Beverley had just become a mother. She was married, but the relationship was not satisfying or close. Beverley had not wanted to become pregnant, but she had carried the pregnancy to term and given birth. Severely depressed throughout pregnancy, Beverley’s contracted sense of emptiness and hopelessness now accelerated. She had recurring thoughts of suicide. And the child would simply not stop screaming!

One evening at bath time, Beverley gently pushed her reclining son’s shoulders down further into the water, causing his face to go under the surface. She kept her hands there until the infant’s movement stopped. The courts later acquitted Beverley for murder on the grounds that severe (postnatal) depression had constituted a mental illness causing her to act irrationally. It didn’t save her son, however; he was a victim of filicide, defined as the killing of a child by its parent (Friedman & Resnick, 2007).

There were 22 filicide cases recorded in Australia between July 2008 and June 2010, or 11 per year on average. Seven involved the death of a child less than one year of age (Chan & Payne, 2013). The United States has a rate of 500 cases per year (Orenstein, D., 2014), with rates of child homicide at 8/100,000 for infants – more than triple the rate for pre-school or school-age children – and these statistics are said to be an underestimate (Finkelhor, 1997). Mothers account for 37 percent of filicide deaths (Mouzos & Rushforth, 2003). An international review of psychiatric literature found that filicidal mothers often experience depression, psychosis, suicidal thoughts, and other prior mental health problems (Resnick, 1969, in Bartels & Easteal, 2013).

Postnatal depression, or PND, figures largely in these sad statistics; it has been estimated that at least one in five mothers of full-term infants suffers from it (Priest et al, 2005, in Statewide Obstetrics Support Unit, 2007), with one to four women per thousand giving birth suffering from post-partum psychosis, resulting in an inability to distinguish right from wrong (Schwartz & Isser, 2007). Filicide is the extreme tragic result of PND disorder.

In this article, we provide you with a brief overview of postnatal depression; including its outset, prevalence, consequences and risk factors.

Onset and prevalence of PND

Giving birth may be experienced by a woman as both joyful and stressful at the same time. In fact, most women experience a range of emotions, including the “baby blues”, a condition striking soon after delivery, peaking around Day 4, and disappearing by Day 10. The baby blues should not be confused with PND, also called “postpartum depression”, or PPD (The Carlat Psychiatry Report, 2013). This latter condition, experienced by about 13 percent of women giving birth, consists of more serious and persistent symptoms that meet the criteria for what the DSM-5 calls “persistent depressive disorder” (identified as a “major depressive episode” in the DSM-IV) with peri-partum (either antenatal or post-partum) onset (Stone, 2013). PND is said to have an onset up to four weeks after childbirth, but many experts use three months as a more realistic time frame (The Carlat Psychiatry Report, 2013).

PND is serious: The consequences

It is grave enough for a woman that she may experience being “down” after childbirth, as such women are more likely to become depressed during future pregnancies (Cooper & Murray, 1995). But the problems do not stop there. Post-natally depressed women also have increased difficulty developing a secure and healthy attachment with their children (Murray et al, 1999). Beyond that, PND has an immediate and lasting impact on the social, emotional, and cognitive growth of children (not only the newborn, but also other children in the family) (Carter, Grigoriadis, Ravitz, & Ross, 2010). Finally, partners of women with PND have been shown to have higher levels of anxiety and depression (Roberts et al, 2006) and greater distress in their relationships with their children and partners than men partnering with non-depressed women (Davey, Dziurawiec & Brien-Malone, 2006). Thus the serious condition of PND affects not just the woman, but the entire family system.

Looking in more detail, we can note that antenatal depression has been associated with higher norepinephrine levels in infants; infants born to mothers who were depressed both before and after childbirth had these changes and also elevated cortisol levels and lower dopamine levels (Diego et al, 2004). Anxiety is also disruptive during the post-partum phase, with identified anxiety equalling known obstetric risk factors in predicting birth complications like premature delivery and low birth weight (Wadhwa et al, 1993). The mother’s depression is also linked to later problems with infant temperament, inappropriate reactions to new stimuli, delayed motor development, and childhood problems such as anxiety, reduced attention span, and behavioural problems (Statewide Obstetrics Support Unit, 2007).

Medical experts contend that antenatal maternal stress triggers a response in the hypothalamic-pituitary-adrenal (HPA) axis to release cortisol, which increases the cortico-tropin-releasing hormone (CRH) in the placenta. Elevated levels of it there are associated with premature birth and restricted growth of the foetus; exposure to stress hormones in the uterus may program the foetus to be more reactive to stressors over the individual’s life. Moreover, maternal stress at the peripartum stage – such as when the mother is under stress, suffering from malnutrition or infections, and/or consumes alcohol or tobacco – may raise glucocorticoids, which interfere with the effects of growth hormone.

Sadly, even though babies with low birth weight catch up by one year of age, there may be permanent changes to the genes which regulate glucose and fat metabolism (thus triggering foetal programming of metabolic syndrome). When a child suffers the early difficulties of a mother with PND, there are also changes in the hippocampus and prefrontal cortex which will predispose the child to depression, anxiety, posttraumatic stress disorder, and cognitive/attentional deficits (Matthews & Meaney, 2005).

With so many vulnerabilities generated by perinatal depression, we would hope that the post-natal environment – meaning the quality of family life and nurturing – would be able to moderate the effects of such prenatally-determined diatheses. But we would be disappointed again. The tentacles of PND are seen to stretch to undesirable parenting practices and poor attachment, as depressed mothers fail to care properly for their infants.

Thus the whole range of cognitive, physiological, and emotional problems generated by PND fails to be mitigated. If we were hoping that the father would be able to compensate for the mother’s anxiety or depression, our final hope would probably be dashed. That is because, while the father might be able to develop a secure attachment with the child, it is more likely that, as stated earlier, fathers partnering with depressed mothers will tend to be more anxious and depressed themselves, thus spawning independent negative effects in the children, such as behavioural and emotional problems (Ramchandani et al, 2005).

What brings on PND: The risk factors

The aetiology of PND is considered to be comprised of multiple factors (Ross, 2004), at psychological, social and biological levels.

Psychological:

• Antenatal anxiety, depression or mood swings
• Previous history of anxiety, depression, or mood swings, especially if occurred perinatally
• Family history of anxiety, depression or alcohol abuse, especially in first degree relatives
• Severe baby blues
• Personal characteristics like guilt-prone, perfectionistic, feeling unable to achieve, low self-esteem
• Edinburgh Postnatal Depression Scale score > 12

Social:

• Lack of emotional and practical support from partner and/or others
• Domestic violence, history of trauma or abuse (including childhood sexual assault)
• Many stressful life events recently
• Low socioeconomic status, unemployment
• Unplanned or unwanted pregnancy
• Expecting first child or has many children already
• Child care stress

Biological / medical:

• Ceased psychotropic medications recently
• Medical history of serious pregnancy or birth complications, neonatal loss, poor physical health, chronic pain or disability (Statewide Obstetrics Support Unit, 2007)

Treatment of PND: A rationale for Interpersonal Therapy (IPT)

We can note how prevalent relationship risk factors are. Highlighting the social factors above, research has confirmed the more specifically stated social risk factors of marital conflict, lack of spousal support, having no partner, and reduced social support (Dennis & Ross, 2006; Beck, 1996; Beck, 2001). Some researchers have hypothesised that supportive relationships may serve as protective factors, buffering against depression (Mauthner, 1995).

The consistent finding of the converse truth – namely that relational factors also play a role in the development, maintenance, and recurrence of PND – means that we have a compelling rationale for a therapy which is interpersonally based. Research since the turn of the millennium, in fact, has had positive results focusing on the marital relationship as an effective place for Interpersonal Therapy interventions (Schulz, Cowan, & Cowan, 2006; Misri, Kostaras, Fox, & Kostaras, 2000). It is not surprising that IPT has been showing effectiveness with this population due to the disruptions to key relationships and social supports associated with PND (learn more about IPT here). The onset of depression when adjusting to motherhood makes IPT interventions working in the focal area of role transitions particularly applicable (Mulcahy et al, 2009).

The other factor guiding treatment choice for women with PND is that many do not wish to expose their breastfeeding infant to antidepressants. Thus, a non-pharmacological treatment such as psychotherapy is a hands-down preferred choice (Pearlstein et al, 2006; The Carlat Psychiatry Report, 2013). The fact that IPT is time-limited as well as interpersonally focused makes it an attractive psychotherapy for new mothers with PND (and sometimes their partners).

This article was adapted from Mental Health Academy’s CPD course “Treating Postnatal Depression with Interpersonal Psychotherapy”. The aim of this course is teach participants how utilise IPT as a treatment for PND.

References:

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