Treatment of Postpartum Depression

The baby is born and everyone is happy, and the mother is expected to be the happiest of all. But often the opposite is true.

After giving birth, the mother is often sad, exhausted, and overwhelmed, not understanding what’s happened to her. She may feel guilty for not being able to show the love; maybe even see yourself as a “bad” mother.

Such a condition appears frequently after delivery and is called postpartum depression.

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In this article, we describe the main characteristics of the condition and the treatment options for postpartum depression in Dubai.

What is Postpartum Depression?

Today the diagnostic manuals introduced the more comprehensive diagnosis: “peripartum depression,” enclosing the old diagnosis: “postpartum depression” or “postnatal depression.” Peripartum depression refers to depression appearing during the pregnancy and within one year after delivery. However, in this article we will use the old term “postpartum depression” as better known to the general public.

Postpartum depression is the most common mental disorder after childbirth. It involves prolonged depressive episodes within the first year after the birth of the child. Mothers with postpartum depression develop sadness, fatigue, apathy, and feelings of guilt. The immediate mother’s environment often shows little understanding. While not understanding the nature of the problem, family and friends of a mother who can’t develop feelings for their children avoid the topic, considering it taboo. Many affected mothers suffer in silence out of shame. They neglect themselves and the infant or provide only “mechanical care.”.

The lack of emotional bond to the child leads to attachment disorders and behavioral problems in the children and later in the mature individuals.

The untreated postpartum depression tends to intensify over time. In the worst case, it can lead to suicide. In the most serious cases, severe postpartum depression can end in an extended suicide when the mother doesn’t see any future for herself and paints the same scenario for her child.

There are three forms of postpartum mood swings depending on the severity of the symptoms: “baby blues,” postpartum depression, and the most severe condition, which is postpartum psychosis.

Recognizing Early Signs of Postpartum Depression

Important indications of postpartum depression are symptoms of depression developing gradually and closely related to childbirth.

“Baby blues” is a transitory condition associated with mood swings, sadness, and fatigue. However, if the symptoms persist for more than two weeks, become entrenched, and intensify, it may indicate the onset of postpartum depression. The condition is not as infrequent as one may think. Approximately 10 to 15 percent of all new mothers develop postpartum depression.

Postpartum depression typically develops gradually, with initial signs appearing around 4 to 6 weeks after birth but can occur even later, up to one year after childbirth. Postpartum depression often goes unrecognized, sometimes until much later or even not at all. Unlike postpartum baby blues, postpartum depression does not resolve on its own. It can have significant effects on the health of both mother and child, necessitating professional medical treatment.

Baby Blues. Temporary Mood Swings after Childbirth

A few days after childbirth, around the time of lactation, the majority of all mothers experience postpartum mood changes called “baby blues.” The condition appears as mild emotional fluctuations, accompanied by sadness, feelings of inadequacy, frequent crying, sleep problems, and exhaustion.

These very common, so-called “crying days” are usually short-lived. They are triggered by hormonal changes, especially a drop in estrogen and progesterone immediately after birth. Estrogen, in particular, has a mood-enhancing and stabilizing effect in the brain. Added to this are the many changes in daily life and the couple’s relationship that a baby brings, as well as sleep deprivation.

The symptoms usually subside after a few days, along with the stabilizing hormone levels and growing daily routine while dealing with the baby. Treatment of “baby blues” is typically not required. Particularly helpful during this sensitive phase are understanding and support from the partner and other close caregivers.

What Is Postpartum Psychosis?

Postpartum psychosis is the most severe form of postpartum depression. It occurs very rarely, affecting approximately 0.1 to 0.3 percent—that is, one to three out of a thousand mothers. It involves a severe depression in which, in addition to symptoms of postpartum depression, features of psychosis emerge. The postpartum psychosis shows similar symptoms as the severe episode of Major Depressive Disorder (MDD) with psychotic features.

The initial signs of postpartum psychosis typically manifest within the first six weeks after childbirth. Alongside the typical characteristics of postpartum depression, such as low mood, low self-esteem, sleeplessness, social withdrawal, anxiety, and irritability, there are also symptoms of psychosis, such as delusions and hallucinations, and often disorganized thinking.

Sometimes mothers with postpartum psychosis can develop overprotective behaviour and irrational thoughts that something bad can happen to the baby. In other cases, the mother can develop thoughts of death or suicide related to herself and even to the baby.

Therefore, postpartum psychosis is always a medical emergency requiring immediate hospitalisation and treatment.

Diagnosing Postpartum Depression at CHMC in Dubai

The main symptoms of postpartum depression are profound lack of energy, loss of interest, emotional emptiness, and frequent crying. Other common symptoms include difficulties with concentration, appetite, and sleep disturbances, as well as headaches, dizziness, heart palpitations, and other psychosomatic complaints. Additionally, there may be feelings of anxiety, irritability, panic attacks, and Obsessive Compulsive Disorder (OCD) with intrusive thoughts such as compulsive destructive images about harming the child.

Crucial for an effective treatment of postpartum depression is early recognition and treatment. Our psychiatric clinic in Dubai offers comprehensive diagnostics and professional treatment by our psychiatrists and psychologists. The main aspect of the treatment is the involvement of the partner in the therapeutic process.

Diagnostic Criteria for Postpartum Depression

In our psychiatric clinic in Dubai, we diagnose postpartum depression based on the criteria enclosed in the diagnostic manuals, DSM-5. It describes postpartum depression as depression with “peripartum onset.” The current psychiatric nomenclature is using the more suitable term, “perinatal depression,” which means that the onset of the symptoms happens either during pregnancy or in the time following the delivery.

The symptoms required by DSM 5 for the diagnosis of peripartum depression are the same as those required for the diagnosis of non-childbirth-related Major Depressive Disorder (MDD). The diagnosis of postpartum depression (DSM-5) requires at least five of the following 9 symptoms:

• Feelings of sadness, emptiness, or hopelessness, nearly every day, for most of the day or the observation of a depressed mood made by others
• Loss of interest or pleasure in activities
• Weight loss or decreased appetite
• Changes in sleep patterns
• Feelings of restlessness
• Loss of energy
• Feelings of worthlessness or guilt
• Loss of concentration or increased indecisiveness
• Recurrent thoughts of death, with or without plans of suicide

Causes of Postpartum Depression

The exact causes of postpartum depression are still not fully understood. However, it is clear that there is not a single cause responsible for the condition but rather a combination of different factors. These factors include:

Hormonal changes

One important factor in the development of postpartum depression is the significant hormonal changes that occur after childbirth. The concentration of female sex hormones, progesterone and estrogen, in particular, drops sharply. Since estrogen plays a stabilizing and mood-enhancing role in the brain, the sudden hormone drop often manifests as a mood slump. Most women are familiar with such mood swings, albeit in a milder form, from hormonal changes within the menstrual cycle. Women who are particularly sensitive to hormonal changes, such as those suffering from premenstrual dysphoric disorder or experiencing mood swings in response to hormonal contraceptives, have an increased risk of developing postpartum depression.

Sleep deprivation

Childbirth and the subsequent care of a baby are extremely demanding. Many women experience severe sleep deprivation, which can lead to physical and mental exhaustion, as well as metabolic imbalances. Added to this are frequent uncertainties and overwhelm due to the new situation, the changing role, the impact on the partnership, and the constant concern of doing everything right.

Pre-existing conditions as risk factors

Personal or family history of depression, psychoses, and anxiety disorders during pregnancy are also significant risk factors. According to a study from 2006, women with untreated depression during pregnancy have a 7-fold increased risk of developing postpartum depression after giving birth.

Social risk factors

Poor marital relationship or single marital status, lack of support from the partner, and social environment. Unplanned/unwanted pregnancy. Loss of mother’s autonomy (feeling of loss of freedom and control over life). Low socioeconomic status. Domestic violence, previous separation or divorce, unintended pregnancy, multiple births, as well as the child’s health problems or excessive crying, are also considered risk factors for the development of postpartum depression.

Trauma as a risk factor

A traumatic birth experience, traumatic events and neglect during one’s own childhood, the death of a loved one during pregnancy, as well as other stressors and critical life events, can contribute to the development of postnatal depression.

Joh Bolby and the Attachment Theory

John Bowlby, a British psychologist, psychiatrist, and psychoanalyst known for his interest in child development, wrote a report for the World Health Organization on the mental health of homeless children in post-war Europe. The result was a text on Maternal Care and Mental Health published in 1951.

Bowlby’s main conclusion was that infants and young children should experience a warm, close, and continuous relationship with their mothers. Emotional and physical absence of the mother will end in serious and irreversible effects on the child’s mental health.

According to his attachment theory, attachment in infants is primarily a process of proximity seeking to an identified attachment figure. Caring and loving parents facilitates healthy, unhindered emotional growth of children. Strong ties with the caretaker shape attachment patterns and guide individuals’ positive emotions, thoughts, and expectations in subsequent relationships.

Risks for Mother and Child in Postpartum Depression

A mother who cannot find joy in her child is still considered taboo within society. Therefore, affected mothers often hesitate to speak about their problems. As a result, the clinical picture of postpartum depression is often recognized and treated late. This leads to a sustained high level of suffering for the mother, which can potentially lead to suicide or extended suicide in the worst case.

Depressed mothers engage in less verbal and visual communication with their infants. The child may experience sleep and growth disorders, feeding confusion, behavioral abnormalities, and attachment issues. In the long term, emotional and cognitive development disorders can also occur, which can have lasting effects into adulthood.

Among 16-year-olds, the risk of developing an affective disorder is four times higher if the mother has experienced postpartum depression.

Common Comorbidities of Postpartum Depression

In addition to postpartum depression, other psychological comorbidities can occur, including

•  Anxiety disorders with exaggerated fears about the well-being of the baby, as well as intense fears and self-doubt about being able to care for the child properly. Additionally, panic attacks can also occur.

•   Obsessive-Compulsive Disorder (OCD) associated with postpartum depression can appear as obsessive cleaning, disinfection rituals to develop, and distressing intrusive thoughts about harming oneself or the child.

Postpartum Depression in Mothers

Untreated postpartum depression usually lasts for a few months. However, sometimes PPD evolves into a chronic depressive disorder, which can last for years. Children of mothers who have untreated postpartum depression are more likely to have childhood or adulthood emotional and behavioral problems. In their adult lives, they are more prone to suffer from socio-behavioral problems, such as an inability to create stable relationships and develop successful, professional careers.

Postpartum Depression in Fathers

Research on postpartum depression has focused primarily on mothers. However, the recent research shows that after the birth of a child, fathers might also be affected. There is a positive correlation between maternal PPD and postnatal depression in fathers. The most likely reason is marital satisfaction. The prevalence of father’s PPD is lower than in women.

Treatment of Postpartum Depression

The clinical picture of postpartum depression is highly complex, encompassing not only the root causes but also the symptoms and co-existing illnesses. The challenge in treatment of postpartum depression is not only symptoms suppression but also the restoration of the relationship between the mother and her child. Conventional medicine recommends the use of psychotherapy, assistance and relief in daily life, and the use of antidepresants. The treatment of postpartum depression with antidepressants is similar to the treatment of Major Depressive Disorder (MDD).

Treatment of Postpartum Depression with Psychotherapy

Cognitive Behavioral Therapy (CBT) and Interpersonal psychotherapy (IPT) are commonly used in treating postpartum depression. However, there are also other therapeutic techniques that proved to be effective. After a profound assessment, our psychiatric clinic offers the below psychotherapy method for treatment of postpartum depression in Dubai.

Cognitive Behavioral Therapy (CBT)

CBT focuses on thoughts’ impacting the feelings, empowering the mother to control and change them. It involves identifying reciprocal thought circles, exploring underlying beliefs, and developing coping strategies.

Interpersonal Psychotherapy (IPT)

IPT aims for symptom relief through direct and active therapist involvement. IPT addresses four problem areas: grief, role transitions, interpersonal disputes, and individual’s deficits. Communication skills are taught to build relationships, social support, and confidence.

Dialectic Behavioural Therapy (DBT)

DBT teaches mindfulness, emotional regulation, and interpersonal effectiveness skills to reduce distressing symptoms.

Psychodynamic Psychotherapy

called also psychoanalytical psychotherapy, explores unconscious conflicts influencing the current behaviour. The insight of the conflict dynamics helps mothers to identify the vicious circle, reducing the stress and promoting healing.

Eye Movement Desensitization and Reprocessing (EMDR)

EMDR is effective for postpartum PTSD, using bilateral stimulation to reprocess traumatic memories.

Solution-Focused Brief Psychotherapy

focuses on positive change by setting goals and emphasizing strengths and skills. It avoids delving into past problems and offers a short-term solution-based approach.

Group Therapy

utilizes community support and dynamics to identify and address problem areas and interpersonal distress. Postpartum depression support groups combine psychoeducation with validation, creating a space for mothers to share and develop coping strategies.

Couples Therapy in Treatment of Postpartum Depression

The birth of a child creates major changes in the dynamics of the couple’s relationship. The mother focuses on the child, frequently feeling depressed and not sufficiently supported by the husband. On the other hand, the husband can feel neglected. The appearance of a baby can be a major stressor in the marital relationship, leading to more conflicts and possibly a divorce.

Therefore, couples counselling, especially in the case of mothers suffering from postpartum depression, is essential for restoring the lost balance. It allows partners to address negative patterns, enhance communication, and navigate challenges during the postpartum period.

Couples therapy might be an indispensable support for individuals and couples facing postpartum difficulties, minimalizing the escalation of conflicts eventually leading to a divorce.

Treatment of Postpartum Depression with Medication

Antidepressants, such as the Selective Serotonin Reuptake Inhibitors (SSRIs), are safe and effective in the treatment of postpartum depression or peripartum depression with the onset of the symptoms during the pregnancy.

There are several antidepressants, for example, Fluoxetine or Sertraline, used for decades to treat depression during pregnancy and after delivery. Studies didn’t show any side effects to the babies by using this medication. In the opposite, the untreated depression during the pregnancy would often end in complications, including a miscarriage.

While treating the mother with antidepressants during the pregnancy, the plasma level of the antidepressant in her and the’ body are nearly identical. By breastfeeding, a significantly lower level of the antidepressant can pass into the baby’s blood. So, the problems of breast feeding and use of antidepressants after delivery are extensively exaggerated.

Prevention of Postpartum Depression

Postpartum depression often goes unrecognized and untreated in many women due to the lack of comprehensive screening after the birth. Low energy and the feeling of shame or guilt are too overwhelming for the mothers to seek help actively. This can have long-term consequences. If left untreated, the symptoms of postpartum depression tend to increase with elevated risk for suicide. Apart from that, affected mothers have difficulties bonding with the child. Lack of emotional connection leads to behavioral problems. Therefore, early screening and prompt treatment are absolutely necessary.

During pregnancy and after childbirth, mothers with symptoms of depression need close monitoring by a gynaecologist and a psychiatrist.

Gynaecologists and obstetricians should ideally inquire about a woman’s mental well-being during postpartum check-ups or at least provide a self-screening questionnaire, for example, the Edinburgh Postnatal Depression Scale (EPDS).

The Edinburgh Postnatal Depression Scale (EPDS scale) has proven particularly effective in identifying postpartum depression. The patient completes the questionnaire, and the sum of the points provides an indication of postpartum depression.

Alternatively, a risk can be detected with two questions:

1. Have you frequently felt down, sad, depressed, or hopeless in the past month?
2. Have you had noticeably less interest and pleasure in doing things you usually enjoy in the past month?

Treatment of Postpartum Depression. Summary

Approximately 15% of all women after the birth of a child are affected by postpartum depression. Postpartum depression usually begins between two weeks and a month after delivery. In about half of the cases, the symptoms of depression already start during the pregnancy.

The birth of a baby triggers hormonal changes that are associated with powerful emotions. The emotions are mostly positive in nature. However, in some cases, they can turn in a short-lasting sadness, called “baby blues,” or into a serious psychiatric condition known as postpartum depression.

Psychiatrists prefer to use the term “perinatal depression,” which relates to depressive episodes appearing during the pregnancy or within one year after the delivery. The most serious form of postpartum depression is postpartum psychosis. In such a state, mothers develop hallucinations and delusional thinking, causing changes in their personalities. Such changes are often associated with suicidal thoughts posing an acute danger to both mother and child. Therefore, the postpartum psychosis is a psychiatric emergency requiring immediate hospitalisation and treatment in one of the psychiatric hospitals in Dubai.

In conclusion, an early recognition of postpartum depression and prompt treatment of mothers suffering from this condition will protect their children from mental health conditions not only during childhood but also in adulthood. The long-term consequences of postpartum depression with emotionally indifferent mothers lead in their offspring to emotional disturbances such as anxiety, depression, personality disorders, and more.