The tragedy of the Andrea Yates family has increased public awareness of postpartum syndrome and generated increased demand for information regarding them.

Rebecca Schmidt, M.D., of Alegent Health Psychiatric Associates, and the Alegent Health Center for Mental Health, defines the syndromes of postpartum depression and postpartum psychosis, discusses their frequency, risk factors, and when treatment is indicated. Find out more about Dr. Schmidt

Postpartum depression is a major depressive episode that begins within 6-12 weeks after the birth of a child. It is longer in duration and causes more disruption in functioning than the traditional "baby blues", which 85% of women experience after delivery.

Women affected by the traditional "baby blues" experience unpredictable sentimentality characterized by brief bouts of joyfulness alternating with episodes of self-doubt and uncertainty about maternal abilities. In 80% of women who experience the postpartum blues", these feelings usually peak within 3-5 days of delivery and resolve with in two weeks. A diagnosis of postpartum depression, however, is considered when the mood liability for more than two weeks after delivery.

The American Psychiatric Association recognizes postpartum depression in the Diagnostic Statistical Manual IV (DSM-IV) as a Major Depressive Disorder with Postpartum Onset. Symptoms must be present for at least two weeks and cause significant impairment in functioning. These symptoms include:

• A persistently depressed mood
• A loss of interest in pleasurable activities
• Changes in sleep , appetite, energy and concentration
• Increased or decreased psychomotor activity, such as staying in bed, pacing or rocking.
• Feelings of despair, worthlessness, excessive guilt, and suicidal ideation.
• Excessive thoughts of maternal inadequacy or thoughts of wanting to harm the newborn.

How long does postpartum depression last?  

Untreated postpartum depression can last for up to a year, and can adversely affect an infant. Studies of depressed mothers have shown that they are less responsive to their children and can be indifferent to the child. In addition, infants of depressed mother can exhibit delay in development and cognition, have difficult temperaments, and may themselves be at increased risk for depression.

What is postpartum psychosis, and how is it different from postpartum depression? 

Postpartum psychosis, like postpartum depression, is a psychiatric condition that begins in the postpartum period. It is usually abrupt in onset and is primarily differentiated from postpartum depression by the presence of psychotic (or irrational) thought processes.

Symptoms of postpartum psychosis include:

• Marked liability of mood,
• Depersonalization, confusion, disorientation and agitation.
• Overt signs of psychosis, such as auditory hallucinations, paranoia, and bizarre behavior.
• Delusional thoughts
• Beliefs that the newborn is possessed or a child of Satan. Some mothers believe in their delusional system that this has occurred because of the inadequacy as a mother.

The symptoms of postpartum psychosis may wax and wane and affected women are often secretive about their thoughts and feelings, a result of the paranoia and excessive guilt associated with his condition.

How common are these postpartum conditions? 

The cause of postpartum depression occurs in about 10-15% of women during the postpartum period, while postpartum psychosis is a much less common condition, occurring in one or two women per thousand births.

What causes postpartum depression or psychosis? 

The cause of postpartum depression or psychosis is unknown. However, it has been hypothesized that the hormonal changes occurring in the postpartum period may contribute to the onset of these disorders.

The following are factors that increase the risk for postpartum depression:

• A past history of depression. In women with a prior history of depression, there is a 25% chance of developing postpartum depression, and in women with a prior history of postpartum depression, the risk for having another episode of postpartum is 50%.
• A family history of depression.
• Psychosocial stresses, such as poverty, lack of extended family in involvement, and single marital status.

Risk factors for postpartum psychosis include:

• A prior history of depression or psychosis, which double the risk for this condition. Women with a diagnosis of bipolar disorder, in particular, are at 50% risk for postpartum psychosis.
• The risk is even higher in women who have had a prior history of postpartum psychosis.
• A family history of bipolar disorder, and medical conditions, such as thyroid disorders and intracranial hemorrhage (Sheehan’s syndrome)

Many women affected by postpartum depression or psychosis will have thoughts of harming themselves or their children, but do not act on those thoughts. This fact is reflected in the low rate of infanticide, which is less than 1 in 50,000 births.

The risk for self-harm or infanticide, however, increases when the woman is unable to recognize the excessive nature of her feelings, or is compelled to follow the command hallucinations she may be experiencing. The presence of a delusional system further impairs a woman’s ability to act in an appropriate manner, so that extreme acts of violence, either against oneself or a child, are justified by the irrational thought process that is occurring.

How has the Andrea Yates’ case affected the general population’s knowledge and understanding of mental health disorders? 

The tragedy of the Yates family has both horrified and confounded the general public. The extreme nature of Andrea Yates' actions has brought the disorders of postpartum depression and psychosis to the public’s attention. Thereby knowledge about postpartum syndromes, and the need for treatment has increased.

However, the verdict in the Andrea Yates trial reflects a very limited understanding of how an irrational thought process consisting of delusions, paranoia, and hallucinations can even override the protective bond between a mother and her children. Consequently, some women who are experiencing these symptoms may be reluctant to seek early intervention, for fear of punishment, even when they have not acted on their thoughts.

When should a woman or a family member seek help for symptoms associated with postpartum syndromes? 

Assessment for postpartum depression is indicated when symptoms of social withdrawal, depressed feelings, or a diminished capacity to function are present. Most often, women will initially contact their obstetrician, who begins treatment for postpartum depression, and then refers the patient to a therapist or psychiatrist when indicated. When suicidal or homicidal thoughts occur or when symptoms of psychosis are present, such as auditory hallucinations or delusional thoughts, emergency psychiatric assessment should be obtained. Postpartum psychosis is truly a psychiatric emergency.

What are the treatment recommendations for postpartum syndromes? 

The treatment of "postpartum blues" is generally supportive. However, as up to 20% of women who experience the "postpartum blues" can develop postpartum depression, they should be monitored for worsening of symptoms.

When women do develop a postpartum depression, psychotherapy and antidepressant medications are commonly used to treat this condition. Hospitalization, however, may be necessary to stabilize mood and thought process.

Postpartum psychosis is a psychiatric emergency. Immediate hospitalization is indicated, and a variety of medications, including antipsychotics, mood stabilizers, and medications to treat anxiety are used to alleviate the symptoms of psychosis.

Where, in the Omaha and surrounding area can women be assessed and treated for postpartum psychiatric conditions? 

In the Omaha metropolitan area, a number of outpatient psychiatrists available for consultation, while emergency assessments are a available at the Alegent Immanuel Medical Center campus at 6901 North 72^nd Street. For more information, call 717-HOPE (717-4673).