Case Study Examining Postpartum Depression Symptoms and Treatment
Postpartum Mood Disorders
The criterion as specified by the DSM-IV-TR for Postpartum Onset Specifier is with Postpartum Onset (can be applied to the current or most recent Major Deprressive, Manic, or Mixed Episode in Major Depressive Disorder, Bipolar I Disorder or Bipolar II Disorder or to Brief Psychotic Disorder) and must have an onset within 4 weeks postpartum (APA, 2000, p 423).
Postpartum Depression also referred to as Postpartum Major Depression (PMD), “occurs in approximately 10 percent of childbearing women and may begin anywhere between 14 hours to several months after delivery” (Epperson, 1999). PPD exhibits all the typical symptoms of depression, but is distinguished by its manifestation after the childbirth. There are three degrees of PPD that can be experienced by a woman after childbirth: 1) “baby blues” which the DSM classifies as Adjustment Disorder with Depressed Mood (309.0) or with Mixed Anxiety and Depressed Mood (309.28) and which resolves without significant consequences; 2) postpartum depression or Major Depressive Disorder, and; 3) postpartum psychosis, Mood Disorder with Psychotic features (296.x4) or Psychotic disorder not otherwise specified (298.9).
As the focus of this paper is Postpartum Depression, it is vital to differentiate the degrees of PPD. “Seventy to eighty percent of U.S. women who give birth experience postpartum blues” (American College of Obstetrics and Gynecologist, 1999). The ‘baby blues’ is characterized by mild and transient mood disturbances with an onset of 1-7 days postpartum with a peak between day 5-6 postpartum. Symptoms include low mood, anxiety, crying, irritability, insomnia, and mood lability. Because of its commonality, it is viewed as a ‘normal’ phenomenon. It can last for a few hours or a few days. At the other end of the spectrum is Postpartum psychosis, a rare illness only affecting 2 out of every 1000 women who give birth (APA, 2000). Onset can be dramatic and abrupt and can begin within 2 to 4 weeks postpartum or as early as 2 to 3 days. Early symptoms include restlessness, irritability and insomnia. Typical features included rapidly evolving or shifting depressed or elated mood, disorganized, confused and disoriented behavior, and the presence of hallucination or delusions typically focus on the infant (Jellineck, Patel, & Froehele, 2002). Psychosis of any kind is considered a psychiatric emergency, however, with postpartum psychosis, potential harm to the infant necessitates immediate attention and evaluation. In between these to extremes lie Postpartum major ,depression (PMD/PPD). PMD/PPD ranges in severity and onset can be insidious, but typically begins within the first 2-3 months postpartum. “More than 60% of women have an onset of symptoms within the first 6 weeks postpartum, providing primary care physicians with the perfect opportunity for diagnosis” (Leopold & Zoschnick, 1995, n.p. ).
Etiology of Postpartum Mood Disorders
“Multiple investigations into the etiology of postpartum depression have not reached a consensus” (Leopold & Zoschnick, 1995), hence the inclusion of it in the DSM-IV as separate category diagnostically different from Major Depression. Biological theories suggest that deregulation of the neurotransmitters serotonin and norepinephrine, epinephrine, and dopamine serve as the origin of PPD. Other biological factors included prolactin levels are rise throughout pregnancy and fall during delivery, and have been considered to be a factor in the onset of PPD. O’Hara, Schlechte, Lewis, & Varner (1991) presented conflicted results showing higher levels of prolactin on postpartum days 2, 4, and 6, while lower levels in by week 6 postpartum. Other hormonal factors such as estrogen levels which decrease significantly in the postpartum period and regulate mood, memory, and cognition and brain function has been thought to play a major role in the onset of PPD. “The specific effects are best characterized in the dopamine system where estrogen increases dopamine turnover through the regulation of tyrosine hydroxylase, degradative enzymes, and turnover dopaminergic receptors” (Leopold & Zoschnick, 1995, n.p.).
Biological factors do not create as much as a susceptibility to Postpartum mood disorders as psychological and social factors. In a controlled re-test study of psychological, environmental, and hormonal variables of Postpartum Mood Disorders, O’Hara et al. (1991) found that “stress interactions accounted for very significant proportions of the variance in the depression outcome. There was very little association between hormonal variables and postpartum depression. Vulnerability coupled with life stress predicated the diagnosis of depression” (p. 68). Vulnerability speaks to the psychological theories of PPD which according to the cognitive model, “a patients negative view of the world and herself leads to depression and low self-esteem and disturb relationships” (Leopold & Zoschnick, 1995). “Three correlates of PPD are consistently found by researchers: marriage problems and lack of social support, particularly the father’s, infant problems, including pregnancy and delivery problems, and a prior history of depression or other emotional problems (Hagen, 1996). “Of the 13 studies addressing the role of socioeconomic factors in PMD/PPD, only two found that low socioeconomic status is predictive of PMD/PPD” (Epperson, 1999). Women who have a prior history of depression or mood disorders displayed a significant influence on the occurrence of PMD/PPD during postpartum. “At least one-third of the women who have PPD/PMD have a recurrence of symptoms while as many as 60 percent with bipolar disorder have a relapse after childbirth” (Epperson, 1999). Adequate screening by healthcare professionals can identify women who are at-risk and provide her with adequate information and resources to reduce the likelihood of occurrence or relapse.
Social, Historical, and Political Impact of DSM Inclusion
The connection between childbirth and psychological instability has been historically validated. Hippocrates describes “puerperal fever” in 460 B.C. “theorizing that suppressed lochial discharged was transported to the branin, where it produced agitation, delirium, and attacks of mania” (Leopold & Zoschnick, 1995). In 1858, Marce’ in his Treatise on Insanity of Pregnant and Lactation Women, “linked negative emotional reactions with childbirth (Griffin Hospital, 2004). It was not until 1958 with the publishing of the DSM II that “Psychosis with Childbirth” was even included. Prior to this, no gender discussion had been included in the DSM, however, “with each edition, of the DSM, there has been greater attention paid to gender issues” (Kornstein, 2010, p. 11). The DSM III eliminated this diagnosis due to lack of evidence that PPS was a distinct entity. With the media attention being given to women who carried out infanticide and/or suicide during the postpartum period the necessity of inclusion of a disorder during the postpartum period became vital. The DSM-IV added “the modifier “With Postpartum Onset” to describe episodes of Major Depressive Disorder, Bipolar I or II Disorder and Brief Psychotic Disorder with onset within 4 weeks after childbirth” (Korstein, 2010, p. 11). The upcoming edition of the DSM-V proposed an extension of the postpartum onset specifier to 6 months. “If included, this would help increase access to insurance coverage to mental health services in pregnancy and postpartum. Additionally, it will encourage funding for researchers investigating perinatal mood disorders incidence and initiation” (Stone, 2010).
Sudi, 29, is a married caucasian mother of two girls living in an affluent community in Maryland. Her and her husband Yao, who is Chinese-American both worked full-time until Sudi became pregnant with their second child, Emma. Sudi first pregnancy went smoothly and she experienced no complications. She returned to work after 6 months and was able to balance her new role as a mother and as a business executive. Sudi decided after Zoe, the first child to wait at least 3-4 years until she would get pregnant again. However, despite her use of contraceptives, she became pregnant when Zoe was 18 months old. Sudi experienced a great deal of internal conflict, about her decision to continue the pregnancy. She was just getting back to her old self, had been promoted to a Director position at her job, and was not ready to start over again with another baby and even contemplated termination of the pregnancy well into the first trimester. Yao, did not believe in abortion, and her decision to proceed with the pregnancy created a strain on the relationship.
Early in the pregnancy Sudi experienced severe morning sickness and was diagnosed with Hyperemesis an hospitalized for 1 month as well as given medication. During the 6 month of pregnancy, Sudi had to be put on bed-rest due to bleeding and frequent fainting spells. Initially, she was relieved as she was much bigger than her first pregnancy and was very tired during the day. But a few weeks later, Sudi began to experience panic attacks, frequent crying, and avoided speaking to family and friends. Yao, became very worried, but Sudi and others ensured him that this was normal pregnant behavior. Emma was born via cesarean 3 months later and initially Sudi was overjoyed, despite her initial feelings and difficult birth. She was visited frequently by her close friends and family who took turns assisting her with adjustment. However, two weeks later, Sudi could not muster any feelings for her Emma. She would often go through the day not speaking to her, only touching her to change her and feed her. She cried frequently, had difficulty sleeping, was unable to concentrate, and began to have disturbing thoughts. Sudi reports “feeling guilt and shame for not being connected to Emma” and was convinced that she was not a good mother, that she was failing Emma and Zoe, and that she was unable to produce enough milk for her.
Sudi, was raised in a middle-class neighborhood by her grandparents who died when she was 16. Her mother birthed her when she was 19, and decided that she was unable to care for her. After the death of her grandparents, Sudi lived with her mother and her brother. Because of the lack of established relationship between Sudi and her mother, there was on going conflict and she was eventually dismissed from her mothers home. She lived with various people before going to college. During that time, she experienced sexual abuse, witnessed crime, and poverty. During her first year of college, Sudi became very anxious, began smoking marijuana and entered a state of depression. She engaged in fights with her roommates and was referred to the school therapists. In her last year of school, she found her father and began establishing a relationship with him and her sisters. She vowed, to never depend on anyone and to never do to her children what was done to her.
Most recently, Sudi expressed to that Yao that “everyone would be better off without her”. She remains in her room most of the day, rocking back and forth in her chair. Zoe has exhibited oppositional behavior because of her lack of attention from her mother, Emma is often inconsolable and colicky, and Yao is been operating off 3 hours of sleep for the past 2 months as Sudi, has had difficulty managing the domestic duties such as cooking, cleaning, and attending to both children. Concerned for her well-being and the well-being of the children, he suggested therapy. Sudi was initially reluctant, telling Yao that she would never harm herself or the children, but after being convinced by her family and friends, she decided to attend.
Unlike other cultures, the postpartum period in Western culture is more relative to the newborn-infant than lavished attention given to the mothers. In an anthropological observation of Chinese culture, extra attention given to the mother from family and social networks, “precluded Chinese women from experiencing PPD as understood by Western culture” (Boyle, 1994, p. 54). Even though Sudi has family and social support, her presentation of symptoms are consistent with Western cultures perceptions of birth and motherhood. The media projection of motherhood creates a fictitious standard by which women such as Sudi who experience Postpartum Depression, become “afraid to speak out about their feelings in case they are judged a ‘bad’ or not a ‘good enough’ mother” (Fraser & Cooper, 2009, p. 683). Sudi unplanned pregnancy “placed her under emotional strain, which can lead to feelings of depression (Wheatley, 2005, p. 18). Research has shown that “unintended pregnancy has been linked to a variety of negative outcomes for both the mothers and the children...particularly depression. Complications during pregnancy is more common in women with postpartum depression” (Iranfar, Shakeri, Ranjbar, Nazhadjafar, & Razaie, 2005, p. 619).
Sudi’s complications during her pregnancy that culminated into a difficulty delivery and traumatic birth experience sets the preface for both depression and a stress-related disorder. Son et. Al (2005), found that “pain as well as intrusiveness of delivery procedure were associated with perinatal dissociation” (p. 307). Additionally, they found that an earlier history of depression and sexual abuse, serves as pathways to postpartum depression and traumatic stress related disorders. Due to more recent media reports of women and postpartum depression, a myth has surrounded that depression in more common in certain populations, particularly white middle-upper class women. This however is not the case. Studies have shown that there is a slightly higher rate of depression among low-income women, even though most are not depressed, and that single women without a co-habiting partner were at the highest risk and rates, without regard to race (Hobfoll et al., 1995).Continued on Next Page »