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  Postpartum Disorders

Salvatore Cullari  
PO Box 595  
Hershey, PA 17033  

Untitled Document

Information About Postpartum Disorders

Please note that reading this information is not a substitute for getting a professional evaluation and appropriate treatment. If you feel you or a family member has a problem, please seek help immediately.

Risk Factors for Post Partum Disorders (PPD) include the first birth of a child, prior PPD episodes, a personal history of mood disorder such as depression or bipolar disorder, anxiety disorders or a family history of these disorders. PDD tends to run in families. Hormonal imbalances may also be involved. The causes of postpartum disorders are still not well understood, but they probably include genetic, hormonal, cultural and psychological factors. For example, after birth both estrogen and progesterone drop rapidly 24 to 48 hours after birth. These hormonal changes and others may trigger symptoms in some women, so treatment may include an estrogen patch or other forms of estrogen therapy. In addition, problems with thyroid functioning (such as hypothyroidism) may be associated with some symptoms. Thyroid hormones (for example, thyroxine) are often used in conjunction with anti-depressants or mood stabilizers.

Postpartum mood disorders are usually divided into the following three categories.

Baby Blues: Probably every new mother experiences the baby blues to some extent. However, official estimates of its occurrence are 70% to 85% of all women. The typical onset is generally a few hours to about 3-4 days after birth. Symptoms may last several days to about two weeks. The average duration is about 12 days, but the worst period is usually around seven days after birth. The symptoms include mood swings, exhaustion, irritability, anger, crying for no reason, anxiety, insomnia, appetite disturbance and lack of interest in personal care or care of the baby. The baby blues are time limited and will go away with no formal treatment. However, social support from the father of the child and other family members can go a long way towards helping the mother cope with the symptoms. In addition, support groups are often very helpful. If you think you have the "baby blues," I would recommend that you visit the sites below. If these symptoms do not go away, it is important to get a complete medical evaluation as soon as possible.

Online support group

A lighter shade of blue

Postpartum Depression (PD): This occurs in about 10%-20% of new mothers, but this may be a low estimate as only about 25% of women with PD seek treatment. Onset may be a few days or weeks after birth, but rarely it may develop up to a year after birth. Symptoms of PD may be similar to those of the baby blues except that they are much more extreme and may last for months. These include depressed mood, anhedonia (inability to feel pleasure), fatigue, feelings of guilt or worthlessness, intrusive thoughts (often about the baby), sleep disturbance, thoughts of suicide, fear for the wellbeing of the baby, difficulty with thinking or concentrating, extreme mood swings, loss of libido (interest in sex), feelings of guilt or low self-esteem. The important point about postpartum depression is that you must get appropriate medical evaluation and treatment as soon as possible.

Treatment Options: If the depression is mild, anti-depressants may not be necessary (you and your physician will decide this together). However, it is probably wise to undergo psychotherapy with someone who specializes in depressive disorders or PPD.

If the symptoms of depression are more severe or last more than a few weeks, anti-depressant medications are often used. These days, the most commonly used anti-depressants for PD are the Selective Serotonin Reuptake Inhibitors (SSRI). These medications tend to have less side effects and drug interactions with other medications than the older anti-depressants. For example, Zoloft (Sertraline) tends to be a popular choice because it seems to have few effects on infants whose mothers are breastfeeding. Other SSRI drugs include Prozac (Fluoxetine) and Celexa (citalopram hydrobromide). Tricyclic antidepressants (TCA, a older generation of anti-depressants) may be used, but these are more lethal in overdose, are more likely to cause weight gain, and generally have more side effects than the SSRI drugs. However, they are a treatment option if SSRI do not work, and some persons may actually find them to be more effective than SSRIs. Examples of some popular TCA drugs are Elavil (Amitriptyline), Tofranil (Imipramine), and Pamelor (Nortriptyline),

Welbutrin (Bupropion) is a so called atypical anti-depressant because its chemical action appears to be different than other anti-depressants. Some advantages of Wellbutrin are that it tends not to cause weight gain, it is a more stimulating and it tends to be less likely to induce a manic episode in women with a bipolar predisposition. However, Wellbutrin should not be used by women who have a history of seizure disorders or eating disorders.

If you are breastfeeding, be sure to check with your physician before taking any anti-depressant drugs. Also, almost all of the anti-depressant drugs may induce a manic episode in some women, so you should carefully discuss your and your family's history with your physician.

If you have a previous history of bipolar disorder, or experience extreme mood swings, your physician may prescribe a mood stabilizer. Please see the list of some commonly used mood stabilizers below. Most of these are actually anti-seizure medications but they have been found to be very effective in controlling mood swings.

Mood Stabilizers

* Carbamazepine (Tegretol)
* Divalproex (Depakote, Depakene, Valproate, Valproic Acid, appears to besuperior for "rapid cyclers")
* Gabapentin (Neurontin)
* Lamotrigine (Lamictal)
* Lithium (most often used for classical manic symptoms)
* Topamax (topiramate-may cause less weight gain)

Go here for information about these and other medications

In cases of severe depression or acute suicidal risk, electro-convulsive therapy (ECT) may be an appropriate treatment option. Although this may be a controversial treatment method, it tends to be very effective and usually does not have many long term severe side effects.

More information about PD

Information about treatment

General information about depression

Postpartum Psychosis (PPP): This is the most severe of all of the PPD and has a prevalence of about 1 or 2 in a thousand births. The symptoms may be similar to postpartum depression (severe insomnia, anxiety and agitation, suicidal and homicidal thoughts, bizarre feelings and behaviors), except that the person experiences psychotic episodes. These may include auditory hallucinations. For example, you or your family member may hear voices when no else one is there. Sometimes the voices are derogatory or command the mother to hurt herself or her baby. The mother may also have delusional beliefs, which are fixed ideas that are not true and are inconsistent with reality. Typically these are of a religious type. For example, the mother may think child is possessed, or the devil or Christ. The onset for PPP is usually within three months after birth. Infanticide, although rare, is most common with this type of psychosis. Treatment for PPP typically invloves anti-psychotic medications. A commonly used anti-psychotic medications is Zyprexa (Olanzapine), which is also FDA approved as a stand alone drug for Bipolar I disorder. It tends to treat all three symptoms of PPP-depression-mood swings and psychosis. Other so-called atypical anti-psychotic medications are also often used, including Risperidal (Risperidone),
Seroquel (Quetiapine) and Clozaril (Clozapine). Sometimes the older "typical" anti-psychotic medications such as Haldol (Haloperidol) may be used but these tend to have more side-effects. The risk of postpartum psychosis increases if the mother had a postpartum depression or if she had a postpartum psychosis The risk of recoccurence is about 30% to 50% after each delivery.

Some professionals believe that postpartum psychosis is a bipolar spectrum disorder and up to 80% of cases have either had a prior bipolar episode or may have a latent predisposition for this disorder. Thus some physicians automatically use a mood stabilizer with PPP even in the absence of mood swings. In a similar vein, in order to prevent PPP, early treatment in women with prior episodes may include psychotherapy, anti-depressants, mood stabilizers or other medications right after birth, before actually symptoms present.

Having treated a number of women with PPP myself, I would like to share that it is an extremely serous disorder and requires immediate attention and treatment. Often the mother may not have any insight that there is something wrong with her or she may continue to believe that the delusions are not real no matter what you say to her. That is way family intervention is very important. The risk of suicide increases with either postpartum depression or postpartum psychosis.

Although these are the most common postpartum disoders, researchers are finding that other mental conditions may also first appear after birth as well. These include obsessive-compulsive disorder, panic disorders and other anxiety disorders. My own opionion is that many other mental disoders may first appear after birth, but little research has ben done in this area so far.


Postpartum Stress Center

More information about suicide

Living with suicide

Depression after delivery

More information about PD and PPP

Salvatore Cullari
Psychological Services

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