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Postpartum Depression

Rebecca Horn, Amanda Franko, Kaylee Franzen, Shelby Fournier, and Mia Stana

Bitonte College of Health and Human Services, Youngstown State University

3749 Nursing Research

Ms. Randi Heasley and Dr. Danielle Class

April 09, 2023

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Postpartum Depression

Giving birth to a child can create a broad spectrum of emotions. It can be an exciting,

joy-filled moment. With this can come anxiety and fear, which can manifest into depression. It is

normal for a mother to go through the “baby blues,” which can cause mood swings, anxiety, and

difficulty sleeping. Some new mothers will experience a more severe and long-lasting form of

the baby blues called postpartum depression. Postpartum depression is a form of depression that

occurs within the first year of giving birth to a child. They are susceptible to the disorder during

this time in a new mother’s life. There are also a wide variety of symptoms of postpartum

depression.

PICO

This literature review was conducted to identify the benefits of screening for postpartum

depression. The following PICO question was formed “How do screenings and treatments for

postpartum depression influence outcomes for the mother and family experiencing postpartum

depression after birth?”

Search Strategy

Using EBSCOhost, a search was initiated with the terms postpartum and depression.

Other databases utilized include PubMed, Medline, and Cumulative Index to Nursing and Allied

Health Literature (CINAHL). Criteria for articles included those written in the past five years,

written in English, and published in academic or E- journals. The initial literature search

included 30,049 different articles. The group reviewed the articles and determined which met the

criteria and were relevant to screening for postpartum depression. The search strategy was

narrowed down to 10,646 to meet the criteria. More specific keywords were implemented to

narrow the search to a more manageable number. The study group implemented four different
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searches and completed them using different keywords. The keywords included were

“instrument-based screening” AND postpartum, postpartum depression AND risk factors, and

postpartum depression AND effects. The articles were narrowed down by the researchers from

there to the ten articles used in this research paper.

Symptoms of Postpartum Depression

There are numerous symptoms a woman may experience if they suffer from postpartum

depression. Symptoms of postpartum depression include “lack of interest, low self-esteem,

tiredness, sadness, sleep disturbance, loss of appetite, hostile attitude towards infants, self-blame,

and feelings of humiliation, with symptoms lasting at least two weeks'' (Liu X et al., 2021, p.

2666). Some other symptoms can be feeling hopeless, loss of energy, and panic attacks. These

symptoms can create many obstacles for a new mother. Postpartum depression can be extremely

taxing on new mothers. Many times, they will not allow themselves to feel this way. In some

sense, they feel as if their feelings are unwarranted. The birth of a child should be an extremely

joyous and happy occasion. Feeling depressed after giving birth can really bring them down even

more, causing a vicious spiral that is extremely tough to get out of.

Risk Factors For Postpartum Depression

Postpartum depression can happen for many reasons. There are things that can increase

the mother’s risk of developing postpartum depression. Some risk factors include “A history of

mood disorders, depressive symptoms during pregnancy, and a family history of psychiatric

illnesses are additional risk factors for postpartum depression.” (Srivastava & Singh, 2022, p.

525). Other risk factors include having a traumatic birth, relationship problems, and even

financial problems. The fact of the matter is that any mother can get postpartum depression for

any reason. While there are common grounds between cases of the disorder, many times it
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cannot be pinpointed directly. One of the biggest issues with postpartum depression is the fact

that it can be so sudden. Mothers may have a fantastic pregnancy with next to zero issues. They

can be excited for the new opportunities forthcoming and even excited for the pregnancy to just

finally be over. After they give birth, they may take a sudden turn towards depression that is

extremely difficult to pull out of. It is very important to keep a close eye on new mothers to make

sure they are mentally okay. And if they are suffering from a form of postpartum depression, it is

extremely important to be supportive and give them the help they need.

Current Screening Methods

Postpartum depression is often challenging to diagnose because many symptoms are

vague and misunderstood. Several screening tools have been developed to assist in the diagnosis.

Many of them are designed to be self-reported. The most widely used tool is the Edinburgh

Postnatal Depression Scale (EPDS). It consists of ten questions that are rated on a four-point

scale. On average, it takes five minutes or less to complete. It focuses on detecting depression

during the perinatal period, ideally before hospital discharge. It measures dimensions such as

anxiety without reason, feeling overwhelmed or miserable, difficulty falling asleep or staying

sleeping, sadness, loss of enjoyment or happiness, fear, episodes of crying, self-blame, loss of the

ability to laugh, and thoughts of self-harm within the last seven days. The maximum score that

can be achieved is thirty points. Mothers that score ten or more possibly have postpartum

depression or are at a higher risk for developing it. Those that score thirteen or above are likely

to have depression. Mothers with higher scores are monitored closely, and healthcare

professionals use clinical judgment to determine the plan of care. More tools exist and are

utilized less in practice. The Beck Depression Inventory (BPI) is a four-point scale comprising of

twenty-one questions. It focuses on the depth of depression and is not specific to postpartum
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depression because it encompasses multiple forms. It assesses components such as negative

feelings towards self, withdrawal from society, pessimism, changes in appetite and weight, loss

of satisfaction, and overall mood. Another tool is the Postpartum Depression Screening Scale

(PDSS). It is a five-point scale consisting of thirty-five questions. It observes seven dimensions

“sleeping and eating disturbances, anxiety or insecurity, emotional lability, cognitive

impairment, loss of self, guilt or shame, and suicidal ideation” (Alba, 2021, p. 37). The Patient

Health Questionnaire 9 (PHQ-9). It is similar to the Beck Depression Inventory because it

focuses on the severity of depression and is not specific to postpartum depression. It is a four-

point scale with nine questions. The dimensions measured consist of feelings of hopelessness,

changes in sleep or appetite, difficulty focusing, suicidal thoughts, and loss of interest in hobbies

and activities. The score is rated on a scale of zero to twenty-seven, and the severity is

determined based on the scale. The higher the score, the more severe the depression is.

Those Responsible for Screening

Screening for Postpartum depression is recommended but not required. There is no

standard for who oversees the screening process. Nurses, nurse practitioners, physicians,

pediatricians, social workers, and mental health providers are involved. Nurses have the most

significant opportunity to screen and assess for postpartum depression. They are typically

involved with the patient from admission to discharge. In addition, nurses “are involved in the

earliest part of postpartum care, placing them in a unique and optimal position to screen”

(Logsdon et al., 2018, p. 324). Nurses see patients in various settings, such as the community,

obstetric offices, pediatric offices, hospitals, and birthing centers. They spend the greatest

amount of time with the patient and can collect both subjective and objective data about the

mother. Nurses have more opportunities to assess and monitor for symptoms of postpartum
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depression, the physiologic state of the mother, bonding, and maternal mood. They build rapport

with the mother and earn their trust. This in turn helps build deeper connections and

relationships. Nurses can recognize postpartum depression and refer mothers to a multitude of

resources in the community, support groups, and involve social work. Nurses provide education

so new mothers can better understand and recognize the signs and symptoms of postpartum

depression.

Effects of Postpartum Depression on the Mother and Infant

Postpartum is a difficult period for mothers, and in some cases, this results in postpartum

depression. Even though postpartum depression may be temporary, it has lasting effects on the

mother and, consequently, her infant as well. Effects that can become lasting for the infant

include lower infant weight gain and weight faltering during the first four months after birth,

poor infant motor development by fifteen months, stunted growth at two years, higher rates of

morbidity when monitored for the first four years due to gastrointestinal and lower respiratory

tract infections, poor cardiac function in their children aged nine and a half years, poor child

behavioral and cognitive outcomes, correlating with behavioral problems at eighteen months,

reduced interpersonal functioning at nineteen months, behavioral problems at two years and

lower cognitive ability at age four (Meyers, 2018). These effects do not just affect the child

immediately after birth but can have effects that can last years after. In some instances,

postpartum depression can start as acute and turn chronic. Chronic cases have higher rates of

lower employment, lower income, and a higher incidence of involvement with federal assistance

programs and child protective services (Mink, 2018). Although these programs are designed to

help, they can also lead to self-esteem struggles and altered family situations. Child Protective

Services can also lead to family separation if the living conditions are unsafe. To continue, the
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mother can unintentionally neglect her child and her own body. Suicide is one of the risk factors

that can come from postpartum depression. Sometimes, the mother may feel that the only way

out of the darkness she is experiencing is to commit suicide. The mother’s body has undergone

significant change, and without proper support and screening, it can lead to mortality.

Postpartum depression affects not only the mother experiencing these dark feelings but also has

lasting consequences on the infant under her care.

Effects of Postpartum Depression on the Father and Families

Postpartum depression does not only affect the mother and infant. It can affect the father,

who may also be struggling with the addition of a new infant and the responsibilities of

parenthood. It can affect the other children, grandparents, and friends around the family system.

Postpartum depression is more than a woman’s struggle, as many fathers may also have

symptoms. They are similar in the male partner’s experience except for some distinct features.

Symptoms include feeling overwhelmed, experiencing neglect in their partner relationships, and

resenting the baby. Several have pressure placed on them to conform to gender expectations. One

study investigated the experience of twenty-seven fathers struggling with postpartum depression

and discovered that some of the challenges they dealt with included trouble concentrating at

work, feeling challenged in their ability to support the family, and feeling as if they were on the

edge of bursting into tears (Alba,2021). In addition, there are several risk factors that put fathers

at risk for being affected by postpartum depression. Those factors include unemployment, lack of

sleep, financial stress, and poor domestic relationships.

Maternal and Paternal Leave Effects on Postpartum Depression

One of many factors that interact with the incidence of postpartum depression is parental

leave from work, whether it is too long, too short, or insufficient time to fully acclimate to the
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responsibilities of a new child added into a family system. The average length of maternity leave

is ten to twelve weeks. The typical length of paternity leave is one week but can less commonly

be up to ten to twelve weeks, like maternity leave. In the aspects of postpartum depression, it is a

big difference between the ten to twelve weeks and one week. The mother, in most cases, only

receives assistance from the father for one week. Then she must care for her new infant and any

other children, animals, or family members that live in or around her household by herself. This

also points to the fact that maternity leave and extended paternity leave are usually unpaid. The

factor of unpaid leave also implies financial hardship in the relationship of spouses going

through this change in life. A new infant in the family adds a considerable amount of stress to a

family. Maternity and paternity leave can also incorporate into causes of postpartum depression

because they are often unpaid. Ineffective coping, financial hardship, and relationship strain are

risk factors for postpartum depression. Ineffective coping is related to depression in either the

mother or father before, during, or after pregnancy. Financial hardship is related to hospital bills,

new child items, reduced work during pregnancy, reduced work due to spousal hospitalization

during pregnancy, and the expenses of other children, on top of monthly bills and the costs of

basic human needs. Furthermore, relationship strain occurs not only during the pregnancy or

postpartum period but can also be a previous feature of the relationship. Sleepless nights,

financial stress, and figuring out responsibilities and teamwork needed to raise a child or family

can all affect a relationship. Another factor would be cases of domestic violence. It increases

rates of postpartum depression because of the nature of the abuse. It creates an unhealthy

environment for the partner experiencing abuse or the child or children living in the household.

Psychological Treatment Interventions for Postpartum Depression

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Evidence-based research has shown that psychotherapies have been effective in reducing

the symptoms of postpartum depression. When breastfeeding, mothers may want to avoid

pharmacological interventions, which may be a barrier to one seeking treatment for postpartum

depression, but psychotherapy has proven to be effective. The first form of psychotherapeutic

therapy is interpersonal therapy which is used to focus on the relation events/persons have to

symptoms of depression (Alba, 2021). This therapy effectively improves the relationship

between the child and mother and other interpersonal relationships. “Kierman and colleagues

describe interpersonal therapy as addressing four common problems- grief, loss, role disputes,

role transition, and interpersonal deficits that are associated with the onset of depression.” (Alba,

2021). Another beneficial form of psychotherapy is cognitive behavioral therapy (CBT). It

combines cognitive and behavioral therapy to identify a correlation between postpartum

depressive symptoms. CBT goes more in-depth into why one may feel a particular emotion and

utilizes coping mechanisms to control these emotional challenges. Systematic reviews concluded

that CCB was effective in reducing the symptoms of postpartum depression and the likelihood of

remission increased (Alba, 2021). Another psychotherapy treatment for those struggling with

postpartum depression is somatic therapy. This form of therapy may be utilized to treat post-

traumatic stress and connect mind and body, like cognitive behavioral therapy. Electroconvulsive

therapy (ECT) is a somatic therapy that can be used to treat severe postpartum depression such as

intractable suicidality or psychotic symptoms (Stewart & Vigol, 2019). ECT treatment uses

electrical currents sent to the brain to create a surge, or seizure, that has effectively reduced

symptoms of mental illnesses. Due to ECT treatment requiring anesthetic which can have

neurological side effects, it may not be an ideal treatment for most women (Stewart & Vigol,

2019). Alternative therapies such as yoga, meditation, aromatherapy, and massage are other
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options a mother struggling with postpartum depression can benefit from. Studies have shown

that “used in conjunction with traditional medicine, alternative therapies have been found to

alleviate stress, anxiety, and depression in women both during pregnancy and after pregnancy.”

(Alba, 2021, p. 38). Herbal supplements can be added to drinks, such as lavender, chamomile, or

ginseng. Lavender particularly has been shown to have positive benefits for mothers and infants

(Alba, 2021).

Pharmacologic Therapy for Postpartum Depression

Pharmacologic interventions to treat postpartum depression may be used in addition to

psychotherapeutic treatment or on their own. The greatest concern for breastfeeding mothers is

the safety of medications for infants. The first-line treatment is selective serotonin reuptake

inhibitors (SSRI) which work by blocking the reabsorption of serotonin into nerve cells, thereby

increasing its levels in the brain (Alba, 2021). SSRI drugs pass into breast milk at a safe level

compatible with breastfeeding. (Stewart & Vigol, 2019). Therefore, a mother may be prescribed

paroxetine (Paxil), citalopram (Celexa), escitalopram (Lexapro), sertraline (Zoloft), or fluoxetine

(Prozac). If SSRIs are ineffective, another pharmacologic option safe for breastfeeding is a

serotonin and norepinephrine inhibitor (SNRI). The action of SNRI drugs is to block the

reabsorption of the neurotransmitters serotonin and norepinephrine into nerve cells (Alba, 2021).

Commonly prescribed SNRIs include desvenlafaxine (Pristiq), duloxetine (Cymbalta), and

venlafaxine (Effexor). This category of drugs is usually considered if all other SSRI drugs are

ineffective to the mother because SNRI drugs are categorized as L3 which are assumed to most

likely be compatible with breastfeeding but very limited data to support their use (Alba, 2021).

New drugs are currently being evaluated to treat postpartum depression. One of the first drugs to

be approved by the US Food and Drug Administration for the treatment of postpartum
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depression is brexanolone (Zulresso) (Alba, 2021). One will receive this drug IV route over sixty

hours, and it has been shown to have a lasting, positive effect thirty days after treatment. The

mother will take a series of surveys, one pre-treatment, some during the treatment, another

following the treatment, and one thirty days post-treatment. These surveys are conducted to

determine how quickly the effects are felt and how long they last. Thus far, the drug has proven

to be more effective with minimal side effects such as minor dizziness and somnolence. (Stewart

& Vigol, 2019).

Conclusion

In conclusion, women suffering from postpartum depression, as well as their partners and

families, are significantly affected by postpartum depression. It is imperative to identify high-risk

individuals so that preventative interventions can be developed and evaluated. Interventions and

screening tools used during pregnancy and the postpartum period have been proven effective

when treating mothers affected by and exhibiting signs of postpartum depression. Preventative

interventions, including the EPDS, BPI, Postpartum Depression Screening Scale, and PHQ-9,

assess the risk of developing postpartum depression. Several studies on children’s

socioemotional development show that the child’s development is adversely affected for years

after the mother has experienced the disorder. As a result of further research, screenings have

allowed struggling mothers to receive effective postpartum depression treatments sooner than

mothers who did not, resulting in their children and families being less negatively affected.

Treatment options, including psychological therapies and pharmacological, continue to be further

developed, focusing on primarily treating postpartum depression.

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