Postpartum Depression: Diagnosis and Treatment

Hormonal Changes
All women are at risk for emotional swings when they experience extreme hormonal shifts. The role of hormones in depression is not clear, but female hormones undoubtedly play some role in premenstrual dysphoria, postpartum depression, and SAD. These forms of depression recede or stop after menopause. Evidence for hormonal causes of depression is mostly based on observations of depression during specific stages in female development.

Early Puberty. Girls who go through puberty early (reaching the midpoint at 11 years or younger) are more likely to experience depression during adolescence than girls who mature later.

Premenopause. Premenopausal women (between the ages of 20 and 45) were most susceptible to depression, with 22% of this age group reporting symptoms of major depression. Premenstrual dysphoric disorder (severe depression before a period) specifically affects an estimated 3% to 8% of women in their reproductive years. [See Well-Connected, Report # 79, Premenstrual Syndrome.]

Postpartum Depression. Nearly every new mother experiences a short period of mild depression following childbirth (known as the "baby blues"). It is not considered postpartum depression, however, unless it persists beyond a week or two and is very severe. Studies have reported that between 8% and 20% of women have diagnosable postpartum depression within three months of delivery, with 5% in one study having suicidal thoughts. One study strongly suggested that the fluctuating levels of estrogen and progesterone accompanying childbirth may play a major role in postpartum depression, at least in women who are sensitive to such changes. Different studies have suggested that the following women may be at higher risk for postpartum depression are the following conditions:
• A history of prior depressive episodes.
• Being a new mother and having an infant with medical problems.
• Psychological distress during or after the pregnancy.
• Lacking social support or feeling as if it is lacking.
• Having two or more children.

It should be noted that many male partners of new mothers also suffer from depression surrounding the birth of a child.

Depression During Pregnancy. A 2001 study found that depression during pregnancy was more common than depression after pregnancy, with the highest depression scores occurring in week 32. The authors commented that depression during pregnancy is a neglected area, and that the effects of depression on the fetus are largely unknown.
Miscarriage. Miscarriage poses a very high risk for depression, particularly in the first month after the loss. Older women with no previous successful pregnancies and those with a history of depression are at particular risk during this time.

Perimenopause. Depression often occurs around menopause (the perimenopausal period), when, in addition to hormonal changes, other factors (cultural pressures favoring young women, sudden recognition of aging, and sleeplessness) are involved. In one study, over half of perimenopausal women were diagnosed with major depression. (Women taking hormone replacement therapy during this period were just as likely to become depressed as those not on hormonal therapy, but the depression tended to be less severe.)

Postmenopause. One study suggests that average depression scores in women who were past menopause were nearly as low as those in premenopausal women. In fact, many women report that after menopause, previous bouts of depression, particularly when caused by seasonal changes or premenopausal syndrome recede or stop completely.
Estrogen. Estrogen replacement therapy (ERT) may relieve menopausal and perimenopausal associated depression and even relieve depression in elderly women who do not respond to standard antidepressants. Studies have reported that estrogen given under the tongue (sublingually) or using a patch has relieved the symptoms of hormone-related depression (postpartum or perimenopausal depression). ERT has a number of health benefits and risks, which a physician should discuss with the patient. (Hormone replacement therapy that contains both progesterone and estrogen may even cause mild depression.)

Cognitive-Behavioral Therapy
In a major analysis of four randomized comparative studies, cognitive behavior therapy was as effective as antidepressants in treating severe depression for many patients. Much of the success of psychologic therapy, in any case, depends on the skill of the therapist. Many studies suggest that combining cognitive therapy with antidepressants offer the greatest benefits for many patients, particularly for dysthymia (chronic depression). Some studies also report that in these patients the benefits of cognitive therapy persist for these patients after treatment has ended, with the risk of relapse reduced by up to 50%.
Best Candidates. Cognitive therapy may be particularly helpful for the following patients:
• Patients with atypical depression.
• Adolescents with mild symptoms of major depression.
• Women with non-psychotic postpartum depression.
• For children of parents with the disorder. In this case, therapy should involve the whole family.

Cognitive therapy does not appear to be as beneficial as antidepressants for most patients with dysthymia.
Approach. This approach focuses on identification of distorted perceptions that patients may have of the world and themselves, changing these perceptions, and discovering new patterns of actions and behavior. These perceptions, known as schemas, are negative assumptions developed in childhood that can precipitate and prolong depression. Cognitive therapy works on the principle that these schemas can be recognized and altered, thereby changing the response and eliminating the depression.
• First, the patient must learn how to recognize depressive reactions and thoughts as they occur, usually by keeping a journal of feelings about and reactions to daily events.
• The patient is often given "homework" that tests old negative assumptions against reality and demands different responses.
• Then, the patient and therapist examine and challenge these entrenched and automatic reactions and thoughts.
• As the patient begins to understand the underlying falseness of the assumptions that cause depression, he or she can begin substituting new ways of coping.

Over time, such exercises help build confidence and eventually alter behavior. Patients may take either group or individual cognitive therapy. Cognitive therapy is a time-limited treatment, typically lasting 12 to 14 weeks. Extending this period, however, may help prevent relapse. In one study, therapy was continued for 10 additional sessions over the following eight months. This extended treatment significantly reduced the risk of recurrence. In fact, some experts believe that short-term therapy is not at all effective for patients with chronic or relapsing psychiatric disorders.
- Depression. Depression Annual Report, Dec2001

Personal Reflection Exercise #12
The preceding section contained information regarding depression.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 26
What differentiates PPD from the "baby blues"? Record the letter of the correct answer the CEU Answer Booklet.