Postpartum depression usually develops gradually over a period of weeks after the baby’s birth. Unlike the baby blues, PPD does not go away by itself after the first two weeks after childbirth. The new mother typically begins to have difficulty sleeping, feels tired and tearful much of the time, may worry a lot about her ability to take care of the baby, loses interest in activities that she used to enjoy, may have difficulty in nursing or otherwise caring for the baby, may feel angry with her husband, and may draw away from friends and family.
Postpartum psychosis, which is rare, has a different pattern of onset; it often develops suddenly. A woman with postpartum psychosis begins to have hallucinations and delusions (false beliefs) within about three days of the baby’s birth. She may believe, for example, that the baby is Satan or is going to die shortly, or she may hear voices telling her to hurt or kill the child. The women most at risk for postpartum psychosis are those with a history of bipolar disorder.
The American College of Obstetricians and Gynecologists estimates that between 70 and 80 percent of new mothers experience the baby blues after childbirth, and about 10 percent suffer postpartum depression. Postpartum psychosis occurs in one or two new mothers per thousand.
Some women are at greater risk than others of having postpartum depression:
• Women with a personal history of depression.
• Women with a previous episode of postpartum depression.
• Women diagnosed with depression during pregnancy.
• Single mothers.
• Women whose pregnancy was unwanted or unplanned.
• Women who have suffered recent losses, such as a death in the family, unemployment, or a traumatic accident.
• Women who were abused by their mothers or had difficult relationships with them.
• Women who are unhappily married or have little social support.
• Women whose income is low; 24.3 percent of women with annual incomes below $10,000 develop PPD compared to 10.8 percent whose income is $50,000 or higher.
• Women with low self-esteem.
• Women whose infant is colicky, temperamental, has birth defects, or is otherwise difficult to care for.
One study of 27,000 women done in 2006 reported that the rate of postpartum depression varies by race or ethnicity even when factors like income, education level, age, marital status, and the child’s health are accounted for. The researchers found that 15.7 percent of their sample suffered from PPD. Of the depressed group, 25.2 percent were African American, 22.9 percent were American Indian/Native Alaskan, 15.5 percent were Caucasian, 15.3 percent were Hispanic, and 11.5 percent were Asian/Pacific Islander.
Nursing Care Plan Signs and SymptomsDoctor have proposed several different explanations for PPD.
• Changes in hormone levels. After childbirth, the levels of estrogen, progesterone, and thyroid hormone in the woman’s body drop sharply within forty-eight hours. Some women appear to be more sensitive to these changes than others, and may therefore develop PPD.
• Other physical changes. Many women feel tired, physically unattractive, and worried about their weight after pregnancy. Many also feel pain in the area around the vagina, or in the abdomen if the baby was delivered by cesarean section.
• Mood changes caused by interrupted sleep and responsibilities related to caring for the baby. Some new mothers feel trapped at home or feel a loss of identity, particularly if they had been working during pregnancy.
• Believing certain myths about “being a perfect mother” or “having a perfect baby.” Women who have unrealistic expectations of motherhood—for example, that they should never lose their temper with the baby—are more likely to feel depressed when they cannot live up to impossible standards.
In addition to tearfulness, anxiety, and fatigue, women with PPD may have the following symptoms:
• Loss of interest in sex
• Extreme mood swings
• Either excessive concern about the baby or at the other extreme, lack of interest in the baby
• Weight loss
• Feelings of guilt or worthlessness
• Feelings of rejection
• Thoughts of suicide or death
• Insomnia and other sleep disturbances
• Difficulty thinking or concentrating
• Inability to enjoy activities that used to give pleasure, satisfaction, or feelings of accomplishment
Nursing Care Plan DiagnosisAfter taking a personal and family history of depression and other mood disorders, the doctor will usually give the patient a blood test to make sure that the moodiness and other symptoms are not caused by an underactive thyroid gland. In addition, the doctor will ask the patient to fill out a questionnaire called the Edinburgh Postnatal Depression Scale. It is a short list of ten questions. A score of twelve or higher, or a “yes” answer to the last question (about suicidal thoughts), indicates that the patient needs further treatment for her depression.
Nursing Care Plan TreatmentTreatment for postpartum depression usually consists of a combination of antidepressant medications and psychotherapy. The medications must be carefully chosen if the mother is breastfeeding because they will be passed on to the baby in the mother’s milk. Some antidepressants will not cause problems for the baby but others have not yet been tested for safe use by nursing mothers. Cognitive behavioral therapy is often recommended for new mothers who feel depressed or incompetent because they have had unrealistic ideas of what it takes to be a “good” mother or what babies are really like. Many women find support groups for new mothers helpful too. Some women with PPD benefit from short-term hormone therapy. Estrogen replacement can sometimes improve mood; its drawbacks, however, include decreased production of breast milk and an increased risk of blood clots in the legs. Other women may need treatment with thyroid hormone. Women with postpartum psychosis require treatment in a hospital as this condition is considered a psychiatric emergency. They are usually given a combination of mood stabilizers, tranquilizers, and antipsychotic drugs.
Most women with PPD start to feel better within two to four weeks of starting treatment, although complete recovery may take months. If the woman has not had a previous episode of depression, six to twelve months of treatment is recommended.
Nursing Care Plan PreventionSome researchers think that a high-protein diet during pregnancy and taking supplements containing vitamins and omega-3 fatty acids help to lower the risk of postpartum depression. Omega-3 fatty acids are found naturally in such fish as tuna and salmon, and in some nuts. They play a role in proper brain functioning. Early treatment of PPD is critical as it lowers the risk of a recurrence with later pregnancies as well as improving the mother’s relationship with her child. A woman who is not treated for PPD has a 90 percent chance of having the illness recur with her next pregnancy.
Adequate recognition and treatment of PPD are important to the wellbeing of the children of these distressed mothers. Since postpartum depression interferes with a mother’s ability to care for her baby, it can lead to serious long-term later problems in the mother/child relationship. About 4 percent of mothers with postpartum psychosis who are not treated end up killing their children.