PostPartum Depression
Dr. Dawn-Elise Snipes, PhD, LPC-MHSP, LMHC
Executive Director: AllCEUs.com
Podcast Host: Counselor Toolbox and Happiness Isn’t Brain Surgery

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)
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

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

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)
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
Interventions for PPD
~ 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

Interventions for PPD
~ 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.
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
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