Betty is eight years old, with bright afro hair and sad eyes. My wife, every time she sees her, tells her, “Betty, I love your hair. Give it to me!” To which she responds with a shy: “Do you like it?” And she lowers her gaze. Despite her young age, one looks at her and feels as if the girl is carrying a great weight.
Her mother committed suicide when she was four years old, a few months after giving birth to her second child. She soon began to show symptoms of depression and to reject the baby. The family was on notice, but at a time when she inevitably had to be left alone, she ended her life.
The balance of this story is the death of a young mother, who leaves behind two orphaned children, a widower and two torn families. It is also the extreme outcome of a condition that, although little known, affects millions of mothers every year: perinatal depression.
Depression and perinatal depression
Depression, as we saw in a recent article, is characterized by persistent sadness and a loss of interest in activities that used to be enjoyed. It is distinguished by the inability to carry out daily activities for at least two consecutive weeks. Time is an important indicator, as occasional episodes of sadness or a slowdown in our usual rhythm are normal, as long as they are resolved in the short term.
Perinatal depression (PND) is linked to the period between the beginning of pregnancy and the first year after the birth of the baby and encompasses both depression during pregnancy (DDP) and postpartum depression (PPD). Symptoms such as irritability, lack of interest, appetite or sleep disorders, and feelings of sadness, guilt, or hopelessness can start at any time during the perinatal period, leading in the most serious cases to destructive thoughts of the mother towards herself or her baby.
Although PND has characteristics similar to other depression symptoms, it differs in the emotional consequences that it can have not only on the mother but also on the child and the bond established between them.
In addition, it has been shown that the children of depressed mothers present deficits in their social development and difficulties in acquiring new knowledge, even as of three months of age. This puts them at greater risk of developing depression symptoms at an early age, which would become manifest in their interaction with others, their behaviors, and their temperament.
The degree of risk of these alterations in children is directly related to the severity and duration of the mother’s postpartum depression. Likewise, adverse effects of maternal depression have been documented in older children, such as difficulties in school and in the relationship with their peer group, low self-esteem and greater behavioral problems.
We have suicide as the tragic and extreme outcome of perinatal depressive manifestations. According to Dr. Moore Simas of the University of Massachusetts, “Maternal suicide surpasses hypertensive and bleeding disorders as a cause of maternal mortality.” This is especially important in high-income countries with strong health systems, where other causes of maternal death are less common.
Depression during pregnancy (DDP)
Pregnancy is supposed to be one of the happiest periods in a woman’s life. But it is undeniable that for many, pregnancy can be a stage of confusion, fear, stress and even depression. According to the American Congress of Obstetricians and Gynecologists (ACOG), between 14-23% of pregnant women will struggle with some symptoms of DDP.
The fundamental cause of the manifestation is the hormonal changes that occur, which can affect the functioning of the brain. This is exacerbated by difficult situations in the environment that surrounds these pregnant women.
The most common symptoms, and that the family should monitor, are the following:
- Persistent sadness.
- Difficulty in focusing.
- Sleep disorders (from insomnia to sleeping too much).
- Loss of interest in activities she used to enjoy.
- Recurring thoughts of death, suicide, or hopelessness.
- Feelings of guilt or worthlessness.
- Changes in eating habits.
The symptoms must remain for a period of time greater than two weeks. On the other hand, a series of factors can predispose to DDP, among them we have:
- Problems with the couple.
- Family or personal history of depression.
- Infertility treatments.
- Abortion in a previous pregnancy.
- Stressful events, such as the loss of a family member.
- Pregnancy complications.
- History of abuse or trauma.
Untreated DDP can lead to nutritional disorders, alcohol abuse, smoking, and suicidal behavior. These are causes of prematurity, low birth weight and problems in the development of the child. Babies born to depressed mothers may be less active, less attentive, or more restless than babies born to non-depressed mothers.
Treatment options for pregnant women with DDP include support groups, individual psychotherapy, light therapy,1 and medication.
There is controversy regarding the use of medications during pregnancy due to the risk that they are associated with problems in the newborn, such as malformations, heart problems, pulmonary hypertension, among others. Therefore, in cases of mild and moderate depression, its use should be avoided.
However, if a pregnant woman is facing severe depression, a combination of psychotherapy and medication is usually recommended. In these cases, risks and benefits are evaluated, and the medical team selects the most efficient drug with the least risk.
The largest volume of information available on the use of antidepressants in pregnancy is associated with Selective Serotonin Reuptake Inhibitors (SSRIs), sertraline, citalopram, and fluoxetine (FDA category C),2 which show little evidence of teratogenicity; that is, malformations in the baby, in relation to its use during pregnancy.
In addition, there are a series of measures that help improve symptoms, such as physical exercise, stable and sufficient sleep schedules, avoiding diets rich in caffeine, sugar, processed carbohydrates, artificial additives, and low in protein.
Postpartum depression (PPD)
PPD usually occurs during the first month after delivery, reaching peak intensity between 8 and 12 weeks after the baby is born. The world prevalence is between 10-20%, increasing to 26% among adolescent mothers and up to 41% of mothers with low socioeconomic levels.
There are a number of factors that predispose to the appearance of the condition, including:
- A manifestation of depression prior to pregnancy or during it.
- PPD in a previous pregnancy.
- History of episodes of sadness or depression during certain times of the month (related to the menstrual cycle) or during treatment with oral contraceptives.
- Close relatives with depression.
- Stressors, such as having relationship difficulties, financial problems, or being a single mother.
- Lack of support from the partner or family members.
- Problems related to the pregnancy (such as premature labor or a baby with birth defects).
- Mixed feelings regarding the current pregnancy (for example, if it was unplanned or abortion was considered).
- Problems related to lactation.
Biological conditions must be added. The sudden drop in hormone levels (estrogen, progesterone, and thyroid hormones) that occurs after childbirth, as well as lack of sleep, can contribute to the development of postpartum depression. In addition, there may be a genetic predisposition.
Early diagnosis and treatment of PPD are important for the mother and her baby. Women should see their doctor for episodes of sadness and difficulty doing their usual activities for more than 2 weeks after delivery or if they have involuntary thoughts about harming themselves or the baby. If family members and friends notice these symptoms, they should encourage the postpartum woman to talk to a specialist.
On the other hand, mothers can take some steps to combat feelings of sadness after having a baby:
- Rest as much as possible; for example, taking a nap when the baby is sleeping.
- Don’t try to do everything; for example, keeping a spotless house or making meals all the time.
- Ask family members and friends for help.
- Talk to someone (partner, family, or friends) about their feelings.
- Shower and groom whenever possible.
- Leaving the house frequently; for example, carrying out procedures, meeting friends or going for a walk.
- Spend quality time alone with your partner.
- Talk with other mothers about common experiences and feelings.
- Join support groups for women with depression.
- Recognize that at this stage it is normal to be tired, have difficulty concentrating and doubts about how to be a mother, and know that these symptoms are temporary.
As in DDP, in PPD the use of drugs is reserved for some cases due to the risk posed to the fetus by stopping breastfeeding due to the use of antidepressants. However, many of these drugs are considered safe during lactation. Among them, selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment in the management of postpartum depression: sertraline, fluoxetine, escitalopram, and citalopram.
In March 2019, Brexanolone, the first pharmacological treatment for postpartum depression, was approved. In an initial version, it would only be available for intravenous treatment, but there is already a pill with the same drug that could have a very favorable effect in patients with PPD. In Cuba, unfortunately, it is not available.
1 Light therapy involves exposure to light brighter than light from indoor environments, but not as bright as direct sunlight. To apply it, a special box is used that emits said light (phototherapy box). It is indicated for patients suffering from seasonal affective disorder (SAD), which is depression related to shorter days and less exposure to sunlight during the fall and winter months. This may be because light therapy replaces lost sun exposure and can help reset the biological clock (circadian rhythms), which controls sleep and wakefulness. Light therapy may be most effective if used first thing in the morning. Response to this therapy usually occurs in 2 to 4 days.
2 The Food and Drug Administration (FDA), which is the United States regulatory body for medicines and food, has established five risk categories for drugs during pregnancy (A, B, C, D, X). The categories are based on the extent to which the available information on these drugs has ruled out the fetal risk, compared to the potential benefits for the mother. They range from drugs that have been proven to have no risk to the fetus and can be used in any trimester (Category A), such as folic acid, to drugs that are contraindicated because they carry a risk that outweighs any benefit (Category X), like atorvastatin.
Category C drugs in animal studies have shown adverse effects on the fetus. However, there are no adequate or well-controlled studies in pregnant women, so they should be administered only if the potential desired benefit justifies the potential risk to the fetus. A large number of drugs are included in this category, especially those recently marketed, for which there is a lack of information.
Other childbirth-related psychiatric disorders
Postpartum dysphoria: it is a manifestation of anxiety, emotional lability, tiredness and sometimes depressed mood. Unlike PPD, it is transient and the symptoms are mild. It usually occurs between the fourth and fifth day after delivery and lasts for a few days. It disappears spontaneously during the first two weeks after childbirth. It occurs in 40 and 60% of women. Due to its transitory nature and the low intensity of the symptoms, it does not require treatment. If the symptoms persist or intensify, a depressive manifestation should be suspected.
Puerperal psychosis: it is considered a psychiatric emergency, 70% of women who present it have a history of bipolar disorder. It occurs in approximately 0.1 to 0.2% of women in the postpartum stage and there is a 4% risk of infanticide. The main risk factors are a previous history of postpartum psychosis or bipolar affective disorder.
It is a manifestation of sudden appearance; in most women, it occurs during the first two weeks after childbirth, although it can start up to the sixth month. It can start with insomnia or difficulty resting, irritability, mood instability, suspicious behavior, mistrust, signs of confusion, exaltation and/or mania, that is, repeated activities, such as washing hands, which evolve into sadness. After the initial phase, usually one week, delusions and/or usually auditory (hearing voices) hallucinations related to the baby appear.
This condition presents a high risk of suicidal or infanticide behavior, which is why, once diagnosed, it requires hospitalization and monitoring. Treatment includes mood stabilizers, neuroleptics, and benzodiazepines. Electroconvulsive Therapy (ECT) is a fast and effective treatment option.