The pregnancy period comes with its changes and adaptation, but once the baby is delivered, it becomes a more difficult time characterized by overwhelming emotional and physical changes. The huge expectations from the baby, relatives, and friends are not easy to meet. The constant crying and feeding of the baby, in the beginning, will often leave you tired, sleep deprived and drained, to say the least.
You may be shocked that after two to three days of trying to cope with these changes, you start feeling a little apprehensive, the motherly bond starts fading, sleep deprivation worsens, and start getting worked up. Up to 80% of women experience maternal blues, but they often go away in less than two weeks. If the blues linger around for more than two weeks, they can be a long-lasting problem of postpartum depression, anxiety or psychosis.
Table of Contents
- What is Postpartum Depression?
- What Causes Postpartum Depression?
- Who is At Risk of Postpartum Depression?
- What are the Signs And Symptoms?
- How is Postpartum Depression Diagnosed?
- Stages of Postpartum Depression
- How Long Does Postpartum Depression Last?
- The Relationship Between Postpartum depression, Baby Blues, Postpartum Anxiety, OCD and Postpartum Psychosis
- Take Home Message
What is Postpartum Depression?
Postpartum depression is a type of mood disorder that is associated with childbirth. It mostly occurs after the baby is born between three and four weeks. The Diagnostic and Statistical Manual of Mental Disorders (DSM 5), a handbook developed by the American Psychiatric Association to diagnose psychiatric disorders, says that postpartum depression occurs within four to six weeks after delivery.
The ICM 10, another internationally recognized psychiatry diagnostic tool, says that postpartum depression is a mental and behavioral disorder associated with the delivery of a child, within six weeks. Other resources suggest that the depressive episodes can occur within six months of birth.
It is important to note that postpartum depression does not only affect women but also men. Its effects can also be seen in a child even after ten years of life. The most hopeful thing is that postpartum depression is temporary and treatable.
What Causes Postpartum Depression?
The precise cause of postnatal depression is not known, but it is strongly associated with physical and emotional factors surrounding pregnancy and birth. The birth of a baby can trigger powerful emotions ranging from profuse joy to overpowering fear and anxiety.
The physical changes manifested by uncomfortable breast engorgement, sore muscles, digestive changes, uterine contractions and healing of a caesarian scar or birth canal, take a toll on the mother in the postnatal period.
The abrupt withdrawal of progesterone and estrogen at birth is also thought to affect mood stability. These reproductive hormones play a significant role in processing emotions, motivation and arousal. Thus, they contribute indirectly to depression postnatally. This is the same thing that happens in Premenstrual Syndrome (PMS), which occurs just before menstruation when the levels of estrogen and progesterone are lowest in the female reproductive cycle. If you ever experienced PMS, then you can relate how the physical and emotional changes can disrupt your daily life.
A drop in thyroid hormones is also thought to have a part in postpartum depression. Pregnancy has a profound impact on thyroid functioning. Even a normal pregnancy alters thyroid hormones levels due to the increased demand by the fetus. In the postpartum period, the levels may fail to get back to normal or even drop further. Thyroid hormones are responsible for regulating metabolism and energy levels. Therefore, if the levels go down, you are left feeling fatigued, sluggish, and depressed.
Social and psychological factors also play a role in the progression of postpartum depression. Poor spousal and social support make the adaption process to the changes at birth poorer.
All the factors mentioned above do not occur in isolation. They combine and make it hard to adjust. You start feeling inadequate, less attractive, and you lose control of your life. All these feelings then build up to depression.
Who is At Risk of Postpartum Depression?
Postpartum depression can occur to both sexes and any parent- whether a first-time parent or in subsequent children. However, there are risk factors that increase its likelihood. These risk factors are not direct causes but attributes that increase the chances of postnatal depression. Having them does not necessarily mean that depression will develop, but means you should apply extra caution to prevent depression and improve your problem-solving mechanisms. Sometimes dealing with them alone may be not sufficient and seeking professional would be wise. Some of the risk factors include:
- If you had a history of postpartum depression in the previous pregnancy
- A history of depression not related to pregnancy and other mood disorders like bipolar
- If you experience traumatic events like the loss of a child, a job or a close relative, divorce or separation, an accident and any other incident enough to elicit strong negative emotions.
- If the pregnancy was not planned for or unwanted
- A history of severe PMS
- Stressful events in pregnancy like illnesses, preterm births or a difficult delivery
- If there is a history of postpartum depression or any other mental illness in the family
- Weak support from a spouse, family or friends
- Alcohol and other drug abuse problems
What are the Signs And Symptoms?
Generally, when depression is mentioned, we think of sadness, despair, and hopelessness. A famous poet once wrote, “People think depression is sadness. People think depression is crying. People think depression is dressing in all black. But people are wrong. Depression is the constant feeling of being numb. Being numb to emotions, being numb to life. You wake up in the morning just to go back to bed again.”
Emotional signals and actual experiences in postpartum depression are never the same. One size never fits everybody, and one story will almost always differ from the next one. Some feel bereft and withdrawn, others are obsessively anxious, and for others, it is a feeling of disconnect and anger. Sometimes depressed mothers give love and attention to their babies, but other times, they are plainly emotionless and unmoved by the distress of their child. For the same mother, one day may be rage and the following day a time of debilitating hopelessness.
Therefore, the symptoms in this article are not a clear-cut for all. In addition, you do not have to have all the signs to seek professional help. Remember, you do not want to get help when everything has fallen apart. Recognizing the signs and symptoms is the very first important step in dealing with it.
a) Dreadful Emotions
Many women describe the feeling of postnatal depression as a feeling that crops up then builds over time. It slowly grows from feeling like the baby requires too much than you can give to heaviness, helplessness, loneliness, and worthlessness.
One feels unbearably empty, drained, exhausted, nauseous and eating becomes a problem. It saps you of your energy and then contributes to the cycle of lethargy and apathy. Even if one has the willpower to attend to the baby, the body energy levels fail them. Milk production becomes another problem and contributes to the emotional issue. So, in postnatal depression, the psychological signs eventually become physical problems.
b) Maternal Disconnect
Some mothers may attend to their daily obligations, but then there is that disconnect with the baby. The long-awaited feeling of being a mommy never rises, and if it was already there, it mysteriously disappears. One may feel like they are babysitting for somebody else, and keep on wishing that the “parents” will pick up their child soonest possible. The feeling that one is not made to be a mother sets in and one may even feel like giving up their baby for adoption. Most of the days are spent missing pre-baby life.
c) Anger And Resentment
Anger is a troubling symptom, mainly because it can lead to harm. It comes in the form of bitterness towards the baby or partner, yelling, arguments, dissatisfaction, violence, and hostility. The feeling is fiercer than tears and is always easily ignitable no matter where or who it is directed towards. Simple things like the baby peeing immediately after you have changed the diaper, people giving you advice, spilled food or even mistakes from your favorite pet get the most irrational emotional and physical reactions.
One thing about postpartum depression is that it feels like a heavy cloud that you desperately want to be lifted off. One is usually conscious of the things that they do, and in the deepest, darkest place, one feels guilty and sorry. There is the remorse of not bonding with the baby, not being able to attend to the baby physically, the rage and sometimes, you even feel guilty for feeling guilty. Even after postnatal depression has been dealt with, you may find yourself feeling guilty and questioning why you were not a good mom.
e) Spontaneous Crying Spells
You may feel the need to cry or weep for no apparent reason. Moreover, if there is a reason, it is usually small things that would never bother you at other times. The tearfulness gets worse in the mornings and evenings, probably because of cortisol levels which peak at these times. The spells are at time relieving as they lighten the mood. You literally feel like something has been lifted off, but you cannot explain it.
f) Excessive Fear and Worry
For some mothers, postnatal depression does not manifest as resentment of the baby but excessive attention and obsession. It is the feeling that something invaluable may be taken away. One may be obsessed with the fear of hurting the baby or relentless worry that the baby may die even when perfectly healthy. One may keep on continually checking the baby or even avoid attending to the newborn due to the frightening thought that they may cause harm. Sometimes one may find themselves lying down, panicking and crying, imagining that they have lost the baby or something has happened to them, and they are not able to take care of their little one.
This symptom can also be a sign of postpartum anxiety or postpartum Obsessive-Compulsive Disorder (OCD) both of which, we shall be tackling later in this article.
g) Loss of Interest
Things and people that you loved no longer become a source of joy and pleasure. You find yourself withdrawing from social contact and wanting to spend time alone. You also see no need to share what you are feeling with your loved ones because according to you, there is no way that they can help. Relations with your partner become slowed not just because of physical limitations related to birth but also because of repulsive feelings towards sex and your partner. It becomes a small world of your own with strongly erected walls.
h) Sleep Disturbances
Your sleep may be altered by the sleeping and feeding pattern of the baby. Sleep may not be as good as it was before the baby, but in postpartum depression, it is much worse. It becomes difficult to fall asleep despite exhaustion and availability of time to take some rest. You find yourself lying awake even when the baby is asleep, sleeping lightly and waking up very early. Sometimes when you are lucky to find some sleep, you wake up feeling tired as opposed to being refreshed and rested.
i) Thoughts of Suicide
Although suicidal ideations are not very common, they are among the leading causes of mortalities in postnatal women. The thoughts are as a result of extreme helplessness or the fear that one is incapable of being a competent mother. The thoughts do not always come as direct plans to take one’s life. They begin with fleeting thoughts like, “a step-mother would be better off for my child,” or “my husband will have peace of mind without me,” or “I cannot take it anymore” and “I will never be the mother that my child deserves.”
The thoughts then graduate to “what if I throw myself from the top floor,” and “how effective are sleeping pills? Will they work immediately or leave me frothing on the floor?” or “I wish I were dead.” The thoughts are generally due to a belief of not being good enough and feeling that the pain is too much to bear. They are indeed dangerous and need immediate attention.
How is Postpartum Depression Diagnosed?
There is no one single test that gives a definite and conclusive diagnosis of postpartum depression. Doctors rely on a comprehensive history of your symptoms, your entire life and family background. They will be interested in finding out whether you have factors that increase the likelihood of postnatal depression by collecting information like your previous medical and mental illnesses, work history, cultural, religious or ethnic orientation, history of drug use and social-economic data.
Doctors also perform a head to toe physical examination to determine your general health status. Lab investigations will also help to determine whether there are other underlying problems such as thyroid hypofunction which may be contributing to the depression.
Your signs and symptoms will form the basis for the diagnosis. The healthcare provider will concentrate on understanding how you feel, in order to make a proper diagnosis. Your clinician may ask you to fill in a postpartum depression screening questionnaire, one of the very effective tools for getting an in-depth view of depressive symptoms.
Once the doctor has assessed the symptoms, they can then go ahead to make a diagnosis. The criteria for diagnosing post-pregnancy depression is the same as that of non-birth related depression. However, for postpartum depression, the onset of the symptoms must have been during pregnancy or after delivery, and they should have lasted for more than two weeks.
The DSM 5, the most widely accepted guideline used by clinicians, recommends that for a diagnosis to be made, one has to experience at least five of the following nine symptoms in a period of two weeks.
- A depressive mood characterized by feelings of sadness, hopelessness or emptiness most of the day nearly daily.
- Loss of interest in activities
- Loss of appetite and 5% of change in weight
- Sleep disturbance, either insomnia or excessive sleepiness
- Low energy and fatigue
- Feelings of worthlessness or guilt
- Inability to concentrate and make decisions
- Agitation, restlessness or anger
- Persistent thoughts of death with or without suicidal ideation or attempts
Stages of Postpartum Depression
Postpartum depression is not something that will be diagnosed then you pop some pills, and it goes away. It recovers in stages and takes anywhere from few weeks to months. It is easy to get discouraged as one goes through these stages, but the best thing is to remember that one will eventually feel better no matter how slow the progress is. The process is met in steps similar to those of grief. In grief, you cope with the loss of a loved one. Similarly, in postpartum depression, you deal with the loss of the perfect mother that you always hoped you would be to your child.
The stages have no specific timelines or sequence- one moves through them with no particular order. Moreover, like in the symptoms, each person has a unique experience with the progress of the stages. One may not go through all the phases, and it is also possible to move back and forth between them.
The series of emotional stages that one goes through are adapted from a psychiatry model developed by Elisabeth Kübler-Ross’, a Swiss psychiatrist. The stages are as follows
The very first reaction to the symptoms of postpartum depression is denial. One reacts by believing that the emotional changes are mistaken, will soon fade away and that depression is a mistaken diagnosis. The symptoms are easily brushed off as baby blues and nothing more. One clings to a false reality that there is nothing wrong.
After denying the diagnosis and changes, one realizes that it is the reality and gets frustrated. When one is asked to seek treatment, resentment comes in, and one feels that other people do not understand them. One asks questions like, “Why me of all those mothers?” or “Why do I deserve this?” and “Why should I go through this with a small baby?”
The bargaining phase is characterized by negotiation of being a better parent. One starts looking for options that can make one feel better and deep down, one starts wishing to have their life back. You start getting ideas like, “this will go away once I catch some sleep” or “I should get some ‘me time’ for me to feel better.”
The depression sets in this stage, when one is overwhelmed by all other factors. At this stage, one can easily despair. Most of the time is spent feeling hopeless, the crying spells get to the peak, one socially withdraws, and suicidal ideations may crop up. It is extremely tough to seek help at this point but, the night is darkest just before dawn. This is the step just before acceptance and recovery.
Finally, one accepts that what they are feeling is not normal, cannot be ignored any further and requires professional help. One stops blaming themselves for the problems. It is also at this stage that one stops comparing themselves to others and reaches out to other people that have had the same problem.
This is the stage that one is actively involved in the management of the depression. The recovery process is mainly self-directed but with a lot of support from healthcare professionals and family. One strives to make a positive change in their health, motherhood and the wellbeing of their child.
Once one has recovered, one may find themselves looking back and worrying that depression may creep back. If not well taken care of, the fear can escalate to anxiety especially in the next pregnancy. Otherwise, these feelings are normal and at times healthy when positively used to reflect on how far one has come. The feelings subside, and one moves to the full recovery state.
How Long Does Postpartum Depression Last?
Once a diagnosis has been made, and the doctor suggests that you should start your treatment, most probably the first that comes to mind is when it will last. There is always the desire to have that energetic, self-driven, loving and caring old-self back. Unfortunately, no single book or research that states exactly how long postpartum depression lasts. You might have heard or read that for so and so, it was four months, another one ten months or even three years. Our bodies and minds are different, so the healing varies from mom to mom and dad to dad.
The period that an individual takes for full recovery can be affected by various factors. If someone sought treatment late, has poor partner and social relationships, has a history of depression, alcohol or drug abuse and has been predisposed to physical and sexual abuse, there is a high probability that postpartum depression will last longer. The severity of the depression and effectiveness of the treatment approaches also play a critical role. The mainstay of dealing with it is acceptance, professional help, and social support.
A longitudinal study published in the journal of Harvard Review of Psychiatry by a team of psychologists showed that postpartum depression lasted for up to one year after delivery in 50% of women receiving medical treatment, while 30% of those not receiving treatment, it lasted for up to 3 years. Therefore, if one seeks treatment early enough, the chances are that they will have recovered by the time the baby celebrates the first birthday. However, for some, it may spill over to the following year(s).
The most helpful thing is to understand that recovery from postnatal depression is not a race. It is not about who is the fastest, perfectness or proving how good you are because hurrying it up, can be counterproductive. Take each day of your treatment at a time, practice patience and do not be too hard on yourself. Above all, do not compare your pace with another mom’s.
The Relationship Between Postpartum depression, Baby Blues, Postpartum Anxiety, OCD and Postpartum Psychosis
Postnatally, mothers are vulnerable to various psychiatric disorders classified as baby blues, postpartum anxiety, OCD, postpartum depression, and puerperal psychosis. We will look at each of them in order to make you comprehend how each differs from the other. They are closely related and can easily be confused with each other.
Baby blues can be casually be referred to as the least severe form of postnatal depression. The blues appear from the second day after birth, and they hit most at four to five days. They are so common that about 80% of women experience them. They are characterized by tearfulness, irritability, restlessness, fatigability, labile moods, lack of sleep, and anxiety. These symptoms are similar to postnatal depression just that they are less severe and disappear between ten and fourteen days.
It is normal to get nervous from time to time and for a mum, it is a natural response to protect the child from harm. About 90% of mothers are anxious about the wellbeing of the baby, but the fear and worry do not persist for long. It becomes a problem if it is frequent, forceful and begins to take control of one’s life and the baby’s.
Postpartum anxiety generally takes the form of generalized anxiety, persistent worry, tension and inability to relax. The worries are focused on the baby’s health and safety. It is characterized by extreme apprehension and fear that something wrong may happen to the baby. The mind gets filled with constant obsession thoughts about the worst-case scenarios. The thoughts are coupled with constant monitoring of the baby. For instance, one may find it difficult to fall asleep, and if one finds some sleep, slight movements and noise are enough to awaken one to check whether the baby is alive. These actions contribute to sleep deprivation and fatigue.
For some women, the body also responds by increasing the heart rate, the chest and throat tightens, one finds it difficult to breathe, loses appetite and it gets hard to fall asleep. These reactions are referred to as panic attacks. It is not every mother who experiences the attacks, and if they occur, it is a type of postpartum anxiety known as a postpartum panic disorder.
A mom with severe postpartum depression may also have symptoms of postpartum anxiety. On the other hand, one may have signs of anxiety without depressive symptoms.
Postpartum Obsessive-Compulsive Disorder (OCD)
In postpartum OCD, one has signs of both obsession and compulsion. In obsession, one has persistent disturbing thoughts related to the baby. One gets obsessed with a sense of impending doom. A mother may continuously keep on getting ideas such as the baby dying when asleep, thoughts of drowning when bathing the baby, thoughts that the baby can be poisoned when feeding or that the baby could choke anytime.
For compulsions, one does certain things over and over to reduce the fears and obsessions. For instance, checking the baby every minute, failure to feed for fear of poisoning or chocking, excessive sterilization of baby’s items, or repeatedly asking for reassurance. The actions end up being harmful to the baby rather than protective.
OCD is closely related to postpartum anxiety. However, in postpartum anxiety, the mom has persistent worrying thoughts but no compelling actions, which are present in OCD.
Postpartum psychosis is a psychiatric emergency as it poses a significant risk to the mother and baby. It is also the severest form of the postpartum mental conditions that we have dealt with in this article. The symptoms mostly set in within two weeks of childbirth and at times it can suddenly occur in the first two to three days.
The signs and symptoms of postpartum psychosis are more dramatic and extreme. They include:
- Sudden thoughts causing harm to the baby
- False beliefs (like believing that someone wants to harm them)
- Seeing, hearing, smelling and tasting things that do not exist
- Lack of emotional response to the baby
- Social withdrawal
- Loss of concentration
- Excessive excitement or irritability
Take Home Message
For postpartum depression and all the other postnatal mental conditions that we have discussed in this article, it is crucial to understand that they are temporary and treatable. Once you realize any of the symptoms, do not be afraid to ask for help-we all need it at some point in our lives.