Postpartum depression

Postpartum Depression
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director: AllCEUs Counseling Education
Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 1

Objectives
 Define postpartum depression
 Identify signs of postpartum psychosis
 Identify Risk factors of PPD
 Identify screening tools and protocols
 Discuss the impact of PPD on the mother, child
and family
 Identify the cause of PPD
 Explore current biopsychosocial interventions for
PPD

 Postpartum depression usually occurs in the first 4
to 6 weeks after giving birth, and it is unlikely to
get better by itself.
 50% of patients experienced depression for more
than 1 year after childbirth.
 Women who were not receiving clinical
treatment, 30% of women with postpartum
depression were still depressed up to 3 years
after giving birth

Define Postpartum Depression
 Perinatal mood disorders (20-weeks gestation to 4 weeks of age)
 According to the Centers for Disease Control and Prevention (CDC), up
to 20 percent of new mothers experience symptoms of postpartum
depression
 Postpartum blues is a relatively common emotional disturbance with
crying, confusion, mood lability, anxiety and depressed mood.
 The symptoms appear during the first week postpartum, last for a few
hours to a few days and have few negative sequelae.
 At the other end of the spectrum, postpartum psychosis refers to a
severe disorder beginning within four weeks postpartum, with
delusions, hallucinations and gross impairment in functioning
 Postpartum depression begins in or extends into the postpartum
period and core features include dysphoric mood, fatigue, anorexia,
sleep disturbances, anxiety, excessive guilt and suicidal thoughts for
at least one month

Signs of Postpartum Psychosis
 Postpartum Psychosis is a rare illness, compared to the rates of postpartum
depression or anxiety. It occurs in approximately 1 to 2 out of every 1,000
deliveries, or approximately .1 -.2% of births. The onset is usually sudden,
most often within the first 2 weeks postpartum.
 Symptoms
 Delusions or strange beliefs which are ego syntonic
 Hallucinations (seeing or hearing things that aren’t there)
 Feeling very irritated
 Hyperactivity
 Decreased need for or inability to sleep
 Paranoia and suspiciousness
 Rapid mood swings
 Difficulty communicating at times
 The most significant risk factors for postpartum psychosis are a personal or
family history of bipolar disorder, or a previous psychotic episode.
 Note: Valproic Acid has a high rate of causing multiple congenital
abnormalities as do carbamazepine and lithium (first trimester)
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Scary Thoughts
 Scary thoughts are a very common symptom of
postpartum depression.
 Scary thoughts can come in the form of thoughts
(“what if I …”) or images (imagining the baby falling
off the changing table)
 Scary thoughts can be indirect or passive (something
might happen to the baby) or they can imply
intention (thoughts or images of stabbing the child)
 Scary thoughts are NOT indication of psychosis.
 Scary thoughts can be part of a postpartum OCD
diagnosis or PPD

Scary Thoughts Interventions
 Scary thoughts will make the woman feel like she
is a bad mother.
 They will make her feel guilty and ashamed.
 It is a good sign if the thoughts are worrisome.
 Remind her that these thoughts are NOT about
who she is or her capability as a mother.

Scary Thoughts
 The nature of these thoughts:
 Scary thoughts typically focus on the baby, but can also center
on thoughts about you, or your partner.
 Scary thoughts can be intermittent or constant.
 They may be accompanied by compulsive behaviors (e.g.
checking)
 Some examples of scary thoughts:
 “I’m afraid I might take one of the knives in my kitchen and stab
the baby”
 “I can picture myself driving off the road with my baby in the car”
 “I think my family would be better off without me”
 “I’m having sexual thoughts about my baby.”
 “I can see terrible graphic violent things happening to my baby.”

Scary Thoughts
 Focusing on the thoughts empowers them
 Distract yourself
 Practice radical acceptance
 Practice mindfulness exercises
 Remind yourself that you won’t always feel this way

Scary Thoughts Interventions
 Encourage the woman to tell someone she trusts how she
is feeling and let them reassure her that she will be okay
when she gets the treatment she needs and that she is
loved and safe.
 If she feels that her thoughts are out of your control or
that she cannot manage the intrusion, make a referral to
the perinatal specialist, psychiatrist or call 911.
 If the woman’s thoughts are worrisome to you but she
feels that her thoughts make sense and everyone else
must be the crazy ones (Psychosis), it is an emergency and
she needs to be evaluated by a psychiatrist or physician.

Question
 What types of things trigger postpartum
depression and why?

Risk Factors for Postpartum Depression
 Women who have experienced postpartum depression
have a 50% to 62% risk for future depressions
 Other risk factors for postpartum depression include:
 History of mood disorders or PMDD
 Depressive symptoms during the pregnancy
 A family history of psychiatric disorders
 Stress factors, such as negative life events
 Lack of support/poor marital relationship
 Having a special needs or medically ‘fragile’ infant
 Substance abuse
 Eating disorders
 Family dysfunction

Risk Factors cont..
 More prominent for partners
 Changing roles and responsibilities
 Feeling excluded when attention is on new baby
 Missing sexual relationship
 Feeling overwhelmed at the financial and care obligations
 Other children may also feel abandoned, jealous or
resentful of the new baby which can add additional
stress/guilt to parents
 Changing duties
 Less attention

Impact of PPD
 Prenatal
 Inadequate prenatal care, poor nutrition, higher preterm
birth, low birth weight, pre-eclampsia and spontaneous
abortion
 Infant
 Behavioral:
 Anger and distancing/averting gaze (protective of coping)
 Passivity, withdrawal
 Poor self-regulatory behavior
 Dysregulated attention and arousal/responsiveness
 Cognitive: Lower cognitive performance

Impact of PPD
 Infant
 Social:
 Mothers with postpartum depression exhibit fewer instances of
maternal-child touch and positive engagement activities such
as reading books, singing songs, and playing games
 Mothers with PPD also display less sensitive behaviors toward
their children, and tend to respond to their children’s needs in
a less responsive, attentive, and nurturing manner
 These withdrawn behaviors inhibit the formation of a caring
and attentive primary attachment (mother-child relationship)
 The attachment relationship also suffers from a lack of physical
touch which is crucial to the development of children’s
regulatory skills and the ability to cope with stress

Impact of PPD
 Toddler
 Behavioral
Passive noncompliance
Less mature expression of autonomy
Internalizing and externalizing problems
Lower interaction
 Cognitive:
Less creative play and problem solving
Lower cognitive performance
https://wp.nyu.edu/steinhar
dt-appsych_opus/the-impact-
of-postpartum-depression-on-
the-mother-child-
relationship/

Impact of PPD
 School age
 Behavioral:
Impaired adaptive functioning
Internalizing and externalizing problems
Affective disorders
Conduct disorders
 Academic:
Attention deficit/hyperactivity disorder
Lower IQ scores
https://wp.nyu.edu/steinhar
dt-appsych_opus/the-impact-
of-postpartum-depression-on-
the-mother-child-
relationship/

Screening for Postpartum Depression
 All women should be screened, even if it is not a first
pregnancy.
 New fathers should be screened as well
 Edinburgh Postnatal Depression Scale (EPDS)
 Maternal mood in the immediate postpartum period (or up
to 2 weeks postpartum) is a significant predictor of
postpartum depression.
 Also watch for upsurge in symptoms after discharge from the NICU
(increased anxiety, decreased sleep…)
 73% of women (who met criteria for PPD) screened in one
study denied feeling sad
 Embarrassment/fear of judgement
 Lack of education about the negative impact of PPD on the child

Causes of PPD
 Hormone changes
 After birth
 When stopping nursing
 Lack of sleep
 Pre-existing anxiety or depression issues
 History of abuse or neglect as a young child
 Maternal chronic illness
 Lupus
 Fibro
 Diabetes
 Lyme disease
 chronic fatigue
 PCOS, diabetes
 Poor control of diabetes can cause symptoms that look like depression)
19

Causes of PPD
 Trauma/Grief
 Miscarriage/stillbirth
 Prematurity
 Birth defects
 C-Section
 Lactation difficulties
 Lack of social support or intrusive social support

Prevention/Early Intervention
 For clients at risk
 Work with the woman and family during pregnancy to
Optimize mental health for all
Increase personal awareness of stress levels and
effectiveness at dealing with stress
Prepare for the new addition
Address any concerns
Develop a postpartum plan
 Encourage breastfeeding or combo breastfeeding and
pumping for late night bottle feeding

Prevention/Intervention of PPD
 Weekly interactions/check-in with a counselor to identify
mental health and self-care needs of BOTH parents
 NEST-S
 Nutrition
 Exercise
 Sleep
 Time for self
 Support
 Emotional support
 Parenting support
 Respite care
 Adult interaction
 Peer support

Interventions for PPD
 Pharmacotherapy or ECT
 Psychoeducation
 Causes of PPD
 Impact of PPD
 Importance of self-care
 Treatment options
 Techniques to address scary or unhelpful thoughts
 Radical acceptance
 Mindfulness
 Cognitive behavioral therapy
 Bright light therapy

 Parent-infant psychotherapy
 Works directly with the parent and infant for ~16 weeks
observing the P-C interaction (direct and video), to:
Identify concerns and worries
Identify patterns of relating and behaving
Support the parent to develop different ways to relate to
their infant
Identify influences from the past that are impeding the
parent-infant relationship
Emphasis is placed on parents’ internal working models or
representations of the infant in the context of their own
caregiving history and attachment experiences
https://www.ncbi
.nlm.nih.gov/pub
med/25569177

 Parent-infant psychotherapy
 The aims are not only to
 Learn to Identify and meet the immediate presenting problems in
the baby
 Educate the parent about the understand the relationship and
develop a healthy attachment
 Help the parent and child feel more positively about themselves
and their interaction.
 Effects
 Increased self esteem
 Improved parent-child interactions
 Reduced parental stress
 Reduced parent-infant conflict

Infanticide
 Many women who commit infanticide have no diagnosable mental
illness that precludes them from being aware of the wrongfulness of
their actions
 The exception is post-partum psychosis
 Questions
 Have you felt irritated by your baby
 Have you had significant regrets about having your baby?
 Does the baby feel like it isn’t yours at times
 Have you wanted to shake or slap your baby?
 Have you ever harmed your baby?
 Do you think the baby (or you) would be better off if the baby was dead?
 Do you have thoughts of harming your baby?
 If yes, proceed with standard SI/HI assessment (plan, means, frequency of thoughts
and what has prevented it until now)

Medications
 The exposure of infants to relatively low doses of
antidepressants through breast milk must be juxtaposed with
that of untreated maternal PPD, which has well-established
negative consequences
 The benefits of breastfeeding for maternal and infants health
are well-documented
 Sertraline (Zoloft) and paroxetine (Paxil) (among SSRIs) and
nortriptyline and imipramine (among TCAs) are the most
evidence-based medications for use during breastfeeding
because of similar findings of undetectable infant serum levels
and no reports of short term adverse events.
 Infants exposed to fluoxetine had higher medication levels,
especially if exposed prenatally.
 Citalopram may lead to elevated levels in some infants, but
more data are needed.
Weissman AM, Levy BT, Hartz
AJ, et al. Pooled analysis of
antidepressant levels in
lactating mothers, breast milk,
and nursing infants. The
American journal of psychiatry.
Jun 2004;161(6):1066-1078.
Hendrick V. Treatment of
postnatal depression. Bmj. Nov
1 2003;327(7422):1003-1004.

Medications
 Effectiveness of strategies to reduce infant exposure to
antidepressants have been suggested (i.e. discarding the breast milk
obtained during the peak serum level) not been established
 Watch for signs of adverse reactions including irritability, poor
feeding, or uneasy sleep.
 Premature babies, those with impaired metabolite efficiency or those
on anti-reflux medications should especially be monitored for adverse
effects.
 Benzodiazepines may be useful PRN for anxiety until SSRIs have taken
effect or to address transient insomnia
Weissman AM, Levy BT, Hartz
AJ, et al. Pooled analysis of
antidepressant levels in
lactating mothers, breast milk,
and nursing infants. The
American journal of psychiatry.
Jun 2004;161(6):1066-1078.
Hendrick V. Treatment of
postnatal depression. Bmj. Nov
1 2003;327(7422):1003-1004.

Opiates and Pregnancy
 Sudden opioid withdrawal for unborn babies can
cause respiratory depression, which can lead to the
fetus not getting enough oxygen and may be fatal
 Neonatal abstinence syndrome (NAS) refers to the
period of withdrawal experienced by newborn babies
born to opiate-addicted women.
 Levels of buprenorphine and methadone levels are
low in breastmilk and breastfeeding should be
encouraged (Fact Sheet 11 Clinical Guidance for Treating Pregnant and
Parenting Women with Opioid Use Disorder and Their Infants)
 Levels of naltrexone are not as well known

Summary
 Postpartum depression affects about 20% of women
 Both the mother and partner should be screened for depressive symptoms
 While PPD can begin anytime between 20 weeks gestation and 4 weeks
postpartum, untreated it can last years
 Scary thoughts are often part of PPD and should be normalized with
parents
 Postpartum psychosis is ego-syntonic and will not produce “scary
thoughts”
 PPD prevention involves NEST-S for both parents
 Treatments involve psychoeducation, cognitive behavioral and/or parent-
child psychotherapy
 Certain SSRIs have been found to be safe when breastfeeding
 There are many triggers for PPD
 Women at risk for PPD should engage in early intervention and planning
while still pregnant
30

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