Postpartum Depression

Riza Angela A. Barazan

 Overview
• The report on Global Burden of Disease estimates the point prevalence of
unipolar depressive episodes to be 1.9% for men and 3.2% for women, and
the one year prevalence has been estimated to be 5.8% for men and 9.5% for
women.
• Women are at increased risk of mood disorders during periods of hormonal
fluctuation: the premenstrual, postpartum and perimenopausal.
 Postpartum depression (PPD)
• Postpartum depression (PPD), also called postnatal depression is a
clinical depression affecting both sexes that commences after giving birth. It
interferes with daily functioning and requires treatment. Treatment involves
counselling and/or medications.
 Epidemiology
• Postpartum depression is found across the globe, with rates varying from
11% to 42%. According to the National Institutes of Mental Health, studies
show that the childbearing years are when a woman is most likely to
experience depression in her lifetime – between 18 to 44 years of age.
• Wickberg and Hwang (1997) reported that Postpartum depression occurs in
approximately 10% to 15% of new mothers - African American mothers to
have the highest risk of PPD at 25% while Asians had the lowest at 11.5%. A
prevalence of depression of 12.5% at 8 weeks and 8.3% at 12 weeks
postpartum.
 Postpartum Psychiatric Disorders

• Postpartum Blues
• Postpartum Depression
• Postpartum Psychosis (PPP)
 Postpartum blues
• Postpartum blues or “baby blues” is a normal condition that does not require
treatment, occurs in 50%-80% of new mothers. Its symptoms include
feelings of loss, anxiety, confusion, fear and being overwhelmed. Occurrence
peak at 5 days after birth and resolve within a few weeks. Baby blues may
represent the initial stages of PPD/PPP.
 Postpartum Psychosis (PPP)
• Postpartum Psychosis is an acute mental disorder or a psychotic reaction
occurring in a woman following childbirth or abortion. It is relatively
uncommon disorder compared to the other maternal mental disorders (1-3
out of 1000 women). It is usually characterized by hallucinations, paranoia
and possible suicidal. PPP requires immediate treatment and possible
hospitalization.
 Postpartum Depression
• Postpartum depression is not as mild or transient as the baby blues but not
as severely disorienting as psychosis. PPD is clinically significant and requires
treatment.
 Etiology
Biological Factors
• Many studies suggest that hormonal changes may play a role. After childbirth, a dramatic
drop of estrogen and progesterone contribute to postpartum depression. Sudden decrease
in blood levels of estrogen and periods of sustained estrogen low levels correlate with
significant mood lowering.
• Alterations in hypothalamic-pituitary-adrenal (HPA) axis function attributable to
childbearing show remarkable similarity to those observed in depressed women (Wisner &
Stowe, 1997). Postpartum woman are also at increased risk for hypothalamic-pituitary-
thyroidal (HPT) axis dysfunction that may increase affective disorder vulnerability. The
development of increased sensitivity of hypothalamic dopamine D2 receptors in the
postpartum period appears to predict the onset of depression (Mclvor et al., 1996).
 Etiology

Psychological Factors
• Theories that predict causes for PPD include a poor marital relationship,
family stress, fewer support systems, stressful life events and fewer personal
resources (Logsdon, McBride & Birkimer, 1994). Low self-esteem was found
to be a reliable contributing factor to PPD in several studies (Chen, 1996;
Fontaine & Jones, 1997). Mothers with low self-esteem were 39 times more
likely to have high depressive symptoms than those with high self-esteem
(Hall et al., 1996).
 Risk Factors
• Previous history of depression and anxiety
• Risky pregnancy
• Low self-esteem
• Reducing social support
• Stress at home and at work
 Signs and Symptoms
• Depressed mood – often with spontaneous crying;
• Markedly diminished interest in all activities;
• Insomnia or Hypersomnia;
• Weight changes (increases or decreases);
• Psychomotor retardation or agitation;
• Fatigue or loss of energy;
• Feelings of worthlessness or inappropriate guilt;
• Diminished ability to concentrate;
• Suicidal idea with or without a suicidal plan; and/or
• Odd food cravings (often sweet desserts) and binges with abnormal appetite and weight gain (Shrock, 1994).
 Plan of care and Management
1. Psychotherapies: Talking therapy
• Psychological therapies (“talk therapy”) is to work with a trained therapist to
find ways to solve problems and deal with all forms of depression, including
postpartum depression. It can be a powerful intervention, even producing
positive biochemical changes in the brain.
 Guided self-help
 Cognitive Behavioral Therapy
 Interpersonal Therapy
 Guided self-help
• Guided self-help is where the mother work through a self-help workbook or
computer course with the support of a therapist. The course materials focus
on the issues woman might be facing with practical advice on how to deal
with them. The courses typically last 9 to 12 weeks.
 Cognitive Behavioral Therapy
• Cognitive behavioral therapy, or CBT, is a common type of talk therapy that
for some people can work as well or better than medication to treat
depression. CBT is based on the idea that how we think (cognition), how we
feel (emotion) and how we act (behavior) all interact together. Specifically,
our thoughts determine our feelings and our behavior. CBT aims to help
people become aware of when they make negative interpretations, and of
behavioral patterns which reinforce the distorted thinking.
 Interpersonal Therapy
• Interpersonal therapy (IPT) is a method of treating depression. IPT is a
form of psychotherapy that focuses on you and your relationships with other
people. It’s based on the idea that personal relationships are at the center of
psychological problems.
• Treatment usually begins with your therapist conducting an interview. Based
on the problems you describe, they can identify goals and create a treatment
outline. You and your therapist will focus on the key issues you’re looking to
resolve.
 Plan of care and Management
2. Administration of Anti-depressant drugs
• PPD is usually treated with antidepressant drugs. If the woman with PPD is
not breastfeeding, then antidepressants can be prescribed without special
precautions. The commonly used antidepressant drugs are often divided into
four groups: selective serotonin reuptake inhibitors (SSRIs), heterocyclics
(including the tricyclics – TCAs), monoamine oxidase inhibitors (MAOIs),
and other antidepressant agents not in the above classifications (Keltner &
Folks, 1997).
continuation..
• The SSRIs are prescribed more frequently today than other groups of
antidepressant medications. Ex. SSRIs:
• Fluoxetine (Prozac)
• Fluvoxamine (Luvox)
• Paroxetine (Paxil)
• Sertraline (Zoloft)
• Citalopram (Celexa)
• Escitalopram (Lexapro)
 Nursing Interventions
• Active – listen and identify client’s receptions of current situation.
• Emphasize the need for continued communication with a partner or a close friend who is
available.
• Encourage verbalization of fears, anxiety and feelings of depression.
• Discuss realities of parenting and the fact that it may be exhausting.
• Point out infant cues and explain their meaning. This helps her feel better about herself and her
ability to care for the infant.
• Include the spouse in discussions about the woman’s condition.
• Emphasize the importance of the mother taking the medication as ordered. Antidepressants are
often used for PPD and may be continued for 6 months or more.
 Case Scenario and Nursing Care Plan
• Case Scenario
Maria Rosales is a 39-year-old woman who gave birth to her first baby
daughter 6 weeks ago after a long history of infertility treatment and is
currently diagnosed with PPD. Maria says that she always feels exhausted. She
has a poor appetite and feels sad most of the time. Maria states that she loves
her baby, but she just doesn’t feel like a good mother.
 Nursing Care Plan
Cues and Evidences
• Subjective:
• “I am not confident with my parenting skills. I don’t feel like a good mother
to my baby.”
• Objective:
• verbalization of role inadequacy or frustration
• negative statements about oneself
 Nursing Care Plan
Nursing Diagnosis
• Impaired parenting related to low self-esteem secondary to Postpartum
Depression
 Nursing Care Plan
Specific objectives:
• At the end of my care, client will be able to:
• Report progress in her situation through verbalization of positive outlook
towards herself
• Affirms desire to develop parenting skills to support infant/child growth and
development
 Nursing Care Plan
Nursing Interventions
• Use active listening to explore parent's understanding of developmental needs and
expectations of child and self
Rationale: Interviewing with empathy while reserving judgment allows parent to more freely
express frustrations and disappointments regarding negative feelings, needs, and parenting skills.
• Spend time with the mother; set aside enough time so that the encounter is calm
and deliberate.
Rationale: Having enough time for the client conveys the nurse’s interest in and acceptance of her
feelings. A trusting relationship is an important factor in building self-esteem.
 Nursing Care Plan
• Present referral information about self-help groups and professional counselling.
Rationale: Professional counselling and self-help groups provide the client with more resources to
sustain the work of rebuilding positive self-esteem.
• Educate the patient about the harmful effects of negative self-talk.
Rationale: Recognition of unfavorable thoughts can lift the client to develop new techniques for
coping. The patient must replace negative beliefs and ideas with positive thoughts about self.
• Administration of anti-depressant as prescribed by the doctor.
Rationale: Antidepressants reduce symptoms of depressive disorders.
 Nursing Care Plan
Evaluation
• Reported progress in her situation through verbalization of positive outlook
towards herself
• Affirmed desire to develop parenting skills to support infant/child growth
and development
Questions?
Thank you!