Postpartum Depression And Postpartum Psychosis

Introduction 

Giving birth is often a challenging time for people assigned female at birth. Firstly, there is the profound change of having a new baby in their life, and secondly, their own physiological changes, including changes to their mental health. The postpartum period generally refers to the first year after giving birth.¹

Postpartum depression (PPD) and postpartum psychosis (PPP) are two different psychiatric illnesses that can manifest after giving birth² and will be discussed in this article. These can also be referred to as perinatal (meaning occurring around the time of birth) depression or psychosis as they can arise during pregnancy too, but this article will use the term ‘postpartum’.⁶

A note on baby blues

“Baby blues” are commonly occurring feelings of sadness, tiredness and apathy after giving birth. These symptoms usually resolve on their own (i.e without any treatment or intervention) within 2 weeks. Baby blues are not considered to be a psychiatric illness like PPD or PPP.²

What is postpartum depression?

The symptoms of postpartum depression are similar to those of clinical depression: a newfound lack of enjoyment in life, feelings of hopelessness, a lack of energy, low self-esteem and changes to eating and sleeping habits. People AFAB can find difficulty bonding with their newborn and feel guilt associated with this. People AFAB can also feel suicidal, and can even act on these feelings.²

Around 10-15% of people AFAB experience postpartum depression, making it one of the most common comorbidities associated with birth.³ Despite being so common, many women do not seek treatment for PPD, so this figure may be an underestimate.⁴

There are many potential risk factors associated with PPD. These include (but are not limited to): 

• lack of social support⁴ 
• lack of finances⁴
• previous depressive episodes⁴
• complications during birth and pregnancy⁴
• a pre-existing chronic illness⁴
• relationship problems (including intimate partner violence – an issue of its own that will not be covered in this article)⁴
• A family history of postpartum depression almost doubles the risk of a person assigned female at birth experiencing it herself³

This has a negative impact not only on the person, but also on their families and partners. It can affect their ability to engage in activities related to the baby and around the house, and if it is persistent over months, it can also impact their readiness to go back to work.¹ Some evidence has also shown that partners of the person assigned female at birth (especially those assigned male at birth) can be more prone to depression in the postnatal period if the person assigned female at birth has PPD herself.¹¹

Additionally, the first few weeks to months of a baby’s life are an important part for their emotional development and bonding, and changes in the mother’s mood can affect this.³

In the most severe cases, postpartum depression can lead to suicide. Suicide is actually one of the leading causes of maternal mortality in the USA within the first year of giving birth. This is of course an incredibly tragic eventuality for the family and community, in a period that would otherwise be joyful with the entering of a new life. Suicide is an avoidable cause of death, and this is one of the main reasons why it is so important for people to seek help for PPD.⁵ 

Treatment for PPD is very much dependent on the case. Psychotherapy is the first-line option for mild cases of PPD. Medication is also commonly used. There are two categories of antidepressants commonly prescribed to postnatal women.

These are selective serotonin reuptake inhibitors (SSRIs) and selective noradrenaline reuptake inhibitors (SNRIs). Their transmission into breast milk is very low. However, the evidence on whether or not antidepressants actually are more effective for PPD when compared to a placebo remains unclear especially in the severe cases. There is a need for more research on this.⁷

Electroconvulsive therapy (ECT) can be used in select, severe cases. This is where a series of electric currents are passed through the brain under medical supervision, and has been shown to have good outcomes. 

What is postpartum psychosis?

Postpartum psychosis (PPP) is a severe psychiatric emergency. It is rare, affecting one to two women per 1000. The onset of symptoms is usually relatively rapid, and starts within a few days after birth. 

Symptoms of PPP include:⁷

• Delusions: fixed false beliefs, even with evidence to prove otherwise
• Hallucinations: seeing/hearing/feeling/smelling/tasting something that is not actually there
• Disorganised speech: what the person says may not actually make sense
• Severe changes in mood: this can be either feeling depressed or manic (e.g. euphoric, elated). Some people present with a mixture of both
• Paranoia and/or catatonia (lack of response to surroundings)
• Thoughts and actions of self harm, suicide. In some cases, harming the baby has also been noted

Those who have been diagnosed with a psychiatric condition such as bipolar disorder or schizophrenia can relapse during the postnatal period, even if they have been well and medically stable beforehand. However, there are an almost equal number of people assigned female at birth who do not have any pre-existing diagnosis of a psychiatric condition who also experience PPP.⁸

A previous history of PPP or family history is a risk factor for PPP, as genetics can influence the hormonal changes occurring around birth. Early childhood adversity can also contribute to the risk. Stress in life at the time of birth and pregnancy has been looked at as well, but the evidence is not convincing that this itself is a risk factor.⁸

PPP requires immediate hospital admission and treatment, mainly because the life of the mother (and child) is at risk. Treatment usually involves medication – this can be antipsychotic medication, mood stabilisers (the most common one being lithium), or anticonvulsants, which are also used in treating bipolar disorder.

Electroconvulsive therapy (ECT) can also be used in cases where medication does not relieve symptoms. This, like in severe PPD, is carried out over multiple sessions under medical supervision. The safety of the mother and baby is the priority. 

Long term treatment can also involve medication, talking therapies and managing any existing psychiatric condition.¹⁰

As with postpartum depression, postpartum psychosis affects the family too. It can be incredibly scary and stressful for the family, but fortunately most patients do respond well to one of the aforementioned modes of treatment.¹⁰

Stigma

As alluded to previously with PPD, there are many cases that go undiagnosed as the women do not always seek help if experiencing symptoms. This is in part due to the stigma attached to postpartum depression, and the expectation that the new mother should be happy after the baby has arrived.

Whilst there have been significant strides in the direction of acceptance of psychological disorders, there is still more that can be done – especially with regards to postpartum psychosis, which has a stigma much larger that of PPD. More open conversation and awareness is important not only for the public, but within healthcare settings too, so that health professionals can seek out information to identify risks and action any findings.¹²

Hormones 

Pregnancy and childbirth are times of major hormonal changes in women. However, the reason for postpartum depression or psychosis is often not singular; there are usually multiple physiological and psychosocial factors that can contribute to them.

Therefore, hormonal changes should be viewed in context. Oestrogen and progesterone levels drop significantly after birth, and this contributes to the decline in mood seen in both PPD and PPP. Cortisol, which is often called the stress hormone, may also contribute to PPD, but there needs to be more research to prove this.⁸

Summary 

‘Postpartum’ generally refers to the period of 1 year after giving birth. During this time, people assigned female at birth can develop postpartum depression, where they can have a persistent low mood, lack of energy and even suicidality.

As well as affecting the mother’s own health, this can put strain on their family and affect their bonding with the baby. Treatment usually involves talking therapy and/or antidepressant medication. There are several factors that can contribute to PPD, such as previous depressive episodes, stress in life during the times of pregnancy and birth, or a family history of PPD. 

Postpartum psychosis is a psychiatric emergency which rarely occurs. The main risk factors for this are a pre -existing diagnosis of either bipolar disorder or schizophrenia, a previous episode of PPD, or a family history of PPD. That said, those with no prior diagnosis are equally susceptible.

The person in psychosis “loses touch” with reality. It is characterised by delusions, hallucinations, and severe changes in mood and behaviour. PPP requires immediate treatment as the lives of the mother and baby are at risk. Treatment is usually with medication, or in some cases, electroconvulsive therapy to stabilise mood and reduce psychotic symptoms. The priority when treating PPP is to keep the mother and baby safe.