Treating postpartum depression

Psychotherapy, rather than medication, should be the first line of treatment, research suggests. By Melissa Lee Phillips February 2011, Vol 42, No. 2 Print version: page 46

After Christina Hibbert gave birth to her first child 14 years ago, she knew something was wrong. I felt like I was the only one who could take care of him, she says. I wasnt sleeping, but I felt like I shouldnt let anybody help me. She called her physician, discussed her symptoms and even suggested that she might have postpartum depression. The doctors office mailed her a brochure about baby blues mood symptoms common in the first week or two after delivery that usually disappear quickly. That didnt sound like what I was experiencing because it didnt go away and it wasnt getting better, she says. Hibbert never did get help for her depression. A few months la ter, she started feeling better on her own. But after that experience, I decided to learn all I could because I knew I wanted to have more kids, and I didnt want to go through that again, she says. Hibbert eventually obtained her PsyD in clinical psychology and did her dissertation on postpartum depression. In 2005, she founded the Arizona Postpartum Wellness Coalition, which provides support for new parents as well as educational training for professionals. Since Hibberts first pregnancy, medical and m ental health professionals have become much more knowledgeable about postpartum depression, Hibbert says. At the same time, scientists are making major advances in illuminating the biological, social and cultural factors that contribute to the disorder, and even developing tests that predict who it will strike.

Still underdiagnosed
Although many more women are diagnosed with postpartum depression today than even a decade ago, clinicians suspect that its still vastly underdiagnosed. Theres so much stigma about postpartum depression, says Susan Hatters Friedman, MD, a psychiatrist at Case Western Reserve University in Cleveland. As a society, we expect it to be the happiest time of a womans life. A lot of women dont report if theyre having symptoms. Studies estimate that 10 percent to 15 percent of women may experience a major depressive episode within three months after giving birth. If minor depressive episodes are included, as many as one in five new mothers suffer from depression. And the disorder isnt limited to mothers: Up to 10 percent of new fathers may experience postpartum depression as well, Hibbert says. It doesnt just affect moms. Its a familial disease. Postpartum psychosis is a much rarer but extremely serious condition characterized by severe depression, psychotic thoughts and hallucinations. Mothers with postpartum psychosis sometimes consider hurting their infants, and the condition almost always requires medication and frequently hospitalization.

Medication has traditionally been the first-line treatment for postpartum depression, says Hibbert, although some studies suggest that therapy may be a better first choice. A meta-analysis by University of Iowa researchers, including psychologist Michael OHara, PhD, found that psychotherapy should be considered a first -line treatment, rather than as an adjunct to medication treatment. (Archives of Womens Mental Health, Vol. 6[Suppl.2]: s57-s69; see further reading for more citations). But because postpartum depression can be diagnosed by physicians with little training in the condition, many women end up either taking medication they dont need or taking the wrong one, Hibbert says. The medications absolutely do help, when needed, says Hibbert. The problem has been that too often women are not given options other than medication. Many women do not want to take medication, especially if they are pregnant or nursing, and many might not need medication to be well, but feel they have no other choice. As a result, points out Hibbert, many women end up on medications who wouldnt need them if they ha d a safe place to talk and receive coping strategies.

Biological factors
Researchers believe that a variety of risk factors influence a new mothers risk of postpartum depression. A previous history of depression, family history of mood disorders, stressful life events, a poor relationship with a partner and weak social support all appear to correlate strongly with postpartum depression risk. Preliminary studies are now revealing that there may also be genetic contributions to postpartum depression. A study published in 2009 in The American Journal of Psychiatry (Vol. 166, No. 11) reported that women with particular versions of estrogen-receptor genes were more likely to develop postpartum depression. Another study, in Psychiatric Genetics (Vol. 17, No. 5) found an association between postpartum psychosis and genes involved in brain circuits that use the neurotransmitter serotonin. Although this genetic work is so far inconclusive, researchers envision tantalizing potential payoffs down the line. Twenty years from now, if we could do a genetic risk test for postpartum depression during other pregnancy or postpartum tests, that would be just an amazing advance, Hatters Friedman says. Psychologist Ilona Yim, PhD, at the University of California, Irvine, is studying other biological influences on postpartum depression. Her work looks at hormonal changes during pregnancy, with the goal of using hormonal signals to predict which individuals are at risk of developing postpartum depression. Her 2009 research, funded by the National Institute of Child Health and Human Development and published in Archives of General Psychiatry (Vol. 66, No. 2), demonstrated that levels of placental corticotropin-releasing hormone during pregnancy predicted whether women developed depression after their babies were born. Work appearing in the Journal of Affective Disorders (Vol. 125, Nos. 13) in 2010 showed that levels of the hormone betaendorphin during pregnancy may also be a predictor of postpartum depression risk for women who show no signs of depression while pregnant. The work, while preliminary, might find some applicability someday in predicting postpartum depression, she says. Yim and her colleagues are now looking at how stress during pregnancy affects these hormone levels, as well as how relaxation techniques such as yoga might protect against hormonal increases and postpartum depression.

Cultural contributors
New research is showing that cultural factors may also influence risk of postpartum depression, according to psychologist Linda Luecken, PhD, of Arizona State University in Tempe, who is conducting a study looking at postpartum depression in more than 300 low-income Mexican-American women. We think this is especially important [work] because there seem to be some pretty significant health disparities, between low-income MexicanAmerican women and white and middle-class populations, she says. Estimates of postpartum depression incidence in this population are particularly high as much as a third or more of new mothers. However, Luecken and her colleagues believe that there may also be factors that protect against postpartum depression risk in this community. They suspect that such cultural factors as strong family ties may keep depression rates lower than they might otherwise be among low-income mothers. Luecken and her colleagues, Keith Crnic, PhD, and Nancy Gonzales, PhD, are also looking at a novel factor in postpartum disease risk: how the mothers relationship with her baby influences her risk of postpartum depre ssion. Most studies look at how moms depression affects the babies; were looking at how babies affect moms depression, she says. Theyre measuring what they call coregulated interactions whether the mothers and babys emotions are in sync with one another, for example. We think its a dynamic process, she says. Certainly moms affect can influence the baby, but we also think that the quality of the interactions can predict moms risk of depression later on.

Researchers are also recognizing that postpartum mood disorders arent limited to depression and psychosis, Hibbert says. Anxiety disorders, post-traumatic stress disorder, and even obsessive-compulsive disorder can all have postpartum onset. Even psychologists dont necessarily know a lot about the various disorders that occur postpartum, she says. But because theyre now getting a lot more attention from medical and mental health professionals, more people are getting help with these disorders than ever before. Understanding the different disorders and how to distinguish them is going to make it so much easier for families to get the diagnosis and the treatment that they need, she says. Thats certainly been true in Hibberts experience. Since her first experience with postpartum 14 year s ago, she has given birth to three more babies and has experienced either postpartum depression or anxiety with every one. It hasnt been prevented, but I knew where to turn, she says. Every experience got easier because I knew how to get help.

Melissa Lee Phillips is a writer in Seattle. See also the Public Interest Directorate's brochure on postpartum depression for additional information.

Further reading

Stuart, S., OHara, M.W., & Gorman, L.L, 2003. The prevention and psychotherapeutic treatment of postpartum depression. Archives of Womens Mental Health, 6[Suppl.2]: s57-s69.) OHara, Stuart, Gorman & Wenzel, 2000. Efficacy of Interpersonal Psychotherapy for Postpartum Depression.Archives of General Psychiatry, 57:1039-1045.