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Postpartum Depression

Gail Erlick Robinson, MD, FRCPC
Director, Women's Mental Health Program,
The Toronto Hospital Professor of Psychiatry and Obstetrics/Gynecology,
University of Toronto

 
q Perhaps you could tell us, Dr Robinson, what got you interested in the area of infertility and pregnancy issues as they relate to mood disorders?

a In general, women get depressed about twice as often as men. To understand this we must look at the things that depress women as a function of the things that they go through in life and also look at the times when they get most depressed. Certainly one major influence has to do with women's reproductive cycles. We see that women get depressed most often in their life during the postpartum period. As well, there are other things related to pregnancy that can cause depressions. People can get depressions during pregnancy. They certainly can get depressions if they can't get pregnant. And they can get depressions if they have pregnancy losses. So all of these are areas of primary interest to women and times in their lives when they might easily become depressed.
   
q Now is there something specific about the hormonal fluctuations, certainly perhaps postpartum depression, that triggers susceptibility to depression, or is there no relationship to the hormonal fluctuations?

a Well the answer to that is yes and no. Because it happens at the postpartum period, everyone tends to assume that there's something wrong with the hormones. In fact there's nothing different about the hormones of women who get depressed at that time as opposed to women who don't get depressed at that time; the levels are the same, the ratios are the same, the rates of fall are the same. Some women have a vulnerability to getting depressed, and that's probably related to a vulnerability in the serotonin system. When the hormones change normally in those women, it is believed that there is a connection to the serotonin system and that causes changes in those chemicals that are responsible for mood. So it's not that these women have abnormal hormone changes, it's that in certain women normal hormonal changes lead to abnormal results. In this case, they can lead to depression.
   
q Are there any identifiable risk factors for a woman who may be more susceptible to develop postpartum depression so the family physician can perhaps be alert and on the lookout for it?

a There are three things that are most commonly associated with postpartum depression. And they are: a woman who has a personal or a family history of past emotional illness; somebody who has current stresses in their life; and someone who has poor support systems. So those should especially alert physicians to be concerned. Women who have troubles during pregnancy, and are depressed or anxious during pregnancy, have a high risk of continuing to have distress after pregnancy. In general, though, I think it's important to realize that ten to fifteen percent of women have a major depression after childbirth. So it's something that you should be thinking about with every woman that you see. One of the difficulties with postpartum depression is that it goes under-diagnosed because women themselves don't have any warning that they might get depressed. They don't realize that this is, in fact, the most common complication of childbirth. So when they're home alone with the baby in those weeks or months after the baby's born, and they begin to get depressed, they don't realize they're getting depressed. They just begin to think they really are terrible mothers, or they have made a big mistake, or they're not feeling as they should feel. But they don't recognize that it's a depression. So we should be alert for it, in all women, and should alert them to the fact that it may happen.
   
q At what point should a physician start to become concerned? I understand that women typically become kind of weepy, and sort of lose it maybe very shortly after the birth of the baby. But at what point should a clinician start thinking this woman has postpartum depression?

a The postpartum blues, as you say, are very common, and they usually occur in the first 3 to 10 days right after birth. They're very transient, and the woman just needs to be reassured and maybe have some education about looking after the newborn. Usually the blues fade away after ten days or two weeks. In some women, there is, in fact, a period of relative wellbeing for several months after that. In other women, the blues keep getting worse. They don't get better after those first couple of weeks. The kinds of things to look for are some of the normal symptoms of depression, such as a low mood, tearfulness, problems sleeping, decreased appetite, decreased energy, and certainly anything serious such as suicidal thoughts. One of the things I think that gets in people's way is that some of the common reactions after a birth can get confused with symptoms of depression. So you can't just say, "Are you sleeping well at night?" because of course most women with new babies aren't. You have to look at the type of sleeping pattern. So a woman who is normal is going to go to sleep, be awakened by the baby's crying, feed the baby and then go back to sleep. A woman who is depressed is going to be lying there unable to sleep, even before the baby cries, and not be able to get back to sleep afterwards. All women are somewhat anxious, especially after their first child, and they have questions or wonder if they're doing things okay. But the woman with normal adjustment, can be reassured. She can find out some information and feel more relaxed, and gradually gain confidence about looking after the baby. Even if she's tired or she's had a worrisome day, if she gets out, gets a break, or friends come over, then she'll probably feel well again. The woman who is depressed can't be reassured. She continues to worry, either worry a lot about the baby's health and welfare, or else worry because she feels very distant from the baby and detached from the baby. Her mood stays low, so it doesn't matter if everything's really going well or if she's doing something that should give her pleasure, she continues to feel low all the time. So those are the kinds of things to pay attention to. It's also very important to make sure you ask the woman about these kinds of symptoms, because, at a time in women's lives when everyone else is saying, "Isn't this wonderful? This is the happiest time in your life," it's very difficult to admit that you are not feeling well, that you're wondering if you made a big mistake and that you're not enjoying the baby. So women are often hesitant to come forward and if they say something tentatively, and you dismiss it as just "adjustment", then they'll shut up. They'll get the message that they're not supposed to talk about this. And you'll miss a depression that's growing worse and worse.
   
q Do women who have postpartum depression respond well to standard antidepressant therapy or do you find that you have to modify your treatment approach for these women?

a As with most depressions, it's helpful to have a combined approach. Antidepressants are frequently very important. Women present with all kinds of conflicts and troubles during this time. As I said, many women will come saying, that they made a big mistake and they shouldn't really have got pregnant. I think it may be a mistake to zero in with intensive therapy at this time, because most often when they've been on an antidepressant for a few weeks, these feelings go away. They're a symptom of the depression, rather than a cause. The women may, however, have conflicts about mothering, or with their own mothers, or with their husbands. These things should be addressed as they're feeling better, and as they're able to cope with any kind of psychotherapy.
   
q In terms of perhaps worrying about the antidepressant getting into breast milk do you advise women not to breast feed if they are on antidepressant therapy or any specific type of antidepressant?

a It's an interesting problem. All of the medications pass through the breast milk and get into the baby. But they tend to be in very small amounts. There's no evidence that the antidepressants, except for lithium, cause immediate difficulties with the babies. Now babies who have had mothers taking antidepressants even during pregnancies have been followed for about four or five years now postpartum, and we don't see any difficulties so there's no clear evidence that says that it's harmful to the child in the future to be having that medication transmitted to them through breast milk. If the mother's very nervous, she may want to discontinue the breastfeeding. Certainly I have a lot of mothers who breastfeed and take antidepressant medication. I think the worst solution is a mother who says, "Oh I'll just continue breastfeeding for six or seven months because this is good for my baby, and then I'll take an antidepressant." It's important to realize that there are great dangers in a mother not being properly treated for her depression. She's not being the best mother just by breastfeeding, and, in fact, she risks harm to the baby, either directly because she gets suicidal or homicidal, or indirectly by not eating properly or neglecting the baby because she's depressed. There may also be ongoing bonding difficulties because she can't really relate. So it's obviously a decision that the mother has to make, and there are no absolute answers, but we do have a sense that it is safe to use drugs during breastfeeding, and that it is very important to treat the mother during this time.
   
q Is it common for women to develop depression during pregnancy or is it more likely to occur at the end of the pregnancy?

a Certainly the postpartum period is the time when women are most at risk for developing depression, but women do get depressed during pregnancy. We used to think that it was kind of a protected period, but in fact it's not. They can get depressed, at almost the same rate that they do at other times in their life. So it's important to realize that that can happen, and to also realize that depressions during pregnancy can and should be treated. Again, you're looking not just at a choice of whether you should give medication to a pregnant woman or not give her any medication. The question is whether you should treat a depression during pregnancy or not treat it. There is no good evidence that any of the antidepressants cause any harm to the baby, either in the first trimester or throughout the rest of pregnancy. Except for the MAOIs, which should not be used, both the tricyclics and the SSRIs appear to be safe during the pregnancy. In contrast, we know for example that neglect during pregnancy and not getting proper prenatal care puts a baby at high risk, so once again, it's important to treat that woman, and not just let her tough it out until she's finished being pregnant, because that may not be the safest for her or the baby.
   
q What about the role of electroconvulsive therapy during pregnancy? Some have suggested that perhaps a woman who is reluctant to take antidepressant medication may find ECT more appealing.

a ECT is a very safe and very effective treatment. Because of some of the press and politics about it, it sounds very scary and so it doesn't get considered as often as it should. But it can cause a rapid improvement in depression and avoids taking medication. I think for some women it may be a preferable option.
   
q Looking at women who are trying to conceive but, for I guess lots of reasons can't, do you find that mood disorders, that is, primarily depression, are fairly prevalent in a woman who has undergone repeated pregnancy losses?
a You have to remember when looking at that, that we see a select group. There are certainly lots of people out there who can't get pregnant and just don't think anything about it and go on with their lives, and that's fine. But people who come for treatment for fertility are obviously people for whom pregnancy is very important. Depression can occur with infertility in two ways. First of all, the diagnosis of infertility is often very upsetting. It comes as a surprise to most people. Most women spend many years trying to avoid getting pregnant, and then assume as soon as they're ready to get pregnant they just have to say "go" and that's it. And then they get very upset. As you say, infertility can happen in two ways: sometimes you can't get pregnant at all and that's very distressing. Sometimes you can get pregnant, but you can't sustain the pregnancy. In that case you're dealing with a succession of losses, which are very hurtful, as well as that fear that you're never going to have a baby. You're never going to have that child that you wanted. So that can be a very upsetting time for women and for the couple. The other hard time about infertility is the treatment itself. It involves a type of monitoring of your life which starts from the moment you wake up in the morning and continues every day of the month. It may involve medications that upset your system and make you emotional and make you depressed. If you're involved in any kind of higher technology, the woman often has to come to the hospital at 6:30 in the morning to get tested . That disrupts her life and she either has to decide whether to tell everybody about it and, therefore, have everybody know what's going on, or to keep it a secret and constantly be lying and getting in trouble at work because she's late. It makes it difficult to make plans. The most private part of a couple's life becomes something that's talked about and discussed and programmed in terms of when they should have their lovemaking. And of course every month there's this whole cycle of the building up hopes, and expectations, getting implanted, hoping that things are going to work out, and then getting disappointed again if it hasn't happened. So all of these add enormous stress to the couple without any certainty that going through all this is going to guarantee a pregnancy by any means.
   
q Has it been your experience that perhaps a woman who has wanted terribly to become pregnant, carry a pregnancy to term and who succeeds in doing so basically can say good-bye to her depression and that it was really the stress of not being able to conceive or have a child that was making her depressed, or perhaps is that too simplistic?

a I think it's too simplistic for a number of reasons. First of all I want to differentiate between a true clinical depression and just a reaction to stress. So lots of people going through fertility problems react to the stress of it and benefit from help getting through that. There are some women who actually trigger into a major depression and need medication at that time. Just as with anybody who has had a major depression, once you've had one, you're at a risk of having a second one. So it doesn't mean that you're scot free for the rest of your life. But even ones who have just had an emotional reaction to the pregnancy don't necessarily have smooth sailing. once they get pregnant or when they have had a baby. Getting pregnant is scary, because once you are pregnant that's great, but then you have to hope that you'll sustain it and you have to worry about whether you should have diagnostic testing to see if it's okay. Once you get through the pregnancy and find out that the baby is well and healthy and has ten fingers and toes, you then often have to turn your mind to something you hadn't really thought about. Because the emphasis has been so much on getting pregnant and having a baby that you maybe haven't really had a lot of thought about raising that child. That child can be a very special child. There can be lots of hopes weighing on this child's head, as you might feel this is the only child you'll ever have. There might be such high expectations of the child and of yourself as a parent after trying so hard for so long that it's hard to just relax and treat it like a normal family from there on. So sometimes people have reactions and struggles even afterwards.
   
q If a woman has had one episode of postpartum depression or major depression, is she predisposed to develop postpartum depression with each subsequent pregnancy?

a She certainly is at an increased risk of having another postpartum depression and of having a depression at another time of life unrelated to the pregnancy. If she has had one postpartum depression, she probably has a one in five chance of getting a depression following another pregnancy. If she's had either a previous bipolar illness, a manic depressive illness, at any time in her life, she has about a 50% chance of developing another episode postpartum.
   
q Would that argue in favour, particularly of the higher risk women, for prophylactic therapy during the pregnancy?

a Well, let me separate the two things. In just the regular kind of postnatal depression, there has not been a lot of work done on prophylactic antidepressants. There are a couple of small studies that have looked at that. It's one of these difficult things because, since we can't guarantee the women will have it, we don't really know whether the medication is helpful or not. I think for most women who have had a postpartum depression, what I tend to do is say, just be careful. Come back and see the doctor prior to delivery, and check in regularly postpartum, and watch for any early signs of depression. If there's anything that suggests that depression is coming on, then start the antidepressant fairly quickly. And for most people that's fine. If somebody has had several postpartum depressions, or has had particularly severe postpartum depressions, I think it's worthwhile starting it in a prophylactic manner. With the more severe, the bipolar affective disorder, there are a couple of studies that suggest that starting lithium almost on the delivery table, very quickly after the birth of the baby, can decrease that 50% chance of recurrence to about 10% so that is a worthwhile prophylactic procedure to try.
   
q Dealing with classic postpartum depression, if you do initiate prophylactic therapy, how soon would you start?

a It depends again how soon the postpartum depression tends to start. So if this was a woman who had been depressed twice before and it would happen within a few weeks after the birth, I would start it even in the third trimester of pregnancy, when it appears safe for her to be taking it. If it's somebody who develops her postnatal depression, say, at two or three months postpartum, I would wait until after the delivery and start it then.
   
q I guess for the primary care physician who is confronting similar difficulties, what are the key issues to keep in mind?

a I think the key issue is informing the woman about the possibilities. Especially with the way we have delivery now, where people barely have time to hang up their hat in the hospital, they're not staying for long periods of time. They go home very quickly. That first week or so there are often people around, but after that, the woman is essentially home alone with the baby, maybe coming for a check up after six weeks. That's a lot of time for a depression to start. We have to rely on the women being informed. We tell them if they bleed or get a temperature to call, but we don't often warn them about what the signs of depression are. When that woman starts to feel low, when she starts to think, "Oh, I'm a terrible mother", instead of just believing that, I want her to say, "Maybe this means I'm getting depressed. I better call the doctor and check." So if the doctor is aware of these risks and informs her, and then, when she calls up, he pays attention to what she's saying, and considers the possibility that this is not just some transient adjustment problem but a genuine depression, then it can be detected very quickly early on and can be treated and we can prevent a lot of problems and on-going difficulties.
   
   


Over one million Canadians suffer from some form of depressive illness.