Postpartum Depression: Beyond the Baby Blues

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By Jennifer Larson, NurseZone feature writer 

It’s not uncommon for women to get the “baby blues” shortly after giving birth. However, as they adjust to their new status as “Mom,” the blues usually go away.

But for some women, the problem is not so short-lived. Their feelings are not just all in their heads, either.

One in ten new mothers experiences postpartum depression to some degree, according to the American Psychiatric Institute. Postpartum depression is characterized by symptoms such as sluggishness, fatigue, feelings of hopelessness, noticeable changes in appetite or sleeping patterns, confusion, bouts of uncontrollable crying and fear of harming one’s self or baby.

The symptoms can occur soon after delivery, but they can occur later on, too, and linger for months. While parenthood requires adjustment for all new moms, some new moms just feel overwhelmed beyond normal levels.

Veronica Feeg, Ph.D., RN, editor of the journal Pediatric Nursing, describes that feeling as “the brain goes to Jell-O pudding.”

As a new mother experiences re-regulation of her hormones, some mood swings are natural, but it becomes a bigger issue when feelings of real despair—postpartum depression—set in.

“It’s not something where you can say, ‘just snap out of it,’” Feeg said.

A 1995 article in the Journal of the Society of Obstetrics & Gynecology of Canada noted that postpartum depression should be treated not only to relieve the mother from distressing symptoms but also to “facilitate good mothering.”

The authors of “Depression During Pregnancy and Postpartum” wrote that depressed mothers can display negative attitudes toward their babies, and children of depressed mothers have higher rates of emotional disturbance.

Cheryl Beck, a professor of nursing at the University of Connecticut, noted that some women are more at risk for developing postpartum depression than others. Doctors and nurse practitioners may want to keep an eye on women who have a history of depression prior to delivery.

However, a woman can be depression-free prior to pregnancy and still find herself in the throes of despair after labor.

The Stigma

While the rate of postpartum depression may hover around 10 percent, some experts question if the symptoms go underreported.

“I think that’s the tip of the iceberg myself,” Beck said. “I think the prevalence rate is higher, but there’s such stigma attached to depression after the birth of a healthy newborn that many women suffer in silence.”

Some new mothers fret that they shouldn’t be feeling bad when they have a healthy new baby. But they feel that society will not accept their negative feelings, which may be true in many circumstances. According to Beck, many people believe that it’s not an acceptable reason to be depressed.

“We have all these myths,” she said. “Motherhood is supposed to be all happiness and joy.”

“It’s a hidden secret,” agreed Marie Kodadek, Ph.D., RN, an assistant professor of nursing at George Mason University in Virginia.

New moms aren’t likely to share their negative feelings with others, especially other people with children, she added. And friends may not even notice that anything is wrong, if the depressed mom can hold herself together for short periods of time.

Postpartum depression has garnered more attention since a Texas woman named Andrea Yates drowned her five children in a bathtub in 2001. Her attorneys claimed that Yates suffered from severe postpartum depression.

Severe cases of postpartum depression can evolve into postpartum psychosis, as in Yates’ case. If the “baby blues” are on one end of the spectrum, postpartum depression occupies the middle part, and postpartum psychosis is far on the other end of the spectrum.

However, postpartum psychosis is rare. The condition, which often includes delusions, hallucinations, bizarre behavior, severe insomnia and extreme agitation, affects only about one of every 1,000 women who give birth.

Although Yates’ case was tragic, there was one good thing to come out of it. More people take postpartum depression seriously, Beck said.

“Prior to that, I don’t think it was taken seriously enough,” she added.

That doesn’t mean that health care professionals couldn’t be doing more to recognize symptoms of depression in new mothers.

Nurses Can Recognize the Signs

Pediatric nurses are well-positioned to notice changes in a mother’s behavior, noted Kodadek.

Pediatric nurses are likely to see a new mother and baby several times for immunizations and well-baby visits. The sequence of visits gives them the opportunity to notice strange patterns in behavior or changes in the mom, like sudden weight gains or losses, irritability, and other red flags.

“One encounter with the mother doesn’t give the whole picture,” Kodadek said.

Feeg agreed that pediatrics nurses are in a unique position to notice the signs. Well-baby visits can be an ideal time for nurses to assess a new mother’s well-being with a few gentle questions.

Also, not every mother suffering from postpartum depression will appear apathetic, a trait often observed in such situations. An overly anxious mom can be just as depressed as one who appears exhausted and disengaged, Kodadek said. The overly anxious mom may be so caught up in the new baby that she is not taking care of herself at all.

Nurses should also listen for offhand comments by new mothers, Kodadek said. One sign of potential problems might be an exhausted “I didn’t have any time to sleep.”

According to Feeg, pediatric nurses could also use a screening tool during a routine office visit. However, care must be taken to ensure that any screening tools or questionnaires don’t become so extensive that they overwhelm an exhausted new mother.

Also, time constraints can be a factor. Office visits only allow so much time for nurses to interact with the new mothers while they’re also trying to care for the new baby.

But it’s necessary to assess the mother for postpartum depression while the opportunity is at hand, Beck said.

“What needs to be done is routine screening for new mothers,” she said. “There’s a long way that we need to go.”

“The baby’s health and well-being is entirely dependent upon the mom,” Feeg added.

Beck even developed her own postpartum depression screening scale. It’s a 35-question tool that a health care practitioners can keep in their office.

The questionnaire presents certain situations that a new mother might encounter after the birth of her baby. She responds by choosing her answer in a range from “strongly agree” to “strongly disagree.” The entire process takes five or 10 minutes, and the mom can complete the survey while her child is in the exam room.

The mother gets points for each answer. If she scores above a certain level, it’s considered a positive screen for postpartum depression.

“It’s a good way to start opening up lines of communication between the woman and the health care professional,” Beck said.

Kodadek likes a questionnaire developed by Johnson & Johnson in the mid-1990s. The questionnaire, titled “Am I Blue”, is a series of questions that a mother can answer while she’s sitting in the waiting room or exam room at the pediatrician’s office.

Although pediatric nurses and physicians can’t treat a woman for postpartum depression, if they notice any disturbing signs, they can refer her to a psychiatrist or social worker for help. But they can’t do that, if they’re not looking for the warning signs.

That concept is supported by Anita Finkelman, MSN, RN, author of an article on mental health policy and its effects on infants and their families in the May 7, 2003 issue of Newborn & Infant Nursing Reviews.

“The newborn and infant nurse may be the first health care provider to recognize a mental health problem or may be the one to encourage a woman to continue her mental health treatment,” she wrote.

Feeg and Beck said they would like to see more education of clinicians so that they can recognize those warning signs.

“It’s great to be able to help mothers,” Beck said. 

© 2003. AMN Healthcare, Inc. All Rights Reserved.