The postpartum period is often and aptly described as a roller coaster—there are ups and downs, highs and lows; it is simultaneously exhilarating and exhausting. While recovering from the physical toll of childbirth, women are required to care for a precious but also highly demanding new human being. This often means that the postpartum mother has to choose between sleeping, eating, bathing and other self-care activities, while her time is otherwise consumed by her infant’s needs. The challenges of the postpartum period can be overwhelming for anyone, but for some there is an additional burden that can often be overlooked and unnoticed, and that is postpartum depression.
Perinatal depression is defined as depression that occurs during pregnancy and/or within 12 months postpartum. It affects one in seven women, and approximately 40% of perinatal depression begins during the postpartum period. A diagnosis of depression involves having a depressive or low mood on most days, in addition to other symptoms that can affect appetite, sleep, energy, physical activity, concentration, and one’s sense of self-worth or feelings of guilt. In more severe cases, depression can also include having thoughts of death or suicide. In actuality, many of these symptoms can overlap with features of the postpartum phase that would be considered to be “normal.” The postpartum woman is overtired, likely lacks energy, has “mom brain,” may be moving more slowly due to physical recovery, and is often consumed with guilt over the tasks that she is unable to accomplish in her day. It is not surprising then that depression and the general postpartum reality overlap, masking the presentation of this major mental health issue.
How can the effects of normal postpartum exhaustion be differentiated from postpartum depression? One of the main distinctions is that in postpartum depression, the symptoms are persistent, pervasive, and cause a significant disruption in daily functioning. Depression involves a consistently low mood, while exhaustion usually involves more ups and downs. Furthermore, depression lasts for an extended period of time (at least more than two weeks), while postpartum exhaustion is typically temporary and can be improved by engaging in self-care. With normal exhaustion, one is able to lean on others for support and gain some relief in doing so. In the case of depression, it is often difficult to reach out to others and maintain relationships. An additional critical differentiating factor is that thoughts of harming oneself or the baby are not present with normal exhaustion, whereas these thoughts can be a very serious symptom of postpartum depression.
It is worth mentioning that there is a condition known as “postpartum blues,” in which many of the usual symptoms of depression are present in the immediate postpartum period, however these symptoms are short lived and largely resolved by two weeks after birth, while in depression the symptoms continue for several weeks to months postpartum.
In order to adequately diagnose and treat postpartum depression, various screening mechanisms can be employed. Among those who carry a diagnosis of depression preceding pregnancy, many will already have established care with a mental health professional and are encouraged to continue close follow-up during the prenatal and postpartum periods. However, for those whose symptoms begin during or shortly after pregnancy, the ob-gyn might be the first line of care to identify and address these symptoms. It is crucial for ob-gyns to screen for signs and symptoms of depression on intake to prenatal care, at various points during pregnancy, and in the postpartum period. Screening can be accomplished in the form of a conversation during a prenatal care visit or more formally using a validated questionnaire, such as the Patient Health Questionnaire (PHQ-9) or the Edinburgh Postnatal Depression Scale (EPDS). It is also imperative that there is a cascade of events following a positive screen, to ensure appropriate follow-up and treatment of depression. There is a network of mental health professionals now who specialize in mental health issues surrounding reproduction, that can serve as an excellent resource for management of perinatal depression.
In addition to screening at the level of healthcare providers, there is a significant role for family and close friends, as well as society at large, in the identification of postpartum depression. The symptoms of postpartum depression may be noticed by the individual herself, but in many cases are first observed by those who are closest to her and interact with her on a regular basis. It is so important for family and friends to check in during the postpartum period and to raise concerns if symptoms are present. Furthermore, as a society, encouraging dialogue about mental health issues during and following pregnancy will create an open space for educating and learning about these issues. An increased knowledge about postpartum depression and other perinatal mental health conditions will enable and empower women and their loved ones to speak up and seek help when it is needed. And promoting self-care, including adequate sleep, exercise, nutrition, and time for oneself, can improve mental health outcomes.
Once diagnosed, postpartum depression can be treated through various modalities. The first line of treatment for postpartum depression is therapy—usually in the form of interpersonal therapy or cognitive behavioral therapy. Therapy can target underlying issues such as birth trauma, difficulty coping with events surrounding birth, or past history that is contributory to the current depression. In addition to psychotherapy, women with depression can be treated with different types of medication. For those who are breastfeeding, there are medications with a low relative infant dose that are considered to be safe for both mother and baby. The general principle in pharmacotherapy is to utilize the lowest effective dose, and to avoid frequent changing of medications or starting multiple medications at the same time. Some medications take two to four weeks to be effective and therefore require this amount of time to assess whether there is improvement of symptoms. Two main classes of medications that are used to treat postpartum depression are SSRIs (selective serotonin reuptake inhibitors) and GABA receptor modulators. The latter is a treatment specific for postpartum depression and is a short-term oral regimen that is thought to work quickly and effectively. These medications can be prescribed by psychiatrists or ob-gyns and should be monitored closely to assess their efficacy in managing symptoms of postpartum depression.
Ultimately, a timely and proactive approach to managing postpartum depression is integral in promoting a positive outcome. The first step in doing so is recognizing what is normal and abnormal during the postpartum period. A key component in determining whether treatment should be sought is ensuring that the postpartum woman is engaged in self-care, and then assessing for improvement in her overall well-being when she does so. As the saying goes, “Put your own oxygen mask on first.” Self-care can come in many forms and may be different for each person. Whether it is taking a daily walk, going out for coffee, taking an uninterrupted nap, getting a manicure, spending time with family and friends, or any other activities (or inactivities), self-care is critical in the postpartum period. As a community we can facilitate postpartum self-care by discussing its significance, participating in meal trains, offering time to help a loved one, and simply noticing if a person seems to be struggling. If one is experiencing symptoms of depression despite self-care measures, and is not coping well, she should know that she is not alone. She may be grappling with the highly prevalent issue of postpartum depression. But she must also know that there is help and treatment that can change the trajectory of her postpartum course.
Dr. Leora Joel is a board-certified ob-gyn who has been in practice since 2017. She is a strong believer in supporting women’s birth choices to achieve the birth they desire. She is a physician at Maternal Resources, a thriving boutique-style practice, with offices in Hackensack, Jersey City, Hoboken, Howell and New York City.
