Case Study Examining Postpartum Depression Symptoms and Treatment
IN THIS ARTICLE
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).
Being cognizant of one’s strengths, weakness, values, beliefs, and prejudices is one of the most important aspects in the determination of effectiveness as a helper (Corey & Corey, 2007). In assessing and diagnosing Sudi, it is important that the therapist be cognizant of her capacity to handle both socio-cultural factors and situations that challenge values and morals. What we presuppose as being right or wrong is variable upon individual definitions and individual realities. However, it is these definitions of right or wrong that lay the foundation for one’s value system (Okun & Kantrowitz, 2008). The reality of the therapist as a mother, a survivor of sexual abuse, and depression, and an Black women of a different socio-economic class, would have to aware of her judgments. The therapist has an ethical duty as provided by the ACA (2005) to be “aware of their own values, attitude, beliefs, and behaviors, and avoid imposing values that are inconsistent with counseling goals” (A.4.b.).
Sudi has family and social support, resources, and basic needs met, all which are typically risk-factors for increased susceptibility to Postpartum Depression or Postpartum Traumatic Stress Disorder. The therapist must also not assume that Sudi has the same coping mechanisms to be able to handle great stress and adjustment. Additionally, the therapist must not be dismissive of her symptoms, writing them off to normal postpartum experiences. What must be the focal point for the therapist is an establishment of an effective client-centered relationship premised upon the essentials of Carl Rogers’ which postulates that empathic understanding, including respect and positive regard, genuiness and congruence, concreteness, warmth, and immediacy, are vital components to the process of therapeutic change and the establishment of rapport with clients. Rogers (1980), asserts the more real the therapist in putting up no professional or personal facades, the greater the likelihood the client will change and grow in a constructive manner. Similarly, the way in which the therapist joins with the client accurately sensing their feelings and personal meaning and communicating this understanding to the client, the likelihood of change increases. He refers to this type of empathetic understanding “ one of the most potent forces for change” (p.116). Sudi’s presentation of symptoms must be taken seriously, without regard to the therapists personal history of overcoming similar challenges. “Practitioners have the abilty to decrease the impact and devastation of postpartum depression by following guidelines for treatment” (Leopald & Zoschnick, 1997). The therapist, could potentially disclose to Sudi her experience with similar situations as a way to foster trust and empathy and to not further the feeling of Sudi feeing “judge or a bad mother” for exhibiting the symptoms she has.
Melchert & Patterson (1999) state “the ethical principle of beneficence underlies mental health professionals duty to warn...this principle obligates health care professionals to attempt to prevent harm to clients and third parties as long as doing so does not present the professional with significant risks or cost and the benefits that clients or other would receive are not outweighed by the risks or costs incurred by the professional” (p. 180). Confidentiality within the counseling relationship has been generally regarded as a key aspect to building rapport with clients. “Mental health professionals generally agree that effective treatment may necessitate full disclosure and that confidentiality is important for the maintenance of the therapeutic relationship” (Chenneville, 2000, p.661). The American Association of Marriage and Family Therapist Code of Ethics (2001) 2.1 requires that therapist review with the client possible limitations of their rights to confidentiality. As Sudi presents probable signs of psychosis, it would be discussed with the client that disclosure to medical professionals and/or her partner would be necessary if she presents a harm to herself or others, in this case her child. After conducting assessment with Sudi, if it is reveal that she is high risk for suicidal idealization, a breech of confidentiality would necessary. The ACA (2000) B.2.a. States that “the general requirement that counselors keep information confidential does not apply when disclosure is required to protect clients or identified others from serious or foreseeable harm…if in doubt, the counselor should consult with other professionals” (p. 7).
Sudi, exhibits all the signs and symptoms of Major Depressive Disorder. She is given the Postpartum specifier as she is still within the range of the four week postpartum period. The inclusion of psychotic features with congruent mood was given as Sudi is delusional regarding her inability to care for her children and her disturbing thoughts. Her delusions are “consistent with typical depressive themes of personal inadequacy and guilt” (APA, 2000, p. 413). As she experienced a period of depression during college, and symptoms of depression during the prenatal period, she was provided an additional specifier of Recurrent as opposed to Single Episode. In order for a diagnosis of Major Depressive Episode with a Postpartum specifier to be given, “five or more of the following symptoms have to be present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interests or pleasure” (APA, 2000, p. 356) Additionally, these symptoms have to occur with four weeks postpartum.
1. Depressed mood most of the day, nearly everyday, as indicated by either subjective report or observation made by others.
A. Sudi has displayed depressed mood for over 1 month everyday and it has impacted her relationship with her husband and her children.
2. Marked diminished interests or pleasure in all, or almost all activities most of the day, nearly everyday.
Sudi depression has caused her to show little to no interests in caring for her children, her home, or engaging with her friends or family.
3. Insomnia or hypersomnia nearly everyday
Sudi reports having difficulty sleeping, frequency and duration of insomnia would have to be determined during assessment.
4. Psychomotor agitation or retardation everyday
Sudi rocks in her chair most the day, everyday, remaining disconnected from her new baby,
5. Feeling of worthlessness or excessive or inappropriate guilt (which maybe delusional) nearly everyday.
Sudi expresses feeling “guilt and shame for not being connected to Emma” and has convinced herself that she is not a good mother and is unable to produce enough milk for her.
6. Diminished ability to think or concentrate, or indecisiveness nearly everyday
Sudi reports difficulty concentrating. Frequency would have to be determined during assessment.
7. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
Sudi has recently expressed to her husband that everyone would be better off without her. Given her other symptoms, suicidal ideation would be assumed, however, assessment would be needed to positively grant criterion.
B. Her symptoms do not meet the criteria for Mixed Episode.
C. Her symptoms have caused clinically significant distress or impairment in her social and family life. She has withdrawn from both family and friends and is neglecting her infant as well as her toddler.
D. Her symptoms are not due to due to the direct physiological effects of a substance or hyperthyroidism.
E. Symptoms are not better accounted for by another disorder
Limitations of Diagnostic Criteria
Postpartum major depression is not recognized by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as being diagnostically distinct from its nonpuerperal counterpart, although the DSM-IV does allow the addition of a postpartum-onset specifier for patients with an onset within four weeks of delivery (Epperson, 1999). Presenting symptoms of depression such as weight loss, loss of energy, and sleep disturbances are more difficult to detect in postpartum women there is a range of normality for which these exists due to adjustment of having a new baby. These limitations of the DSM-IV-TR in providing clinicians with clear guidelines for diagnosis, allows for PPD to remain largely underdiagnosed and undertreated as the risk factors are not reliably identified. Additionally, “obvious limitation of the temporal criteria used within the DSM-IV is that it excludes all cases which have an onset later than 4 weeks postpartum” (Stewart, Robertson, Phil, Dennis, Grace, & Wallington, 2003, p. 22). “Before a definitive diagnosis of PMD/PPD can be made, depression caused by a medical condition such as thyroid dysfunction or anemia must be ruled out” (Epperson, 1999).
During the treatment phase with Sudi, the therapist would gather information regarding the frequency and duration of her depressive symptoms. Family history of mental illness would inquired upon through the use of a Genogram which would also help the therapist gain insight into relationship dynamics between family members as well as her circle of support which will be an important aspect in treatment planning. There will be an additional inquiry about Sudi’s prior sexual trauma and if this played a role in her initial onset of depression. Subsequent questions surround her initial depression episode would included whether or not a diagnosis was given, the duration of the episode and her symptoms. Also, the duration of treatment and what method(s) were utilized would be of importance. The therapist would also inquire about her feelings regarding her pregnancy and birth of her child to determine whether trauma existed. She would be asked if she is feeling overwhelmed, stressed, anxious or depressed. The therapist should inquire about how she is feeling physically and how her energy level is. Lastly, her feelings about the baby would be inquired about.
In addition to the Genogram, the Edinburgh Postnatal Depression Scale, The Self-Control Questionnaire and The Pilkonis Life Events Schedule. The Postnatal Depression Scale is a 10-item, self-rated instrument that is “useful because a threshold score higher than 12 has been 100 percent sensitive and 95.5 percent specific in detecting major depression” (Epperson, 1999). The Self-Control Questionnaire is a 41-item instrument designed to assess women’s attitudes and beliefs about their own self-control behaviors. “The SCQ had correlated significantly with both prepartum and postpartum depression levels” (O’ Hara, et al., 1991, p. 65). The Pilknois Life Events Schedule is used for indexing stressful life events that occur during pregnancy and postpartum. “In earlier work, the number of life events that occur during pregnancy and the first 9 weeks postpartum has been found to be associated with diagnosis of postpartum depression” (O’Hara, et al., 1991, p. 65). Determining the cause and contributing factors to Sudi’s depression as well as cultural factors will dictate which form of therapy will be utilized.
Postpartum Depression is “considered a major public health problem and has been associated with adverse outcomes for the infants’ cognitive, emotional, and social development” (Reay, Robertson, & Owen, 2002, p. 211). “Until recently, the treatment of PMD has not been a subject of research because most investigators and clinicians have considered PMD too similar to its nonpuerperal counterpart to warrant such investigation” (Epperson, 1999). For Sudi, the focus of therapy would be assessing how she is viewing her current situation, confronting her negative thoughts regarding her pregnancy, her child and her role transition as mother of two children, focusing on her marital strain, and helping her to focus her attention on positive thoughts and actions. Treatment goals involve: 1) reducing her depressive symptoms 2) alter her negative thoughts regarding her role as a mother 3) increasing congruent communication between her and Yao 4) developing a plan to help her adjust to her having two children and continuing her career 5) improving social adjustment. As Sudi exhibits more severe symptoms than supported by psychotherapy alone, she would potentially benefit from a combination of medication and Interpersonal Therapy (IPT) is a “time-limited, interpersonally oriented therapy that has been empirically demonstrated to be effective in the treatment of depression. It is readily available as a cost-effective intervention and can be delivered in a variety of clinical settings” (Reay, et al, 2002, p. 212). “Interpersonal psychotherapy helps patients with PPD to understand their associated life experiences within 3 problem areas: interpersonal disputes; role transitions; and bereavement. IPT recognizes the role of biological and psychological factors in the cause and vulnerability to depression, it focuses on social factors and working through interpersonal problems to alleviate depression” (Grigoriadis & Ravitz, 2007, p. 1471-1472). The beginning phase of therapy would involve educating Sudi about Postpartum Depression and its functional and interpersonal effects. Sudi would be encouraged to to reach out to family, friends, and her local new mother and breastfeeding support groups. The middle phase and focal problem areas of treatment “guide therapeutic interventions and link symptoms of depression to interpersonal events, losses, or changes” (Grigoriadis & Ravitz, 2007, p. 1472). To address the interpersonal role disputes, primarily the incongruent communication between Sudi and Yao, IPT utilizes communication analysis to “reveal ways in which patients interact with others that might inadvertently exacerbate conflicts” (Grigoriadis & Ravitz, 2007, p. 1472). Regarding Sudi’s role changes and adjustments as mother of two children, a Director, and wife, she a variety of role s to integrate, each having their own set of responsibilities and demands. IPT will aid Sudi in establishing balance in her perception of her roles while evaluating and modifying expectations that may have been unrealistic, and set new priorities that would give her a sense of control and stability. The therapist will provide Sudi with homework assignment to aid her developing a schedule that helps her to adapt to new time, emotional, and physical demands, while balancing her needs and desires as well. Once Sudi has developed a healthier balance of time and renegotiated her priorities, the relationship with Emma and Zoe would be of primary focus. “Attachment between mother and infant is crucial in the development of the infant’s sense of security and safety” (Grigoriadis & Ravitz, 2007, p. 1473) and it would be the goal of the therapist to aid Sudi in developing a healthy relationship with Emma, giving attention to Zoe to alleviate her physical symptoms, and be more attuned and responsive to both her children as she transitions through recovery.
Due to the degree of dysfunction Sudi is experiencing according to GAF score, Sudi would be recommended for Antidepressant Therapy coupled with IPT. As Sudi is breastfeeding Emma, it is of importance the type of antidepressant used to avoid contamination of breastmilk. Research has found that selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants “should be seriously considered in lactating and non-lactating women who have moderate to severe PMD, suicidal thoughts or difficulty functioning” (Epperson, 1999).
Pregnancy, childbirth, and motherhood is one of the most significant and stressful times in the life of woman. Societal pressures to wear the mask of a “joyful motherhood” forces many women to suffer in silence, in the confines of their own minds. The media projection of motherhood as euphoric phase, is far from the initial reality of sleep deprivation, hormonal fluctuations, adjustment to various roles, and the responsibility for another life. Interpersonal psychotherapy proves effective in helping women experiencing interpersonal disruptions in this phase of life as it is short-term, problem focused, and specific.
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