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Sleep, support essential in treating postpartum depression

NEW ORLEANS — Getting adequate amounts of sleep and receiving good social support are major factors in reducing symptoms of postpartum depression and major depressive episodes, according to a presentation at Psych Congress.

For many women, the postpartum period is a very vulnerable window of time, making mood disorders and anxiety common after childbirth, Marlene P. Freeman, MD, of Harvard Medical School, said during her presentation.

Postpartum blues

The postpartum “blues” — a transient period when some women may have more emotional sensitivity — occurs in about 70% to 80% of women after delivery, according to Freeman. In fact, the blues are not actually a disorder, as this feeling does not affect self-esteem or function; rather, the blues are a superficial sense of sadness, she said. Postpartum blues are normal and generally resolve without treatment, but clinicians should monitor mothers for more serious disorders, such as early signs of a major depressive episode, she said.

“What can be confusing, though, is that sometimes women who do have depression are told ‘Oh, that’s normal — you’re supposed to feel that way,’ because the blues are so common, but that is absolutely not what we want,” Freeman said.

Postpartum depression

Postpartum depression is the most common complication of childbirth and approximately 10% to 15% of women experience major depressive episodes after delivery, according to Freeman.

Many women start feeling depressed during pregnancy, which usually worsens after childbirth, suggesting the need for preventive steps during pregnancy to minimize the risk of postpartum depression, she said.

Symptoms of postpartum depression are similar to nonpuerperal major depressive episodes and include depressed mood, insomnia, fatigue, anhedonia and suicidal ideation, according to Freeman.

Anxiety is also prominent in postpartum depression and is often indicated by obsessive thoughts or behavior, she said. When obsessions start to become a problem and affect functioning, clinicians should be concerned, she added.

“Maternal psychiatric illnesses affect not only the woman but her whole family, and treatment can have such a positive effect on the woman, the children and the entire family,” Freeman said. “It is so important that moms are treated and treated to remission. It is very clear in terms of postpartum depression that there are risks to almost every aspect of child development. It extends beyond postpartum to maternal depression, which has a lot of consequences for children as well, including insecure attachment, behavioral problems, and childhood psychiatric diagnoses and symptoms.”

Freeman noted a large study found that treating the psychiatric symptoms of the mothers to remission alone resulted in a significant decrease in psychiatric symptoms and diagnoses among despite no direct additional therapy for the children. This study showed that the mother’s mental health has a definite impact on the child’s mental health, and focusing on treatment for the mothers can result in significant benefit for both mothers and children, Freeman said.

Screening

Strong predictors of postpartum depression include history of depression, and depression and anxiety during pregnancy, according to Freeman.

“It is helpful to screen to pick up postpartum depression, but it is only part of the solution,” she said. “When we screen and women screen positive, we need to make sure that there’s actually treatment engagement and better outcomes.”

Since postpartum depression is often a missed diagnosis, screening can be useful; however, there are not many studies showing that screening yields better outcomes, according to Freeman.

“The key is if we have screening programs, we need to make sure we have health care providers that not only have the expertise to care for women who are postpartum but also have the accessibility,” Freeman said.

Treatment

According to Freeman, the treatment is the same as treating the underlying postpartum depression or anxiety disorder.

“We can reassure women that it is very common to experience postpartum [obsessive-compulsive disorder] and they will get better,” she said. “But it is tough because if a woman vents to her obstetrician and she expresses these scary thoughts, it can be hard to tease apart when there is a real element of danger.”

Freeman noted that antidepressants should be the first-line treatment for patients with postpartum depression. Clinicians should use the lowest effective dose, but should be careful not to undertreat — the goal is to treat to remission, she said.

“Psychotherapy is the most important nonmedication treatment,” Freeman said. “Postpartum depression can be a very [isolating] experience; group therapy and support groups can be profoundly helpful for many women.”

Good social support is associated with faster recovery, less symptoms and better prophylaxis against depressive episodes, according to Freeman.

Engaging women in therapy is essential ; however, caring for a newborn baby can make it difficult for women to make time for themselves, she said.

“In fact, many women will feel so guilty for taking time away from the baby that many women will often forgo care for themselves,” she said. Therefore, it is important for clinicians to remind these women that taking good care of themselves is taking good care of their babies.

Sleep is also extremely important in treating postpartum depression, according to Freeman. Planning ahead for postpartum sleep deprivation is essential and it may be helpful to conduct an appointment with the mother and her partner or another supportive family member to discuss sleep, she said. The most feasible option for a majority of people is tending to the infant in shifts for nighttime feedings, so both partners can get adequate amounts of sleep, she said. This will not last forever — about 2 to 3 months until the baby has a consistent sleep schedule, but in the beginning, clinicians should continue to address adequate sleep, she said.

Many complementary alternative treatments — including omega-3 fatty acids, exercise and folate — can also be part of the treatment plan, but clinicians need to ensure that women do not defer effective treatment because they are afraid to try standard treatment, Freeman said.

Breastfeeding

A significant point of discussion in postpartum treatment is the role clinicians play in helping mothers make decisions related to breastfeeding, according to Freeman.

“Breastfeeding is optional. When you have a woman that is struggling with a serious psychiatric disorder and she is postpartum, her mental health takes priority over whether she is breastfeeding or not,” she said. – by Alaina Tedesco

Reference:

Freeman MP. Postpartum mood disorders. Presented at: U.S. Psychiatric and Mental Health Congress; Sept. 16-19, 2017; New Orleans.

Disclosure: Freeman reports receiving research support from the Alkermes, AstraZeneca, Forest/Actavis Pharmaceuticals, JayMac Pharmaceuticals, National Pregnancy Registry for Atypical Antipsychotics, Ortho-McNeil Janssen, Otsuka Pharmaceutical, Sunovion Pharmaceuticals and Takeda Pharmaceuticals. She also reports advising and counseling for Janssen, JDS Therapeutics, Sage and Sunovion.