Guide to Postpartum Depression (PPD)

Contents

What is Postpartum Depression?
Things You Can Do Now
Figuring Out Postpartum Depression

PPD Risk Factors
The Symptoms of Depression

Explanation of Specific Symptoms
What to Expect with Evaluation and Treatment

Medicines
Therapy
What your partner or friend should do to help during treatment

Recovery
Tracking Charts     (click here for pdf version)

How to Use This Guide

Most women experience some sort of down feeling after the birth of their child.  For some, this continues into clinical depression.  The big problems are that identifying depression requires looking at behavior and feelings over a two week or longer period and you may not see what is happening since you are in the middle of it.

Thus, you need someone, your husband or a friend, to see the big picture, look for trends and take steps to help correct any problems.  This section helps you or your friend to identify the trends and keep track of things over the first six weeks following the birth of your child.

If you don't get this book before your child arrives, you can still use it.  Mark through “2 wk” on the symptom chart and write “now.”  If you have several of these symptoms and it is more than 6 weeks after the baby was born, do not wait.  Get to a doctor for an evaluation.  

What is Postpartum Depression (PPD)?

Remember during the first few months of pregnancy.  The changes in your body caused nausea, vomiting, fatigue, mood swings, cravings and some other emotional changes. Well now that the baby is here, your body is trying to get back to normal.  You are going through withdrawal from drugs of your own making called hormones.  About the only thing that helps lessen the severity of this withdrawal is breastfeeding because some of the hormones remain high so you can produce milk. 

Just as the increase in hormones affected the brain and emotions, this withdrawal does also.  Most women, about 80 percent, experience what are called “Postpartum Blues.”  These are feelings of moodiness, irritability, crying frustration, anxiety, exhaustion, etc.  This can begin 2-3 days after the birth and may last up to two weeks.  These feelings and emotions are normal following the birth of a child. 

Every mother and every pregnancy are different, so you may or may not suffer from the blues.  You may have had them with the first child but not with the second and vice versa.  The emotions can range from mild to severe.  When these feelings hang around for more that two weeks you start thinking about depression. 

Postpartum depression is clinical depression closely associated with child birth.  In other words you have an episode of depression that requires some treatment to help cure it.  The symptoms are the similar to the blues and discussed in detail later.  Postpartum depression is the result of a chemical imbalance in the brain.  The chemical affected is a neurotransmitter called serotonin.  All the physical and emotional stress of pregnancy and childbirth upset the balance of serotonin.  

It is important to remember that this is a medical problem.  You didn't choose for this to happen and try as you might, you will need help to get it fixed.  You would not just hope for an infection to go away, you would see a doctor.  This is the same.

Postpartum Psychosis affects very few women, but is a serious situation that may require immediate intervention by professionals.  The two key indicators are

   ● You are thinking about harming herself, the baby or others.
   ● You are not functioning and has thoughts and behaviors that just don't match what is really going occurring. 

      These are often bizarre.     

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Things You Can Do Now

If your helper is a guy, he will want to do something about a problem.  However, it is going to take four to six weeks to figure out if there is a problem to fix. 

During this time you don't have to just hurry up and wait.  Until it becomes obvious that you may be suffering from postpartum depression, you can do some things that will make life easier for everyone, may reduce the postpartum blues and may help to prevent postpartum depression.

   1.  Get some sleep.  The biggest single thing you can do early on is to arrange to get some good nights sleep.  Sleep deprivation causes some of the same symptoms as depression such as inability concentrating, racing thoughts, exhaustion and irritability.  Because continued sleep deprivation does affect the brain, it may cause the change in brain chemistry that leads to depression.  Most people can function on 6 hours of uninterrupted sleep a night.  If you have three hours or less for three or more nights, you have a big problem.

Sleep Strategies

       ·  Sleep when your baby sleeps.
       ·  Reduce caffeine, sugar & alcohol intake before bedtime.  While initially relaxing, you get a rebound effect from alcohol as your body breaks it down.
       ·  Get help from relatives and friends to spread out the work.
       ·  If you have figured out your baby's schedule, such as eating every three hours or always waking up around 2:00 a.m., you can take turns with your partner.  One parent takes waking before a certain time and the other takes waking afterward.  This is pretty easy to do when bottle feeding.
       ·  If you are breast feeding, your partner can bring the baby to you, change the diaper and put the baby back to sleep.  Neither mom nor the baby has to be fully awake to feed.  I recommend a “feed from one breast, change the diaper, and then feed from the other breast” sequence.  This keeps your baby from becoming fully awake and pissed off because he is hungry.
       ·  Arrange a baby sitter a couple of times a week during the day so you can get a decent nap.
       ·  Go with expressed or pumped breast milk at night.  Discuss this with a lactation consultant first.

   2.  Get Help.  Accept voluntary help or pay for assistance.  Just about anything that reduces the overall workload is beneficial such as providing a meal, doing grocery shopping, laundry, cleaning the house, watching the baby for a few hours, etc.

   3.  Take time off work.  If possible your partner can adjust work hours or take vacation time to be home when your baby comes home during the first two weeks or longer.

   4.  Laugh.  Everyone is learning and will make mistakes.  Lots of things you have to do may be messy but are also funny.

   5.  Talk to someone.  Find a friend, counselor, chaplain, etc. just to vent your thoughts and feelings.  For guys, let her talk without telling her what to think or how to feel, and without offering a solution unless specifically asked.

   6.  Make big decisions together with your partner.  This removes some of the stress especially if you aren't good or don't like making decisions.  

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Figuring Out Postpartum Depression

Unlike an infection, the symptoms of postpartum depression are not blindingly obvious.  It is not just a matter of thoughts or emotions but how intense they are and how long they last.  Your partner or friend has to take the extra effort to look beneath the surface and figure out what is really happening despite what you say.  It is a lot like playing poker.  What is mom really holding?  Is she playing straight or bluffing?   

PPD Risk Factors

The following are things that increase mom's risk of getting post partum depression.  Just because these things occur, doesn't mean that it will happen.  It is like insurance premiums.  You pay more for the red sports car than the green mini-van because of the increased chance of a claim even though you are a good driver.

   ● You have suffered depression before or has a family history of depression
   ● You had moderate to severe PMS before the pregnancy
   ● You are taking certain medications such as: blood pressure medicines and steroids.
   ● You had a difficult pregnancy or birth
   ● Your pregnancy was unplanned
   ● Your partner is unsupportive or often away from home.
   ● You are going through a separation or divorce
   ● You feel isolated by being home all day
  ● You are experiencing other serious life stressors such as

         Serious illness or recent death of close friend or relative
         Just moved to new place to live
         Recently changed jobs, quit or was fired
         Spouse is deployed

At the end of this book is a tracking chart that lists the symptoms of depression.  This will help you determine what is going on since the key issue is how long the symptoms last. 

See why you need a chart?  For most women only 3-4 of these symptoms will be a big problem, just as your fellow poker players will only have a few things that tell you they are bluffing.  Risk factors and a detailed description of each symptom follow. 

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The Symptoms of Depression

The symptoms of depression are the clues to what is going on inside mom's head.  You have to put the pieces of this puzzle together to get the full picture.  However, in this case some of the pieces are missing and you may have extra ones that go to another puzzle.  When evaluating the symptoms look for three things:

   ·  A big change from previous behavior—usually prepregnancy behavior. 
   ·  A smaller change that continues 4-6 weeks or longer.
   ·  Her statements not matching what she does or says at other times.

You will not have all the symptoms listed.  In most cases of depression only three or four will be significant problems though the number may increase as time goes by without treatment.  Some may go away and others appear.   

Everyone has good days and bad days.  The problem symptoms will probably be present even on the good days.  If you have more bad days than good, you can safely say that behavior is a symptom.

Finally, your sensing a problem is a good thing though it may be scary.  The hard part is when you constantly deny something is wrong though your actions are screaming for help.  Likewise it is hard when you deny something is wrong and there really isn't a problem.

The primary symptoms are

Irritability	Unable to experience pleasure
Crying/weepy/feeling sad	Loss/Increase of appetite
Feeling inadequate as a mother or wife	General guilt
Anxiety	Disinterested in sex
Feeling exhausted most of the time	Guilty or ashamed of her feelings
Lack of motivation	Concerned about intrusive thoughts
Difficulty sleeping	Worried you are going crazy
Difficulty concentrating	Afraid you will leave her
Ruminating thoughts	Worried it will never get better
Intrusive thoughts

Explanation of Specific Symptoms

Irritable:  A low tolerance for perceived stupidity, inconsideration or foolishness in others.  It includes a lower tolerance for frustration.  Your reaction to an incident may be excessive.

Crying/weepy/feeling sad:  This is often the reaction to frustration, feeling overwhelmed, or stressed out.  Women who normally avoid confrontation will probably have this reaction.  It is enhanced by the hormonal changes that are occurring.

Feeling inadequate as a mother or wife:  This is a common feeling especially if you doesn't have a lot of experience with babies.  “Advice” from relatives, magazines, women's shows, etc. may make you feel like a bad mother or wife. 

Anxiety:  This is excessive worry about stuff, especially things you can't control or inconsequential things.  You may describe your feelings as being nervous or having nervous energy.  Think of it as a super charged fight or flight reaction with no immediate outlet.  Physical actions may include pacing, hand wringing, talking, grooming, or other personal habits.  If you has had an anxiety attack before, you understand what is happening.  If not, it is harder to describe your feelings.

Feeling exhausted most of the time:  Taking care of a newborn is tough and because of their need to eat every 2-3 hours, most parents get little sleep.  Exhaustion is normal; however look for feeling exhausted even after adequate rest.

Lack of motivation:  Initially you will not be motivated to do more than the minimum.  Everyone has days when they just don't feel like doing stuff.  This symptom is a continuing lack of motivation where doing the simplest tasks around the house or for yourself (like bathing) seem an effort.

Difficulty sleeping:  This is not lack of sleep caused by the baby or being a “light” sleeper, but the inability to get to sleep despite being sleep deprived or exhausted.  It is also the inability to get to sleep after you have eliminated other causes such as caffeine, sugar or alcohol intake, doing serious thinking or exercise just before bed.  Often the trouble falling asleep comes from not being able to slow down or stop your thoughts which may be disorganized or racing.  Note: alcohol initially relaxes the body, and then it rebounds by being more alert.

Difficulty concentrating:  Trouble focusing on a task or organizing your thoughts.  Interruptions caused by the baby do not count.  Interruptions cause by other thoughts popping up in your head do. 

Ruminating thoughts:  These are thoughts that:

   ·  Repetitive thoughts that occur over and over with difficult stopping them.
   ·  Thoughts that preoccupy the mind push out other things.
   ·  Thoughts racing from one subject to another without much linkage.
   ·  Obsessive thoughts are similar to repetitive except that they cause more disruption and take over more time.

Intrusive thoughts:  This is a tricky area.  In this case intrusive thoughts are extreme thoughts that pop up out of no where and hang around a while.  You may fear that you will hurt yourself, hurt the baby, worry about a catastrophe or exaggerate the effect of a simple mistake.  The key is frequency.  An occasional thought during an emotional or frustrating time that dissipates quickly is normal. 

NOTE:  Do not ignore this.  If the thoughts increase or change to thinking about hurting yourself or the baby, Get help immediately.

Unable to experience pleasure:  This isn't about sex.  You doesn't get any pleasure from things you previously loved to do. 

Loss/Increase of appetite:  This can vary and many women may welcome the loss of appetite, if it helps them loose weight gained during pregnancy.  Watch for loosing weight too fast or ignoring a balanced diet.  You may also seek comfort foods to make you feel better.  A little doesn't hurt and it is normal to want to enjoy some foods without a little foot kicking your stomach.  Again look for a big change from previous habits.

General guilt:   Some women feel guilty over just about anything good in their lives or bad in someone else's.  You may not be able to forgive yourself for a simple, normal mistake in caring for the baby.  Look for guilt about minor things that cause no permanent harm

Disinterested in sex:  This one generally becomes a key symptom later than six weeks; though it may be high your partner's list.  After major abominable surgery or pushing a big baby through a small opening, most women are not immediately interested in sex.  Look for lack of interest in any intimacy such as cuddling, kissing, hand holding, massages, etc. Your lack of interest may lead to feelings of inadequacy as a wife and the fear that your partner will leave you.  This is one of those tricky areas where you need to talk and figure out a solution that works for both of you.

Feelings about Feelings

Some women spend a lot of time analyzing their own emotions and the emotions of others.  They read more into a situation that is really there.  You may start being concerned about your feelings soon after child birth.  In this case it is more a question of identifying what is normal instead of looking for a real problem. 

If you are concerned about your feelings at the four to six week mark, this is a good indicator that you need further evaluation by a doctor.  Remember that pain is an indicator of injury, fever an indicator of infection.  This concern about feelings may be an indicator of a physical problem known as postpartum depression.            

Guilty or ashamed of your feelings:  This is more specific guilt about having normal feelings such as frustration, irritability, being overwhelmed, exhaustion, feeling kind of down, etc. 

Concern about intrusive thoughts:   This may indicate that these thoughts are increasing in frequency and staying around longer.  If the fear you might do something changes to plans about doing harm to yourself or the baby or fear that you can no longer control yourself, you need to see the doctor immediately.  For partners and friends, the blunt approach is the best.  Asking if she has such plans will not give her ideas.  In fact it usually breaks the last barrier stopping her from seeking help.

Worried you are going crazy:  This generally associated with an overreaction when you are irritable, anxious, unable to sleep, have difficulty concentrating and experience ruminating thoughts.  Being worried about it actually indicates that you are not going crazy.

Afraid your partner will leave you:  This may or may not be rational since a new child and your behavior certainly puts a strain on your relationship.  Women tend to spend more time thinking about and analyzing relationships than men.  If you become preoccupied with this fear, it is a problem.  A casual mention of this is probably a request for reassurance. 

Worried it will never get better:  As these feelings persist longer you think they should, you can start to believe that you are doomed to stay this way. Your loss of hope does not make things easier.

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When You Think You have Postpartum Depression

The primary focus of this section is to help you figure out if you are suffering from postpartum depression.  This requires an open mind.  You may or may not be suffering from it.  You and your partner or friend's job is to identify the possibility and provide facts that a doctor or other health professional can use to make an evaluation.      The trigger points for seeking an evaluation are: 

   ·  Anytime you think you may harm herself or the baby.  This is more than fear that you might do it. 
   · Symptoms that continue just as strong or worse at the six week point. 
   · Symptoms that start showing up at the 4 and 6 week mark or later.
   · You have the “feelings about feelings” symptoms at the 4 or 6 week mark.
   · Your initial evaluation is more than 4 weeks after the birth of your baby and you have three or more symptoms.

An evaluation does not mean you are suffering from postpartum depression.  It means that you need a more professional opinion.  This evaluation may lead to treatment for a diagnosed problem or may provide reassurance that nothing is really wrong.

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What to Expect with Evaluation and Treatment

Getting to a doctor for evaluation is the biggest step.  An evaluation for postpartum depression should be part of you six week postpartum check up, but some doctors don't go in depth unless the patient asks about it.  Thinking about this before the appointment helps everyone involved.

The doctor will evaluate you by asking a series of questions.  The chart in the back of this book can help answer these questions.  The doctor may refer you to a specialist for further evaluation.  Other than “wait and see,” the treatment options are generally, medicines that help reset the brain chemistry, therapy to change views or a combination of both. Consistency and follow up with either approach are the keys to success.

Treatment for PPD will probably take 4 weeks or longer to see significant changes.  However, you may feel somewhat better immediately due to finally identifying the problem and doing something about it.  This isn't a cure but more relief.  

Medicines

The medicines are usually anti-depressants that affect the production and use of serotonin in the brain.  Most of the medicines get into the breast milk.  If you are breastfeeding, you must discuss this with your doctor or pharmacist. 

It commonly takes 4-6 weeks for the brain chemistry to readjust.  Currently the American Psychiatric Association recommends staying on the anti-depressant medicine for 6-9 months after you start feeling better.  This allows the adjustment of brain chemistry to become more permanent and prevent a relapse.  The decision to stop taking the medicine should be made with your doctor, since it is better to taper off than quit cold turkey.

The doctor may also prescribe anti-anxiety drugs.  While anxiety is often found with depression, its cause is different.  Anti-anxiety drugs should be used for a short time and taken only as needed. 

Any of these drugs can have side effects.  Some like a headache will go away after a few days.  Others like nausea require some tricks to manage them.  If the side effects are more than you can handle, go back to the doctor.  He may change the dose or prescribe a different medication.  A drug doesn't do any good if you don't take it because you feel worse when you do.  Ask your pharmacist about counter acting the side effects.

Therapy

Therapy is basically talking to someone who is skilled at asking the right questions and getting you to think about things.  It also helps you release pent up emotions and develop strategies to deal with your problems.  Psycho-therapy, talk-therapy and counseling are common terms for this. 

Most people don't know exactly why therapy works, but it does.  Not knowing the “why” is not such a big deal.  Doctors only figured out how aspirin works a few years ago, despite using it for centuries.

Therapists help the patient see things from a different angle, think in new ways and provide mental/physical techniques to make changes.  These new ways of thinking or different perspective may result in changes in brain chemistry. 

Therapy generally takes longer to see progress or feel better than medicines but produces more permanent changes.  After an initial evaluation, most therapists want patients to commit to a specific length and course of treatment.  Four to six months is not unusual.

Psychotherapists, Psychiatrists, Psychologists, Social Workers, Chaplains, and other counselors can provide these services.  The therapist should have training and experience in treating depression or postpartum depression.   For this to work you need to feel comfortable with the therapist.   

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What your partner or friend should do to help during treatment

   ·  Get her to see and talk to a doctor.
   ·  Don't let her slide on treatment—make sure she goes to appointments, takes her medicine, avoids alcohol, exercises, etc.
   ·  Do things to help mom get adequate rest.
   ·  Don't blame her for the way she is feeling, because she has little control over it.
   ·  Pick up the slack around the house if necessary, but don't let her wallow in self pity.  Even though she is suffering from depression, in most cases she can still function.  It will be just plain hard for her to do some things, but she still can. 
   ·  Encourage her to talk or vent.  All you have to do is listen.  She probably doesn't want a solution anyway.  This will be hard on you because guys generally want to fix things. 
   ·  Get her out of the house and do things she used to enjoy doing.  Do this even though she doesn't seem to want to.  With lack of motivation, the biggest challenge is to just get moving.  After treatment begins, enjoyment of these activities usually returns and provides a sign of progress toward getting better.  This in turn provides more hope and motivation to continue treatment.
   ·  Don't expect an overnight cure.  In some ways this was nine months in the making, so the solution will not happen in a week.

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Recovery

While treatment for postpartum depression takes a while, it isn't a lifetime commitment.  Things will get better.  You will have good days and bad days.  Then one day you will discover that this isn't a problem anymore and continue with the new normal that is your life.  You didn't really expect everything to go back to the way it was before you had a baby, did you.   

Symptoms Tracking Chart

Place a check or X in the appropriate block to indicate this symptom is present.  You could also rate it as

   1= mild (it is present but not really a problem)
   2= moderate (it is a problem, but your handling it)
   3= severe (it is a problem and is interfering with normal life)

The rating is not scientific, it just helps you judge if the symptom is getting better or worse.

The 2 week check should coincide with your baby's well baby check.  You will have to remember the check at 4 weeks on your own.  The 6 week check should coincide with mom's 6 week postpartum physical. You can use this chart to discuss postpartum depression with her doctor.

Click here for pdf version of the Symptom Tracking Chart

 

Symptom Tracking Chart Baby was born:______________
Symptom	2 wk	4 wk	6 wk	Comments
Irritability
Crying/weepy/feeling sad
Feeling inadequate as a mother or wife
Anxiety
Feeling exhausted most of the time
Lack of motivation
Difficulty sleeping
Difficulty concentrating
Ruminating thoughts
Intrusive thoughts
Unable to experience pleasure
Loss/Increase of appetite
General guilt
Disinterested in sex
Feelings About Feelings
Guilty ashamed or her feelings
Concerned about intrusive thoughts
Worried she is going crazy
Afraid you will leave her
Worried it will never get better

 

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