Postpartum and Perinatal Depression and Anxiety
By Dr. Laura Fadell

We have all heard of postpartum depression (PPD), especially with up to 80% of women experiencing some form of depressive symptoms following childbirth with some continuing through the first 12 months. Someone we know, or know of, has likely experienced some form of “baby blues”, sadness, or even severe depression.

Unfortunately, despite this high rate of occurrence, not all obstetricians or pediatricians routinely screen for PPD. In fact, more often than not, it is the woman herself who recognizes the symptoms and asks for help, and yet PPD is still underdiagnosed (Spinelli, 1998; Georgiopoulos, 2001).  For example, in one study of outpatients from an obstetrics practice, only 6.3% were spontaneously identified as suffering from PPD; however, when they were screened using the Edinburgh Postnatal Depression Scale, the detection increased to 35.4% (Evins, Theofrastous, Galvin, 2000 – scale provided at the end of this article).

Risk factors for developing PPD include: (1) younger maternal age, (2) lower education, (3) personal or family history of mood disorder, (4) depression during pregnancy, (5) psychosocial stress, (6) lack of social support, (7) marital or relationship conflict, (8) financial pressures, (9) recent loss or disappointment, (10) low self-esteem, (11) complicated pregnancy or birth, (12) difficulty nursing, (13) difficult baby, and (14) being separated from newborn due to medical issues (e.g., infant in NICU).

Symptoms of PPD includes having the “baby blues” that do not fade after 1-2 weeks; strong feelings of depression and anger that start 1-2 months after childbirth; feelings of sadness, doubt, guilt, or helplessness that increase each week and get in the way of normal functioning; not being able to care for yourself or your baby; trouble doing tasks at home or on the job; changes in appetite; things that used to bring you pleasure no longer do; intense concern and worry about the baby or lack of interest in the baby; fears of harming the baby; and thoughts of self-harm (American College of Obstetricians and Gynecologists, 2006).

Post Partum Depression puts mothers at risk of future depression and untreated maternal depression can result in poor outcomes for the health and welfare of both mothers and their children. There is substantial empirical evidence that maternal depression can have a negative impact on the cognitive, social, and behavioral development of children, including infants as young as three months of age.    

In addition to depression, research I have come across has shown that women who are pregnant, or who have recently given birth, are at an increased risk of developing anxiety, especially in the form of Obsessive-Compulsive Disorder (pOCD). The difference between “regular” OCD and pOCD is that the prior tends to begin gradually, while pOCD occurs more rapidly and coincides with feelings of being responsible for the newborn. In pOCD, the anxiety is usually focused on the newborn (or unborn) infant. Obsessions consist of the baby being hurt, contaminated, sick, or lost; and compulsions include checking, mental rituals, and seeking reassurance from others (Abramowitz, 2009). For example, I had one patient, a new mother, who would awaken and get out of bed multiple times a night to ensure her baby’s blanket was covering the baby “just right” – translation: there were no wrinkles and the corners were squared up and even. I also worked with a young mother who became obsessed with checking her toddler for rashes and would spend literally hours each day examining every inch of skin for “dots.” These are just a few examples of how I have seen pOCD or Post Partum Depression manifest.

Treatment for PPD and pOCD can be very successful. The most promising method of treatment for Post Partum Depression I have found is Cognitive-Behavioral Therapy (CBT) with an emphasis on Exposure and Response Prevention (ERP). This type of therapy emphasizes not only challenging irrational and unwanted thoughts, but also slowly exposes the person to the feared situation(s). During these “exposures”, the person is not allowed to engage in any of the behavioral compulsions, which only serve to ameliorate their anxiety for brief periods. In addition, Selective Serotonin Reuptake Inhibitors (SSRIs) can also be quite beneficial for both depression and anxiety – depending upon the physician’s recommendation for pregnant or nursing mothers.

Not all obstetric practices neglect screening for Post Partum Depression and pOCD, but these are the exception rather than the rule, especially with regard to anxiety. I remain hopeful that screening will become universal, and have had the good fortune to work with some very fine physicians who do indeed make this standard practice in their offices.

“I started to experience a sick sensation in my stomach; it was if a vise were tightening around my chest.  Instead of the nervous anxiety that often accompanies panic, a feeling of devastation overcame me.  I hardly moved.  Sitting on my bed, I let out a deep, slow, guttural wail.  I wasn’t simply emotional or weepy, like I had been told I might be.  This was something quite different.  This was a sadness of a shockingly different magnitude.  It felt as if it would never go away.”

-from “Down Came the Rain: My Journey Through Postpartum Depression”
Brooke Shields, 2005

Edinburgh Postnatal/Post Partum Depression Scale (EPDS)

As you are pregnant or have recently had a baby, we would like to know how you are feeling. Please check the answer that comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feel today.

In the past 7 days:

1.  I have been able to laugh and see the funny side of things:
___   As much as I always could
___   Not quite so much now
___   Definitely not so much now
___   Not at all

2.  I have looked forward with enjoyment to things:
___   As much as I ever did
___   Rather less than I used to
___   Definitely less than I used to
___   Hardly at all

*3.  I have blamed myself unnecessarily when things went wrong:
___   Yes, most of the time
___   Yes, some of the time
___   Not very often
___   No, never

4.  I have been anxious or worried for no good reason:
___   No, not at all
___   Hardly ever
___   Yes, sometimes
___   Yes, very often

*5.  I have felt scared or panicky for no very good reason:
___   Yes, quite a lot
___   Yes, sometimes
___   No, not much
___   No, not at all

*6.  Things have been getting on top of me:
___   Yes, most of the time I haven’t been able to cope at all
___   Yes, sometimes I haven’t been coping as well as usual
___   No, most of the time I have coped quite well
___   No, I have been coping as well as ever

*7.  I have been so unhappy that I have had difficulty sleeping:
___   Yes, most of the time
___   Yes, sometimes
___   Not very often
___   No, not at all

*8.  I have felt sad or miserable:
___   Yes, most of the time
___   Yes, quite often
___   Not very often
___   No, not at all

*9.  I have been so unhappy that I have been crying:
___   Yes, most of the time
___   Yes, quite often
___   Only occasionally
___   No, never

*10.  The thought of harming myself has occurred to me:
___   Yes, quite often
___   Sometimes
___   Hardly ever
___   Never

Source:  Cox, JL; Holden, JM, and Sagovsky, R. 1987.  Detection of postnatal depression:  Development of the 10-item Edinburgh Postnatal Depression Scale.  British Journal of Psychiatry 150: 782-786.

Users may reproduce the scale without further permission providing they respect copyright by quoting the names of the authors, the title, and the source of the paper in all reproduced copies.

Scoring:  
Questions 1, 2, and 4 (without an *) are scored 0, 1, 2, or 3 with top spot scored as 0 and the bottom spot scored as 3.

Questions 3, 5, 6, 7, 8, 9, and 10 (marked with an *) are reverse scored, with the top spot scored as a 3 and the bottom spot scored as a 0.

Maximum Score:        30
Possible Depression:     10 or greater

Mothers who score above 13 are likely to be suffering from a depressive illness of varying severity. The EPDS score should not override clinical judgment.  A careful clinical assessment should be carried out to confirm the diagnosis and determine what treatment for Post Partum Depression is necessary.

ABOUT DR. LAURA FADELL
Services offered by Dr. Fadell include individual, family and couples therapy (ages 5 through adult); cognitive therapy for weight loss and maintenance; women’s issues; and psychological testing for ADHD and learning challenges. Dr. Fadell is in private practice in Bloomfield Hills and on staff at St. Joseph Mercy Hospital. Visit www.drfadell.com for more information.