Postpartum depression
OB/GYN Module Training Conference
May 16, 2005
Elyse R. Park, Ph.D.
Massachusetts General Hospital/
Harvard Medical School
Prevalence
For women ages 15 to 44, depression is the leading
cause of disease burden worldwide.
Being a mother of a young child increases the risk of
depression and depressive symptoms.
Additional risk: Low SES
More than 1 child
Epidemiological and clinical studies suggest that 812% of women may experience postpartum
depression, and elevated depressive symptoms may be
present in 24% of mothers.
Maternal Depression
Maternal depression encompasses several
DSM-IV diagnoses including postpartum
depression (PPD) and major depressive
disorder.
PPD occurs immediately after delivery and can
last up to one year postpartum.
Women who experience postpartum depression
are at higher risk of subsequent episodes of
depression.
Impact of Maternal Depression
In addition, extensive research has shown the
negative impact that maternal depression,
experienced during the postpartum period and
beyond, can have on children’s social,
cognitive, and behavioral development.
Effects of Maternal Depression
Maternal depressive symptoms are associated with:
 newborn irritability
 sleep difficulties
 attachment and parenting difficulties
 delayed development
 behavioral and school problems
 impediment of parental prevention practices
Women’s Medical Care Use
Lack of recognition and treatment of depression is more
pervasive and the consequences potentially more serious
for mothers of young children.
Women are likely to be overlooked because of their
pattern of medical care use.
An examination of utilization patterns of women with
children less than 36 months in the National Health
Interview Survey by Auinger at the University of
Rochester Child Health Research Center showed that
13% of these women had no medical care contacts in the
previous 12 months and an additional 15% had only one
visit.
Diagnosing maternal depression
Physicians often underdiagnose and undertreat
depression.
25-50% of depressed patients are not
recognized at a primary care visit (Williams et
al., 1999).
Although most PCPs endorse their role in
diagnosing depression, fewer endorse a role in
treatment of depression.
Clinician’s attitudes about
depression
Clinicians’ attitudes about treating depression
are influenced by their perceptions about
mental illness, comfort level with discussing
mental health issues, and fear of stigmatizing
patients.
Other concerns are that patients might fail to
acknowledge symptoms, reject a physician’s
diagnosis, or be resistant to treatment
recommendations (e.g. referral to a mental
health provider).
Clinician’s Confidence &
Depression
Although clinicians report being confident in being able
to identify depression, they are not confident in their
ability to counsel patients for depression.
Gerrity and colleagues (2001) developed the ‘Perceived
Self-Efficacy in Diagnosing and Treating Depression’
scale. 71% of physicians had low self-efficacy scores.
Rates of being ‘very confident,’ by specialty:
Family physicians (64%)
General internists (33%)
OB/Gyns (16%)
Pediatricians (3%)
Maternal Depression
 What are the types?
 Who is susceptible?
 What are signs and symptoms?
 What are the causes?
 What are the screening tools?
 What are helpful resources?
Types of Depression: Major
Depression
Major depression is characterized by a
combination of symptoms that interfere
with the ability to work, study, sleep, eat,
and enjoy once pleasurable activities. A
disabling episode of depression like this
may happen only once, but more
commonly people experience several in a
lifetime.
Types of Depression: Dysthymia
Dysthymia, a less severe type of
depression, involves long-term, chronic
symptoms that are not disabling, but keep
one from functioning well or feeling good.
Many people with dysthymia also
experience major depressive episodes at
some time in their lives.
Types of Depression:
Postpartum Depression
Postpartum depression occurs within four
weeks of childbirth. Most new mothers
suffer from some form of the “baby blues.”
Postpartum depression, in contrast, is major
depression, thought to be triggered by
changes in hormonal flows associated with
having a baby.
Signs & Symptoms of PPD
 Crying that lasts for days
 Suicidal thoughts
 Thoughts of harming the baby
 Intense fatigue or sleeplessness
 Feelings of hopelessness and helplessness
 Lack of motivation/interest
 Difficulty with daily functioning
 Feelings of guilt, worthlessness, helplessness
 Loss of interest or pleasure in hobbies
Signs & Symptoms of PPD
 Difficulty concentrating, remembering
 Inability to think clearly
 Weight loss or gain
 Restlessness, irritability
 Decreased energy, fatigue, feeling "slowed down"
 Persistent physical symptoms that do not respond
to treatment, such as headaches, digestive
disorders, and chronic pain
Causes for PPD
Physical changes
 Hormone levels fluctuate - levels of
estrogen and progesterone drop dramatically
 Changes in blood pressure and your immune
system
Causes for PPD
Emotional factors
 Sleep difficulty & feeling overwhelmed can
be exacerbated by:
• A sense of lost identity
• An unsatisfying birth experience (e.g.
medical complications)
• Anxiety, doubts or unrealistic expectations
• Feeling less attractive
• Feeling less in control over your life
Causes for PPD
Lifestyle influences
 A baby with a high level of needs
 Exhaustion from caring for a new baby or multiple
children
 Financial problems
 Lack of support from partner, family or friends
 Postpartum pain or delivery complications
 Problems with breast-feeding
 Relationship difficulties
Treatment for PPD
Antidepressant medications
 Many women with postpartum depression are treated with
antidepressants called selective serotonin reuptake inhibitors
(SSRIs), which seem to work by increasing the availability of
the neurotransmitter serotonin in your brain.
 Studies suggest that they're just as effective as oldergeneration antidepressants, such as tricyclics and monoamine
oxidase inhibitors (MAOIs), but have fewer side effects.
 Commonly prescribed SSRIs: paroxetine (Paxil) and
sertraline (Zoloft).
Treatment for PPD
Counseling
 Short-term counseling can be effective treatment for
PPD.
 If symptoms of postpartum depression are
mild, psychotherapy may be all that's needed.
 The number of sessions required typically
ranges from six to 12.
 More severe cases of postpartum depression
typically require both psychotherapy and
medications.
Treatment for PPD
Hormone therapy
 Using an estrogen patch — a patch containing
estrogen that you wear on your skin — can
help counteract the rapid drop in estrogen that
accompanies childbirth.
 Risks:
decreased milk production
blood clot in the legs
EPDS
 Developed at health centers in Livingston
and Edinburgh.
 10 short statements.
 The mother underlines which of the four
possible responses is closest to how she has
been feeling during the past week.
 Administration time: less than 5 minutes.
EPDS detection rates
Study
Detection Prevalence
Rate
by EPDS
Setting
Barnett,1993
1.0%
39.0%
Mothercraft Hospital
Bagedahl, 1998
2.0%
14.5%
Well Baby Visits
Bryan, 1999
3.7%
Evins, 2000
6.3%
35.4%
6 week ob/gyn visit
Morris-Rush, 2003
13.0%
22.0%
6 week ob/gyn visit
Chaudron, 2004
4.0%
27.0%
Well Baby Visits
6 week ob/gyn visit
EPDS Instructions
1) The mother is asked to underline the response
which comes closest to how she has been feeling
in the previous 7 days.
2) All ten items must be completed.
3) The mother should complete the scale herself,
unless she has limited English or has difficulty
with reading.
4) The EPDS may be used at 6-8 weeks to screen
postnatal women.
Website
http://www.nlm.nih.gov/medlineplus/
postpartumdepression.html
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Overview of PPD
Diagnosis/Symptoms
Treatment
Coping
Clinical Trials
Mental Health Directories
Mental Health Organizations
Statistics for Depression in Women
Study Goal
The goal of this study is to obtain pilot data
on the impact of depressive and anxiety
symptoms on postpartum relapse.
Summary
 The proposed research addresses the need to
deepen our understanding about the effect of
mood symptoms on postpartum tobacco use.
 Throughout the 3-month postpartum period, we
will look at the prevalence and impact of
depression and anxiety symptoms among a
cohort of women who were smokers prior to
their pregnancy and quit upon learning about
their pregnancy.
Purpose
To examine:
1) the prevalence of anxiety and
depression among women who had
remained quit during their pregnancy
2) when, in the postpartum period,
increases in depression and anxiety
symptoms and smoking relapse may
occur
3) factors related to postpartum relapse
Purpose
Among a subset of women with elevated
depression and/or anxiety symptoms, we
will qualitatively explore:
1) mood symptoms experienced
2) attributions for mood changes and/or
relapse
3) coping mechanisms and support
4) stressors
Study Rationale
 Of women who do quit approximately two-thirds
relapse within the first 3-6 months postpartum.
 Among smokers, depression and stress are
commonly cited barriers to smoking cessation and
triggers for smoking and relapse, and perceived
stress is related to less favorable cessation outcomes.
 Studies conducted with pregnant women show that
women who quit smoking upon learning that they are
pregnant have lower levels of stress and depressive
symptoms compared to women who continue
smoking during their pregnancy.
Study Rationale
 Since the postpartum period is a time when women
are vulnerable to mood fluctuations, an examination
of the relationship between mood and smoking
behavior during this time is of particular importance.
 To date no study has conducted an in-depth look at
the role of depression and anxiety in postpartum
relapse.
 The purpose of this study is to determine if and
when mood plays a role in relapse and guide the
development of a postpartum relapse prevention
intervention.
Study Population
Inclusion criteria
Postpartum women identified recent quitters are
eligible for the study if they:
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smoked within six months prior to conception but
did not smoke during the last month of pregnancy
have access to a telephone
are at least 16 years of age
speak English
Exclusion criteria
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
current major depression or a history of other severe
psychiatric illness
a newborn with a major congenital anomaly or <28
weeks’ gestation.
Design
 Preliminary longitudinal cohort study using both
quantitative and qualitative methods.
 We will enroll 60 postpartum women at delivery.
 Surveys administered : at delivery, 2 weeks, 4
weeks, 6 weeks, and 3-months.
 Subjects who relapse or meet criteria for either
mild depression (BDI >9) or anxiety (BAI>9),
will also be interviewed qualitatively at the 4week and 3-month period.
Study Design
Recruitment at delivery
Eligible
Enroll/consent
BL survey
Refuse
Ineligible:
Current Major Depression
Psychiatric history
Newborn < 28
weeks/congenital anomaly
2 week survey
4 week survey
+++++++++
Qualitative interview if BDI or
BAI > 9
+++++++++
Qualitative interview if BDI or
BAI > 9
6 week survey
3 month
survey
Measures
Measures
Demographics
Age
Marital Status
Education
Race/ethnicity
Parity
Insurance
Breastfeeding intention
Length of time breastfed
Survey period (in weeks)
BL
2
4
6
12
x
x
x
x
x
x
x
x
Measures
Measures
Smoking information
Prepregnancy smoking rate
Smoking status
Smoking rate (relapsers)
Smoking in environment
Motivation to stay quit
Survey period (in weeks)
BL
2
4
6
x
x
x
x
x
x
x
x
x
x
12
x
x
x
x
Measures
Measures
Psychosocial
Confidence to stay quit
Social support
Weight concern
Stressors
Mood
BDI
BAI
SCID
Qualitative questions
Survey period (in weeks)
BL
2
4
6
12
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Primary Aim
To compare rates of depression and
anxiety experienced by relapsed smokers
versus continued quitters.
 H1. At 3-months postpartum, significantly
more relapsers will experience mild
depression (BDI score > 9) or anxiety (BAI
score >9) symptoms compared to women who
have remained quit.
Secondary Aim
To repeatedly assess postpartum mood
symptoms and smoking status to determine
at what time mood symptoms increase and
relapse occurs.
 H2a. An increase in mood symptoms, during the
first 12 weeks postpartum, will be associated
with relapse to smoking.
Secondary Aim
Aim: To determine if baseline mood or increases in
mood symptoms are associated with increased risk of
relapse.
H2b. Relapse by 12 weeks will be associated with:
 depressed/anxious baseline mood
 increases in mood symptoms
Controlling for:
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


a high prepregnancy smoking rate
high number of family and friends who smoke
low support to stay quit
low motivation to stay quit
low confidence in ability to stay quit
high weight concern
Qualitative Aims
Among a subset of women (n=approx. 18) with
elevated mood and/or anxiety symptoms, the aims
are:
 To understand the mood symptoms (type of
symptoms experienced, quality of symptoms,
severity of symptoms).
 To explore attributions for mood changes
 To examine support and coping skills that
women use to deal with mood.
 To explore postpartum stressors.
Qualitative Aims
Among a subset of women who relapse (return
to smoking >1 cigarette per week), the aims
are:
 To understand relapse episode
 To explore attributions for relapse
 To examine support and coping skills that women
use to deal with staying quit
 To explore postpartum stressors