Postpartum depression is an affective disorder caused by adaptation to the role of the mother and hormonal changes in the woman’s body. It is manifested by a depressed mood, unreasonable tearfulness, anxiety, irritability, increased vulnerability, fears about the child’s health, and uncertainty about one’s own care and education skills. Diagnosis is made with a clinical interview and specific questionnaires to identify depression. Treatment is complex and includes the intake of antidepressants, tranquilizers, psychotherapy and counselling by a psychologist.
F53.0 Mild mental and behavioural disorders relating to the postpartum period, not elsewhere classified
The first descriptions of postpartum depression were found in the writings of Socrates (700 BC). However, official medicine did not recognize this disorder as an etiopathologically distinct entity for a long time. Currently, psychotherapeutic support for women after childbirth is provided at women’s clinics, psycho-neurological clinics and private clinical centers. According to official statistics, the prevalence of depressive disorders in the postpartum period is 10-15%. But due to the fact that many cases go unnoticed by specialists, the real figures may be higher. Supposedly, emotional disorders occur in 50% of young mothers.
Emotional disorders in the postpartum period develop under the influence of several factors. A woman’s body undergoes stress during childbirth, her hormonal background changes dramatically, a new social role of the mother appears, and her home and family relationships are restructured. There are many reasons for the formation of depression, the most common are:
- Heredity. This factor includes features of the nervous system that determine the body’s ability to adapt to physical and psychological stress. There is an inherited predisposition to melancholy and depression.
- Hormonal shifts. Progesterone and thyroid hormone production is reduced, synthesis of prolactin increases. Active endocrine restructuring affects the work of the CNS, provoking emotional instability, a decrease in performance, and depression.
- Changes in the social situation. The role of the mother implies the fulfillment of certain functions, a restructuring of the way of life. The source of depression becomes fear of incompliance with the expectations of others and your own image of an ideal mother, a lack of interesting events and communication.
- The complication of everyday life. After the birth of a child, new responsibilities are added to a woman’s usual duties: care, feeding, visiting doctors, upbringing. Exhaustion and depression are formed as a result of the lack of time to restore moral and physical strength.
- Deterioration of marital relations. The infant requires constant attention, and both parents become tired more often. The sexual sphere of life is limited for the period of recovery of the woman’s body. All this becomes the reason for more frequent quarrels, emotional coldness of spouses and increases the risk of depression.
The origin and development of postpartum depression is considered within the framework of the polyethiological theory. According to this approach, the emotional disorder is formed by the combined influence of three factors: heredity, specific physiological changes, and psychosocial features. The preponderance of mothers with depression have a constitutional predisposition – a weak unstable type of higher nervous activity, reduced production of neurotransmitters responsible for emotion and performance (serotonin, dopamine, noradrenaline).
Specific physiological mechanisms underlying the disorder are an abrupt change of hormonal background (termination of pregnancy), pain and other discomfort associated with the childbirth process. A common psychosocial factor provoking depression is a change in a woman’s role, reduction of time for usual pleasant activities, the need to take care of an infant around the clock.
Symptoms of postpartum depression
The general manifestations of depressive disorder include depressed mood, gratuitous fickleness of emotions, tearfulness, irritability, decreased motivation to any activity. Sleep disorders are manifested by insomnia or excessive sleepiness. Appetite becomes excessive, up to and including gluttony, or disappears completely. Subjectively, women experience a sense of worthlessness, blame themselves for their inability to perform the functions of a mother, in the absence of affection and love for the child. They experience an inability to concentrate on household chores and are unable to make independent decisions in daily activities. They withdraw from habitual communication, from contact with close people. In a severe course of depression, thoughts of inflicting harm upon themselves and the child arise.
There are several forms of postpartum depression according to the nature of the course. When the neurotic version of the disorder is an exacerbation of negative experiences that appeared during pregnancy and labor, for example, provoked by the threat of miscarriage. A characteristic symptom is increased anxiety. Patients are in constant expectation of a bad event (illness, the baby’s death, family dissolution). Tension manifests itself through irritability and dysphoria. Women become irascible and sometimes aggressive. In severe cases, panic attacks, hypochondria, headaches, and retrosternal pains, attacks of tachycardia, sweating, and shortness of breath develop. The condition gradually worsens during the day, by evening there is mental and physical exhaustion – loss of strength, weakness, apathy, inconsolable crying.
In depression with neurotic components, somatic disorders develop as the main symptoms. Emotional experiences are rejected by the patient as unacceptable, shameful. Insomnia, decreased appetite and weight loss come to the fore. Often there is a compulsive fear of harm to the child, hypercontrol over his or her condition. Such a disorder is based on the influence of psychologically traumatic situations before and during pregnancy.
Another variant of depression is melancholia with a delusional component. The key symptoms are psychomotor retardation and a feeling of guilt. Women acutely experience an imagined inadequacy, call themselves a “bad mother. Self-blaming, self-deprecation and suicidal tendencies prevail. This form of disorder is capable of developing into a more severe illness – postpartum psychosis.
The most common variant of depression among young mothers is the protracted form. It runs masked, often perceived by patients as fatigue, moping, adapting to the child’s regimen and the role of the mother. The development of symptoms is slow, so referral to specialists is extremely rare. Women experience weakness and exhaustion, which are mistakenly associated with the experience of childbirth and blood loss. Tearfulness and irritability increase, and it is difficult to tolerate waking up at night to feed the newborn. Caring for the child is burdensome, but a critical attitude to one’s own experiences persists.
Any form of depression in the mother reduces the level of emotional intimacy between her and the infant. Alienation, absence of love and affection interfere with the formation of a feeling of basic safety, which later serves as a basis for mental diseases in the child. A woman’s concentration on her own worries often results in a lag in the mental development of the baby (lack of stimulation, organization of play). The most severe complications occur with untreated melancholic depression. Self-blaming ideas and pathological fears develop into persistent delusions, suicide attempts and maiming of the child – postpartum psychosis develops.
Postpartum depression is most often formed in the first months after delivery, and the duration of the disorder is individual: from several weeks to several years. The initial examination is performed by a psychiatrist, and consultations with a psychologist and gynecologist (endocrinologist) may also be prescribed. The following methods are used in the complex approach to diagnosis:
- Clinical and anamnestic. The doctor determines the patient’s anamnesis, analyzes complaints: asks about the presence of depressive symptoms before pregnancy, mental disorders in the patient herself and her closest relatives. Determines the financial status of the family, the composition and nature of relationships, and peculiarities of the course of the prenatal and natal period. Complaints of decreased mood, anxiety, apathy, weakness and tearfulness serve as confirmation of the diagnosis.
- Psychodiagnostic. Among specific instruments, the use of the Edinburgh Postnatal Depression Scale is common. It belongs to methods of express-diagnostics and allows revealing the depth of an emotional disorder. The Montgomery-Asberg Depression Rating Scale, Hamilton Scale, Beck Self-Assessment Scale, personality questionnaires (SMIL, Eisenk’s test and others) are used to determine more precisely the nature of a patient’s experiences.
- Laboratory. If endocrine disorders are suspected, the psychiatrist needs to confirm or exclude them as a cause of depression. A consultation with an endocrinologist is prescribed, and blood tests for thyroid and sex gland hormones are performed. Depression can be triggered by low levels of thyroxine and progesterone.
Treatment of postpartum depression
Help for mothers with depressive disorder is determined by its severity: with a mild form, consultations by a psychologist or psychotherapist are sufficient; with moderate symptoms, psychotherapy sessions and medication correction are recommended; with severe illness, hospitalization, intensive drug therapy and psychotherapy are required. The entire spectrum of medical and psychological support includes:
- Psychological counseling. With mild symptoms of depression, the patient’s own resources are used – the ability to relax, maintain a high level of energy, and organize interesting pastimes. The patient is advised to exercise, massage, and delegate the care of the infant to grandmothers, her husband, or a babysitter.
- Psychotherapy. Techniques of the cognitive-biocognitive and psychodynamic direction are widely used. During sessions, personal conflicts and destructive attitudes toward maternal functions and feelings (always showing love, thinking only of the child) are recognized. Ways to restore and optimize marital relations are discussed.
- Medication therapy. From medications, antidepressants, tranquilizers and hormonal drugs are prescribed. The former normalize the emotional state, eliminate anxiety and depression. The need for hormonal medications is determined individually. Estrogens and thyroxine preparations are prescribed.
- Social support. At low-grade postpartum depression in the recovery stage, women need psychological and social support in informal conditions. For this purpose it is recommended to attend group meetings of mothers, training courses on nursing a baby, independent organization of joint walks by mothers. This function can be partially performed by the home nurse, the district pediatrician.
Prognosis and prevention
Postpartum depression is successfully treated, so the prognosis is often favorable. Prophylaxis should begin several months before childbirth. It is recommended that you learn relaxation techniques – breathing exercises, gymnastics, auto-training (self-hypnosis). Regular exercise should become a habit, because when depression approaches, there is no strength for new endeavors. It is worth discussing in advance with your husband, mother, mother-in-law the readiness to help (volume, frequency, duration). In your daily and weekly plan, time should definitely be allocated for activities that bring pleasure, joy, contribute to an increase in self-esteem – dancing, massage, spa treatments, meetings with girlfriends.
1. Postpartum depression / Garnizov T., Khadzhideleva D.// Bulletin of Pedagogy and Psychology of South Siberia. – 2015.
2. Postpartum depression as a central problem of early maternal mental health / N.A. Kornetov // Bulletin of Siberian Medicine. – 2015.
3. The role of psychological and physiological conditions of motherhood in the development of postpartum depression / Yakupova VA // Russian Psychological Journal. – 2018.
Stress after childbirth: let’s consider in general terms
Svetlana Valeryevna Zolotareva Perinatal psychologist, head of the School of Maternity at the maternity hospital at the Yudin State Clinical Hospital
13% of mothers experience postpartum depression . Depression, apathy, anxiety, guilt, fatigue – many women ignore these symptoms, and society censures those who do not experience the joy of motherhood. Meanwhile, depression can and should be treated, and even better – warn, time to notice the alarming signals.
The birth of a child – a new reference point in her life. Everything changes:
- Social role: together with the child, the woman is born as a mother herself. New tasks, duties, responsibilities arise.
- The body: during pregnancy we “rent it out”. Carrying and giving birth is a risk to life, it is always associated with anxiety.
- Hormonal status: during pregnancy a huge amount of hormones are produced, and after delivery their levels drop sharply. This causes mood swings.
There is such a concept as baby blues – a depressed state that occurs two or three days after delivery and lasts up to three weeks. It’s a natural history associated with hormonal restructuring. It may manifest simply as tearfulness: a woman looks at the baby, everything seems fine, but her tears are flowing. Or a more complicated case: the birth was normal, the baby was welcome – and then comes the realization: this is forever, and with it something has to be done. It seems that you are incompetent as a parent, that nothing is working out. There can be jealousy of nurses and grandmothers (“With them, the child keeps quiet, and I cry”), envy of “older” mothers.
It passes in two, maximum three weeks. And postpartum depression begins about a month after delivery, when it seems should “let go”. The second option – in 7-8 months. By this time fatigue, lack of sleep, feelings of misunderstanding on the part of loved ones accumulate.
There are things that should alert the mother and her relatives. Not necessarily all of this list.
○ Sleep disturbance: you either stop sleeping because you are overloaded and overexcited, or you sleep all the time.
○ Systematic nervous breakdowns – anger, aggression toward loved ones and/or the child.
○ Feelings of hopelessness (“Why have children at all”, “Life is over”).
○ A child is not happy, not even a smile is a cure.
In the first year of life, the foundation of the psyche is laid, a basic trust in the world is formed. Mom is a reflection of the world. Through her reactions, she shapes the baby’s self-image and makes him realize that he is loved and needed.
Depressed women are usually emotionally detached. The child divides into a “living” and “dead” mother: she seems to be there, but she is “cold”, “undead. All his life, he will be looking for a warm, sympathetic person who can love him.
In childhood, such children are more anxious. They may cry a lot, get sick more often, and their absorption of nutrients may decrease. Sometimes this progresses to psychosomatic illness.
Self-confident moms have it easier than anxious ones who control themselves, their husband, their doctor, God. Such people can be overwhelmed by despair that it won’t be like before, freedom is over, Groundhog Day has begun.
“There is evidence that women who give birth using epidural analgesia are less likely to suffer from postpartum depression.” 
Sometimes there are endocrine disorders: deficiencies in the neurotransmitters serotonin, norepinephrine, and dopamine, and vitamin B12 deficiency. There can also be an exacerbation of psychiatric disorders that existed before pregnancy.
Women who have had a difficult, painful birth and have experienced midwifery aggression are at risk. This is a very traumatic experience that leaves a mark on the psyche.
And another important factor is the lack of support from loved ones.
I often remind women who have given birth of the “three C’s” rule: Make your baby full, calm and dry – and you are a good mother. And your mother or mother-in-law should make a well-fed, quiet and dry you! Make soup, wash the floors, praise. Ask, “What can I do to help?” Ask to cook food – cook it, but not what you think you need, but what mom is allowed to eat.
- Give a young mother the necessary dose of attention during the day. Sometimes you don’t have to rush to the rescue, just listen
- Master baby-related household tasks, so that she can change diapers, put her down, change her clothes on an equal footing with her mother.
- If a woman is having a hard time, but she refuses to go to a psychologist, go to him yourself. A specialist will give you instructions on how to behave and what to say.
- Recognize a woman’s right to fatigue. No “You have to love the child” and “Didn’t you know what you were going for?”
- Don’t compete with mom for success with the baby.
In a state of psychosis, don’t be afraid to call hotlines. Have a psychologist’s contact handy. It is good if it is a perinatal psychologist: he knows how to work with women who have given birth and are pregnant, because this is a borderline state of the psyche due to hormonal changes.
The Institute of girlfriends and mothers does not always save, because there is no complete acceptance. A psychologist is the most neutral person who will accept you with your tears, anger, frustration and will not criticize you. He will admit: yes, you feel bad, but you are not alone. Will help replenish internal resources, find the root causes of difficulties, change your way of thinking, and get on with your life.
If the depressed state has lingered, there are manifestations such as sleep and appetite disorders, suicidal thoughts, psychosis, apathy, it is worth visiting a psychiatrist. This is not terrible: there are specialists who work with mothers and even pregnant women. With depression, it is most effective to work with both a psychiatrist and a psychologist.
You have to understand: mothers are not born, they become mothers. After all, you are learning a new profession – a nurse. If you view the current situation as a development, including professional development, it can give you support.
Where to contact?
● +7 (495) 989-50-50. Emergency Psychological Assistance Center of the Russian Ministry of Emergency Situations.
● www.msph.ru. Moscow Psychological Aid Service (free psychologist appointments and online consultations are available).
● (495) 051 (from cell phone) and 051 (from city phone). Emergency telephone numbers for psychological help in Moscow.
● Take Care of Yourself. Facebook support group for moms with postpartum depression (and not only).