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BABY BLUES AND DEPRESSION

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Women might experience emotional changes before, during and after pregnancy.


Baby blues


Pregnancy is a special time in the lives of most women. But sometimes, instead of the pregnant or recently delivered woman being in the brink of health, full of excitement and joy, the woman may be struggling with depression.


Let us look into the emotional changes experienced in the period before, during and after pregnancy.


Before pregnancy


Many women expect to conceive naturally, when she plans to start a family, as will her spouse and their extended family too. This expectation can itself be stressful if conception is difficult. Some women may then choose to conceive by artificial means, but this can sometimes be even more stressful if the attempt fails. On the other hand, some pregnancies may not have been planned or wanted, and the woman may well be continuing with her usual habits of drinking or smoking or even abusing drugs. All this may later contribute to problems for the mother, such as depression, and for the baby, such as a low birth weight.


Then there are women who already have some form of psychological problems or distress, and perhaps would be on some medication that needs to be stopped for the safety of the baby, whose organs are developing. This may therefore result in the woman being more susceptible to the stress of having to adjust to pregnancy, and later, motherhood.


Keeping in good spirits and physical health is something that goes towards ensuring a good pregnancy. The universal advice of a healthy lifestyle would apply: eating wisely in moderation, avoiding alcohol and smoking, regular exercise, maintaining supportive relationships and participating in a fulfilling activity or hobby. In addition, women and their spouses should make preparations for a new baby, and be mentally prepared for the changes.


During pregnancy


Many pregnant women describe pregnancy as a glorious time, and glow radiantly, and there is evidence to suggest that pregnancy has a protective effect against some psychiatric disorders.


Sometimes, however, the physical and psychological changes can be so overwhelming, and professional attention may be necessary when the pregnant woman’s emotional wellbeing is affected. Some women are more affected by the physical changes, such as weight gain, stretch-marks and morning sickness. Also, the idea that she will have to be fully responsible for another life, and thereby losing her freedom can be difficult to accept.


For the pregnant career woman, sometimes it can be difficult if colleagues are not understanding and supportive. One in five pregnant women is likely to have significant depressive symptoms in Singapore.


Those especially at risk for psychological distress include the teenage mother, single mothers, those with previous psychological problems and those who abuse alcohol or drugs.


For the first-time mother, the unfamiliarity with pregnancy and life thereafter can make her more susceptible to mood swings.


Other factors associated with psychological morbidity include poor socio-economic status, marital conflicts or lack of support. Then should the pregnancy end either in a miscarriage or abortion, there would be an increased risk of depression as a result of the loss and feelings of guilt.


Some of the disorders include mood swings, anxiety attacks, unusual appetite cravings, and even severe morning sickness (otherwise known as hyperemesis), which can sometimes be disabling.


Antenatal depression


Depression in pregnancy, or antenatal depression, is often the first time a woman experiences depression in her lifetime. The common features of depression are also common to the pregnancy state, such as the loss of appetite, poor sleep, feeling tired and forgetful.


More useful symptoms to look out for would be the emotional features and the negative thinking pattern: easy tearfulness, low mood, irritability, a loss in interest, excessive self-blame and feeling hopeless or that life is meaningless.


As mood swings are quite common in pregnancy, one clue to look out for is if these are associated with an impairment of social or occupational functioning.


The management of antenatal depression involves looking at the stresses, gathering support for the pregnant woman, and counselling and other forms of psychological therapy. When the depression is severe, especially when associated with suicidal feelings, medication would be necessary, and sometimes even electroconvulsive therapy, which is actually quite safe. The choice of medication must be carefully made, and treatment monitored closely as some of these medications can affect the baby.

Case Study

Kai Li was a 34-year-old mother who experienced mood swings, loss of appetite and interest and was unable to concentrate at work. She also had excessive self-blame, but did not have any suicidal feelings. The main stressor she experienced was her breech pregnancy, and her worries of the outcome. As she was already in her third trimester, her doctor did not prescribe her medication as it could affect the baby.


She received supportive therapy, and her husband was encouraged to spend time with her. Her in-laws, who had mistakenly believed that she was somehow responsible for the complicated pregnancy, were also advised and educated on the nature of breech pregnancy. Fortunately, she had an uneventful delivery by Cesarean operation, and delivered a healthy baby girl.


After pregnancy


When the baby arrives, many expect the mother will be happy and perfectly at peace with the arrival of the new addition. Also, where she was given special attention and care during pregnancy, the focus is now on the newborn and the new mother sometimes is relegated to being the “milking machine” or “nappy changer”. These pressures on the mother can be immense. Her needs are no longer important, whereas the needs of the infant come first. If there is inadequate support and help, especially from the husband, it may be even harder to adjust to the changes.


The common postnatal syndromes that can set in include postnatal blues, postnatal depression and postnatal psychosis. Others include underlying psychiatric disorders that can worsen with the stresses after delivery.


Postnatal blues


Commonly occurring in two-thirds of women, the blues hit in the first week after delivery, and is usually short lasting, subsiding within a few days to weeks. Those affected will feel irritable, weepy and moody. There may be excessive anxiety about being able to cope with the baby, or even feeling frustrated with the baby’s crying.


Postnatal blues are more commonly seen among first-time mothers who have no previous experience with motherhood, and those with poor support.


As it is usually short lasting, and does not typically affect the mother’s ability to care for her infant and her functioning, most mothers with ‘the blues’ do not need specialist attention. They can benefit with support, encouragement and reassurance from loved ones. Being aware of its occurrence and the normality of having such symptoms is helpful for the woman.


However, if you feel that these symptoms persist longer than two weeks, seek further advice from your doctor.


Postnatal depression

Women suffering from postnatal depression often think of themselves as weak or abnormal, but postnatal depression is common, affecting 1 in 10 recently delivered women. Typical symptoms include low mood, irritability, poor sleep, tiredness and a loss of interest in activities.

Bodily symptoms such as aches and concurrent anxiety symptoms are also common, as are negative feelings towards the baby. It is important for the affected woman to seek help, as untreated postnatal depression can affect the ability of the mother to bond with her child, and possibly result in problems in the emotional and intellectual development of the child.


Women at risk of having depression after delivery include those with past psychiatric illness, especially major depression. Those women who were depressed in pregnancy are also more likely to be depressed after delivery. Women who have little support and marital dissatisfaction are most prone to postnatal depression.

Case Study

Nurul started feeling depressed and weepy, and tired about two months after the delivery of her first son. She also had difficulty sleeping and had no interest in doing anything much. Although she had eagerly awaited the arrival of her son after trying to conceive for two years, she was alarmed that she felt resentful and frustrated with his incessant crying, and sometimes even had an urge to smother him.


Her husband sensed something was wrong, for she had changed from her usual bubbly self, and brought her to see a psychiatrist. She was diagnosed to suffer from postnatal depression, and started on a course of antidepressant medication, with advice to stop breastfeeding. Her mother was roped in to help with the care of her son. And as her mood lifted, she received psychotherapy, which helped her come to terms with her own inner conflicts.


The management of postnatal depression involves consideration of both the needs of mother and the infant. Psychological treatment, or “talk therapy” is especially useful, especially for patients who are reluctant to use medications, or have milder forms of depression. The formal psychological therapies include interpersonal therapy, which focuses on interpersonal relationships, and cognitive-behavioural therapy, which addresses faulty thinking and patterns of behaviour.


Some important issues new mothers often feel troubled about are a perceived lack of support or inability to cope with the demands of caring for a child. When the depression is more severe, medication will be required, along with psychological therapy. The choice of medication should take into consideration possible side effects as well as the individual patient’s previous response or particular needs.


Women often fear seeing a doctor, because they are concerned about taking medication if they are breastfeeding. The good news is that there are some medications that are compatible with breastfeeding, so that the mother can continue nursing her baby, for a most beneficial outcome.


Sometimes, when the depression is extreme, and the woman has suicidal feelings or thoughts of hurting her child, a period of hospitalisation may be recommended, along with intensive treatment.


Postnatal psychosis


This most severe form of postpartum psychiatric illness occurs rarely, at a rate of 1 to 2 per 1000 women after childbirth. Also known as puerperal psychosis, it usually presents dramatically within the first two to four weeks after delivery, with features of restlessness, irritability, confusion and insomnia. Rapid shifts of mood are common, from depression to euphoria, and behaviour is often disorganised. There may be delusional beliefs, for example, that the infant is a god, or auditory hallucinations that instruct the mother to harm her child.


Hospitalisation is required for this illness, which is considered a psychiatric emergency. There is a high risk of self-harm and harm of the infant.


Treatment includes antipsychotic medication, antidepressants or mood stabilisers. Electroconvulsive therapy may also be rapidly effective, and this is beneficial as it enables the mother to recover quickly and return to care for and bond with her baby.


Meanwhile, the infant must be put in a safe environment with another caregiver, with the mother encouraged to have contact under supervision. After the mother recovers from the episode, a period of treatment follow-up is advisable as there is a likelihood that there will be further recurrent episodes of non-pregnancy-related psychosis.

Case Study

About three weeks after delivering her first daughter, her family noted that Indirah was dazed and irritable. She would frequently look out of the window and mumble to herself, whilst neglecting her baby’s cries. In fact, she refused to carry her child, for she believed that he was an evil spirit and he would contaminate her. Her appetite was poor and she refused to bathe for a number of days.

Her family finally brought her to the hospital when she was found sitting on the parapet, and she underwent electroconvulsive therapy. Eventually, she made good recovery and was discharged home to be with her husband and baby.


Conclusion


The period before, during and after pregnancy can sometimes be met with various psychological disturbances and disorders. However, with early recognition and treatment, recovery can be good. The goal of treatment is to enable the mother to experience the joy of bonding with her baby.


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By Dr TAN Thiam Chye, Dr TAN Kim Teng, Dr TAN Heng Hao, Dr TEE Chee Seng John

Sources:
The New Art and Science of Pregnancy and Childbirth, World Scientific 2008.