Yet multiple factors must be
considered in the subsequent discharge plan to ensure the safety and healthy development of
both the baby and its mother. This plan often involves a multidisciplinary team structure to
follow-up on mother, baby, their relationship and the entire family.
• Suicide is rare, and infanticide extremely rare, during these episodes. It does occur, as
illustrated by the famous cases summarized below. Infanticide after childbirth is usually due to
profound postpartum depression (melancholic filicide) when it is often accompanied by suicide
Premenstrual Dysphonic Syndrome
• (PMS) that is so severe it can be debilitating due to either physical, mental or emotional
symptoms. Treatment is recommended because PMDD interferes with the sufferer's ability to
function in her social or occupational life. The cardinal symptom—surfacing between
ovulation and menstruation, and disappearing within a few days after the onset of the
bleeding—is irritability Anxiety, anger, and depression may also occur
Symptoms
• feelings of deep sadness or despair, possible suicide ideation
• feelings of tension or anxiety
• increased sensitivity to rejection or criticism
• panic attacks
• mood swings, crying
• lasting irritability or anger, increased interpersonal conflicts. Typically sufferers are unaware of
the impact they have on those close to them
• apathy or disinterest in daily activities and relationships
• difficulty concentrating
• fatigue
• food cravings or binge eating
• fatigue
• insomnia or hypersomnia; sleeping more than usual, or (in a smaller group of sufferers) being
unable to sleep
• feeling overwhelmed or "out of control "
• increase or decrease in sex drive
• increased need for emotional closeness
• physical symptoms: bloating, heart palpitations, breast tenderness, headaches, joint or muscle
pain, swollen face and nose, feeling fat
• Five or more of these symptoms may indicate PMDD.
• Symptoms occur during the 2 weeks before the
• menstrual cycle and disappear within a few days after
• the onset of the bleeding,
• There are co morbidity of anxiety ,depression,
• recent studies demonstrated that PMDD women had greater sensitivity in responding to stress
and pain .
Treatment
1-Lifestyle changes such as regular exercise and a well balanced diet
2-Vit B6 in doses up to 100 mg
3-SSRIs-Fluoxetine Escitalopram oxalate Paroxetine
4-studies showed that L-Tryptophan provide significant relief when supplemented daily in a
large dose of (six grams) per day
Menopause
• is the permanent cessation of the function of the ovaries in human female
The word "menopause" literally means the "end of monthly cycles" from the Greek words
pausis
( cessation) meaning (month),
• midlife phase,where the end of fertility is traditionally indicated by the permanent stopping of
the menstrual cycle .
• also exists in some other animals, many of which do not have monthly menstruation.
• The date of menopause in human females is formally medically defined as the time of the last
menstrual period (or menstrual flow of any amount however small), in a woman who has not
had a hysterectomy
Signs and symptoms
• Not every woman experience the same severity of the symptoms that can be started even
before cessation of LMP, symptoms are due to fluctuation of estrogen level in the blood for
example hot flashes and mood changes that disappear after the transition from pre menapause
to post menopause has over it may take several years
1-hot flashes
2-palpitation
3-lethargy ,lack of energy
4-skin tingling sometimes to the degree of formication due to hormone withdrual
5-skin and vaginal dryness
6-anxiety ,irritability, depression,mood swings
7-memory problem and lack of concentration
8-urgency of urination
9- night sweat
10-back ,joint ,muscle pain
11-desturb sleep, poor quality, insomnia
12-breast tenderness or atrophy
13- decreased libido ,dyspronia
Average age is 51
Management
1-Hormonal replacement therapy—premarine-raloxifine—tamoxifine
2-anti-depressants –SSRI improve sleep and hot flashes and mood swings
3-Gabapentin-Lyrica improve hot flashes
4-Clonidine
5-education-