Different Clinical Presentations of Depressive Symptoms

Excerpted from the CAMH publication: Postpartum Depression: A Guide for Front-Line Health and Social Service Providers, Chapter 1 - Clinical Overview

On this page:

• Depressed mood
• Depression with anxiety
• Anhedonia
• Weight changes and appetite
• Sleep disturbance
• Fatigue
• Psychomotor retardation or agitation
• Excessive feelings of guilt or worthlessness
• Diminished concentration, inability to “think straight”
• Recurrent thoughts of death or suicide

Depressed mood

Women often do not admit to being depressed. They may use other words to convey being depressed, such as despondent, low, sad, irritable, restless, numb or empty. The woman may be tearful or cry more than usual, or say that she is past the stage of crying because she is so empty. Often women express strong feelings of inadequacy, particularly regarding their abilities as a mother, and talk about their inability to cope or fear of being labelled as “a bad mother.” They may compare themselves with other new moms or female relatives, which increases their feelings of inadequacy.

In some cases, a woman will not disclose that she has psychological problems but will instead focus on physical symptoms. The mother may complain to her doctor or public health nurse of stomach ache, headache or backache. Some women simply cannot disclose their psychological state, and find that focusing on physical symptoms is a more comfortable means of conveying their distress. Other women will focus on the health of the baby, making repeated visits to the doctor’s or nurse’s office with physical concerns, even if the doctor or nurse has said that the baby is fine.

Depression with anxiety

It is very common for women experiencing PPD to also exhibit anxiety. Within the context of a PPD, the mother may experience anxiety about the baby’s health or her own ability as a mother or concern over how she will cope with childcare responsibilities.

While anxiety is a common feature of depression, some individuals exhibit only anxiety. That is, they experience anxious feelings but do not have depressed mood or loss of interest or pleasure. (Please see discussion of postpartum anxiety)

Anhedonia

Women with PPD may lose interest or no longer enjoy activities that used to give them pleasure, such as being with the baby, watching a favourite television program, reading or spending time with a partner, family or friends.

Weight changes and appetite

Health professionals usually define the symptom of weight change as a significant weight gain or loss (in the absence of actively dieting). However, this can be hard to assess in new moms whose weight will change after having a baby. Service providers may prefer to inquire about women’s desire for and enjoyment of food; for example, do they still want food (even if they don’t have time to prepare something), do they enjoy it and still like their favourite items?

Sleep disturbance

Sleep disturbance is a common symptom of depression. However, this is extremely difficult to gauge in new moms. Service providers may prefer to ask about a mom’s ability to sleep or get rest when she has the opportunity—for example, can she sleep when the baby falls asleep; or if someone else is watching the baby, can she sleep, nap or rest? Does she have difficulty falling asleep? Does she wake in the middle of the night and can she fall back to sleep? Does she have difficulty waking up in the morning and does she feel refreshed after sleep?

Fatigue

It is hard to estimate the real extent of tiredness in new moms. The fatigue associated with depression is a prevailing sense of exhaustion irrespective of the amount of sleep or rest obtained.

Psychomotor retardation or agitation

Psychomotor retardation refers to physical feelings of being slowed down, moving slowly or experiencing sluggishness. Psychomotor agitation refers to feelings of being restless, jumpy and on edge. As well as the mother feeling like this, other people will likely have noticed the movements too, and may have commented on them.

Excessive feelings of guilt or worthlessness

Some individuals have excessive and inappropriate feelings of guilt or worthlessness. This does not just relate to being ill, but is much more severe. They may negatively interpret everyday activities as confirming their low sense of worth; for example, “The other mothers don’t talk to me because I don’t deserve to have friends because I’m such a bad person.” These women may feel guilt to delusional proportions; for example, some women may feel that they are responsible for world poverty or something bad happening to someone else.

Diminished concentration, inability to “think straight”

Clinicians variously describe lack of concentration as slowed thinking, inability to concentrate on the task at hand, being unable to finish a job or having trouble making simple decisions. Some women complain that they “can’t think straight” when confronted by the simplest of tasks.

Recurrent thoughts of death or suicide

Thoughts of death or suicide are a common feature of depressive illness. In many cases, these thoughts express not simply a fear of dying but a preoccupation with death. Women may not explicitly use words such as suicide, death or killing. But they may say things like “The baby and I would be better off dead,” or “The world is such an awful place to bring a baby into that we would be better off out of it.” Some women feel that they can no longer go on, but cannot bear the thought of leaving the baby behind so would take the baby with them.

Some women have thoughts about hurting the baby that make them feel deeply frightened or ashamed—even though the vast majority would never act on these thoughts. For instance, they might imagine how easy it would be to smother or drown the baby, or throw him or her out of the window. In other cases, women feel it would be a blessing if they went to sleep and didn’t wake up, but would not actively do anything to hurt themselves. Some women are obsessed with such thoughts, but most would never act on them. (See Chapter 6.)

Although highly publicized, acts of infanticide and suicide are rare in postnatal illness. Infanticide is estimated to occur in one to three in 50,000 births (Brockington & Cox-Roper, 1988; Jason et al., 1983). Health professionals estimate that 62 per cent of mothers who commit infanticide also go on to commit suicide (Gibson, 1982).

Suicide is a risk factor in depressive illness that must be considered. Chapter 6 further discusses assessing risk of suicide.

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