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The New Therapist
with Anthony D. Smith, LMHC

Signs of Major Depression Subtypes: Peripartum Onset

Not all mothers with newborns have the pictured, smiling experience. How could such a joyous occasion become so warped? It’s most likely hormonally-influenced and compounded by social stressors (Chisholm, 2016), and it engenders one of the most poignant cases of mental illness’s ripple effect in a family. Babies born to depressed mothers often develop attachment issues, don’t develop  as normal, and may even have failure to thrive (Langan & Goodbred, 2016).

What was historically known as postpartum (after birthing) depression has been re-termed peripartum (around the time of birthing) depression. This is because it has been recognized that the onset of the depressive episode often tends begin in months prior to birth. Just like MDD with Seasonal Onset is different from the “winter blues,” so is Peripartum Onset different from “baby blues.” It is not merely some lethargy and feeling a little moody, which occurs in up to 80% of women after giving birth (Barlow & Durand, 2015). Peripartum Onset is a maternally-experienced Major Depressive episode that initiates around the time of giving birth. Estimates vary, but hover around 7-10% of mothers experiencing Peripartum Major Depression.

Peripartum Onset obviously only applies to female patients and is the most common perinatal disease (Hübner-Liebermann et al., 2012).  Like Seasonal Onset, Peripartum Onset, may be the only time the woman becomes depressed, or she could experience other MDD episodes throughout her life. A cursory look at research clearly indicates that having a history of MDD in general, or even a family history of MDD, puts mothers-to-be at risk of a Peripartum episode. Under the influence of significant hormonal upheaval, depression-prone women are ripe for evolving an episode. It is noted in the Diagnostic and Statistical Manual of Mental Disorders, Version 5 (DSM-5) that approximately 20% of women with Peripartum Onset MDD also experience Psychotic Features.

The presentation:

MDD in women with this specifier tends to be marked by crying spells and fatigue that is beyond what’s expected of normal duties caring for a baby. Intense ruminations of worthlessness/inability to be a good mother and anxiety is often present. Take the case of Peggy:

Peggy always wanted to be a mother. Now, at age 28, married and happily settled with good careers, she and Andy were ready! Peggy’s pregnancy was uneventful until the last month when excitement turned to anxiety, and she found herself sobbing periodically. The pregnancy “glow” seemed to have drained from her as she worried about if she’d have what it took to be a champion parent. She thought perhaps she was just expecting too much of herself. Despite reassurance from Andy and her family and friends, Peggy got sulky and wanted to avoid the rest of the pregnancy. “This is just great! I can’t stand being pregnant anymore. Does that mean maybe I don’t even want a baby? Maybe I’m a bad person,” she berated herself. Her mind reeled with anxieties about what Andy may be thinking and that she is burden on him. “I’ll be ruining the lives of all off us,” she sobbed to her mother, Alice. Alice phoned Peggy’s midwife, who had been very helpful. The family attended an office visit, and, suspecting peripartum depression, the midwife referred Peggy to her Ob/Gyn. Peggy’s medical exams came back normal, and the doctor referred her to a psychiatrist specializing in pregnancy.

The DSM-5 criteria for Peripartum Onset is straightforward:

  • A Major Depressive episode beginning either during the pregnancy or up to one month after giving birth (some researchers believe that Peripartum Onset can develop months afterwards, however).

Treatment Implications:

As noted, Psychotic Features can be present in Peripartum Onset MDD and are associated with infanticide. Mothers may hear voices to harm the baby or develop delusions that the baby is possessed and must be killed, for example. Working with someone with acute Peripartum depression must include monitoring for Psychotic Features.

Given the correlation between a history of MDD and Peripartum Onset, therapists should carefully monitor pregnant women with a history of MDD. Should symptoms arise, the therapist will do good to intervene with not only psychotherapy, but in being the conduit for further services. Various researchers have found that certain antidepressants can be safe and highly effective in Peripartum Onset MDD (Harvard, 2011). Some researchers have found that light therapy similar to that for Seasonal Onset can also be beneficial to expecting mothers. Therefore, referral to a psychiatrist specializing in pregnant women, or an Ob/Gyn with psychiatric interests, is ideal. The patient’s Ob/Gyn should always be informed of  her state given the effects it can have on the mother and child. They can also screen for if the depressive symptoms may be better accounted for by anemia or thyroid issues that developed during pregnancy.

As for psychotherapy, there is a good chance material will focus on the patient’s ability to mother. Perhaps she has reservations because she feels she will mirror her parents and give the child a poor upbringing. Perhaps there is no obvious reason aside from the angst of all that coming with being a new parent brings. It is not unusual for couples to attend therapy, as having a depressed partner amidst a newborn in the home can cause turmoil and added stress.

At it’s worst, like other varieties of MDD, Peripartum Onset may require inpatient care and even ECT, especially is Psychotic Features are present. Very often, psychotherapy with antidepressant medications, dietary alterations and Ob/Gyn interventions suffice. Catering to depressed mothers is a mood disorder niche, and interested readers are encouraged to explore expanding their knowledge and skills. Helping a struggling mother and thus paving a better developmental path for her child is one of the ultimate returns on investment for therapists!

References:

Chisholm A. (2016). Postpartum depression: the worst kept secret. Harvard Health Blog. Retrieved from https://www.health.harvard.edu/blog/postpartum-depression-worst-kept-secret-2017020811008

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, 2013

Harvard (2017). Depression during pregnancy and after. Harvard Health Publishing. Retrieved from https://www.health.harvard.edu/womens-health/depression-during-pregnancy-and-after

Hübner-Liebermann, B., Hausner, H., & Wittmann, M. (2012). Recognizing and treating peripartum depression. Deutsches Arzteblatt International109(24), 419–424. https://doi.org/10.3238/arztebl.2012.0419

Langan R, Goodbred AJ. Identification and management of peripartum depression. American Family Physician. 2016;93(10):852-858.

 

 

Signs of Major Depression Subtypes: Peripartum Onset


Anthony Smith, LMHC

Anthony Smith is a licensed mental health counselor in Massachusetts with 20 years of experience. He has worked in facilities and in private practice performing therapy and diagnostic evaluations across a wide array of populations both demographically and clinically. This includes 17 years in the forensic arena, where he currently provides assessments for the juvenile courts. Aside from interest in the intersection of psychology and law, Anthony is particularly in interested differential diagnosis and supervision of new practitioners. He regularly teaches abnormal psychology and creates courses on the lived experience of people with mental illness, along with supervising graduate student counselling practicums at a local university. When not providing clinical services, teaching or blogging, Anthony can be found hiking and fly-fishing around the Northeast and American West.

 


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APA Reference
Smith, A. (2020). Signs of Major Depression Subtypes: Peripartum Onset. Psych Central. Retrieved on October 29, 2020, from https://pro.psychcentral.com/new-therapist/2020/07/signs-of-major-depression-subtypes-peripartum-onset/