Postpartum Depression (PPD)

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

On this page:

• What is PPD?
• Does it differ from other depressions?
• What causes it?
• How common is it?
• When does it start?
• How do clinicians diagnose it?
• How can service providers rule out other causes?
• How long does it last?
• Will it come back again?

What is PPD?

Clinicians and researchers use the term “postpartum depression,” or “PPD,” to refer to non-psychotic depression that occurs shortly after childbirth.

Does it differ from other depressions?

Apart from the fact that it happens soon after childbirth, PPD is clinically no different from a depressive episode that occurs at any other time in a woman’s life. The symptoms are the same as in general depression, and must meet the same criteria for diagnosis. However, not surprisingly, the content of the symptoms of PPD often focuses on motherhood or infant care topics.

What causes it?

Although health professionals do not know what causes depression (and therefore PPD), they accept that there is no single cause. Physical, hormonal, social, psychological and emotional factors may all play a part in triggering the illness. This is known as the biopsychosocial model of depression, and is accepted by most researchers and clinicians. The factor or group of factors that trigger PPD vary from one individual to the other.

How common is it?

PPD is the most common complication of child-bearing. Although the rates given in individual studies vary greatly, a meta-analysis of 59 studies of more than 12,000 women found that PPD affects an average of 13 per cent of women (O’Hara & Swain, 1996).

When does it start?

The time period used to define “postpartum” varies, from immediately following childbirth to four weeks (according to formal diagnostic classification systems) after childbirth or up to a year, according to some research studies. Symptoms usually begin within the first four weeks postpartum, although they can start up to 12 months afterwards. However, service providers may not detect and treat PPD until much later. Often, questioning will reveal that the symptoms actually began much earlier than the woman had disclosed to a health care provider.

How do clinicians diagnose it?

A physician or licensed psychologist makes a formal diagnosis of depression. Professionals use numerous methods to elicit the information needed to make a diagnosis, including standardized clinical interviews. The clinician’s judgment is essential in deciding whether or not an individual’s symptoms meet diagnostic criteria, in terms of severity or duration of symptoms. The formal classification system used in North America is the American Psychiatric Association (APA) Diagnostic and Statistical Manual of Mental Disorders, Fourth edition, or DSM-IV (American Psychiatric Association, 1994).

To indicate an episode of PPD using DSM-IV criteria, the physician or psychologist would indicate that it is an episode of major depressive disorder with the specifier “postpartum onset” (which means that the symptoms occurred within four weeks of the woman’s having given birth).

Individuals must have exhibited either a depressed mood or a loss of interest or pleasure in usual activities (called anhedonia) continually, for a minimum of two weeks. In addition, they must have experienced other symptoms from a given list of seven, for a minimum of two weeks.

A clinician will diagnose major depression if the individual has a low mood or anhedonia, plus four other symptoms (for a minimum of five symptoms). People with a low mood or anhedonia with fewer than four symptoms will receive a diagnosis of minor or moderate depression.

How can service providers rule out other causes?

It is imperative that the symptoms displayed a) represent a change from the individual’s normal functioning and b) cause impairment in everyday life. Through referral to the family doctor or another physician, as appropriate, providers should rule out other medical conditions that may cause similar symptoms and may be common in the postpartum period (e.g., thyroid dysfunction, diabetes, anemia, autoimmune diseases).

How long does it last?

The length of an episode varies from a number of weeks to a number of months. Some women say it can take up to a year for them to feel back to their normal selves. In a small number of cases, the episode may not remit and the women experience chronic episodes of depression.

Will it come back again?

Experiencing an episode of depression, at any time in life, increases the likelihood of experiencing further episodes. Research suggests that the minimum risk of experiencing a non–childbirth-related episode of illness is 25 per cent (Wisner et al., 2001) and the risk of having another postpartum episode may be as high as 40 per cent, with approximately 24 per cent of all recurrences occurring within the first two weeks postpartum (Wisner et al., 2004).

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