Meet Christine. She is a married 30-year-old woman who just had her first baby about 3 weeks ago. While the pregnancy went smoothly, the experience of labor and delivery was difficult. After nearly 20 hours of labor, Christine had an emergency caesarean section. The baby was healthy, but he had difficulty breastfeeding. Christine was worried that she was not producing enough milk. Her baby lost more than 10% of his weight during the first week, and Christine was forced to supplement with formula.
Christine went to see her obstetrician two weeks after delivery because she was worried that her C-section incision site was infected. Her obstetrician reassured her that there were no signs of infection but was concerned because Christine was not her usual self. She was tearful and reported that she was having problems falling asleep, fearful that something might happen to her baby. Christine’s obstetrician set up an appointment for Christine to meet with the OB social worker the following week.
When Christine met with the OB social worker, she denied feeling depressed. She acknowledged feeling sleep-deprived, unable to sleep restfully and persistently worried about the baby’s health and his ability to gain enough weight. Although her mother was willing to help care for the baby, Christine did not feel comfortable leaving the baby with others. When she was away from the baby, she was plagued by persistent, intrusive thoughts of something horrible happening to the baby — for example, the baby suffocating in his bed sheets.
Christine is not an actual patient but an amalgam of the postpartum women we see at our clinic. During the postpartum period, there is a confluence of many significant events: recuperation from labor and delivery, sleep-deprivation, breastfeeding, negotiating the transition to parenthood. During the first few weeks, many new parents may recognize that things are not going well but may not be able to distinguish what is normal and what is a problem.
Postpartum Depression or Postpartum Anxiety?
Postpartum depression first gained medical attention in the 1970’s. Like depression which occurs at other times in a woman’s life, researchers observed that postpartum depression is characterized by feelings of sadness, irritability, tearfulness, appetite changes, and sleep disturbance. But what we have learned over time is that many women with what we typically call “postpartum depression” also have significant anxiety symptoms.
This most commonly takes the form of generalized anxiety, persistent and excessive worries, feelings of tension, and inability to relax. Often these worries are focused on the baby, his or her health and safety.
Many postpartum women have symptoms consistent with obsessive-compulsive disorder (OCD). Obsessional thoughts are experienced as intrusive, unwanted and inconsistent with one’s typical personality or behavior, and patients often express fears of even thinking these thoughts, particularly when they involve thoughts of harm to their baby. One study demonstrated that 57% of women with postpartum onset major depression reported obsessional thoughts (as compared to 36% of women with non-postpartum major depression). In addition, women with postpartum obsessional thoughts had more frequent obsessional thoughts than women with non-postpartum obsessional thoughts.
How postpartum depression and postpartum anxiety relate to one another is not fully understood. Clinically, it seems that women with more severe depressive symptoms also have comorbid anxiety symptoms. We do see non-depressed postpartum women with generalized anxiety disorder (GAD) or OCD; however, it seems that many women who have postpartum GAD and OCD ultimately report some depressive symptoms, especially when their symptoms are more severe or prolonged.
A recent study attempts to better understand the relationship between postpartum depression and anxiety. This was a prospective study of obstetric patients (n=461) recruited immediately after delivery and followed for 6 months; 331 (72 %) of the women completed the assessment at 6 months postpartum.
At 2 weeks postpartum, 28 (19.9 %) of the women with depression had anxiety symptoms, compared to 4 (1.3 %) of the women who screened negative for depression (p?<?0.001). Similarly, 36 (25.7 %) women with depression endorsed obsessions and compulsions compared to 19 (8.4 %) women without depression (p?<?0.001). Anxiety symptoms seemed to subside over time. By 6 months postpartum, there were no differences in symptoms between women with and without depression. Conversely, the differences in obsessions and compulsions between depressed and non-depressed women persisted.
Does It Matter? Do We Need to Distinguish Between the Two?
As we move toward universal screening of postpartum women, it is interesting to note that many of the tools commonly used to identify women with postpartum depression also detect women with postpartum anxiety. For example, the Edinburgh Postnatal Depression Scale (EPDS) consistently identifies women with anxiety symptoms and total EPDS scores appear to correlate with disorder type. Women with no disorder have the lowest scores, followed by women with anxiety only, then by women with depression only. Finally, women with a combination of depression and anxiety scored the highest of the four. While these screening tools may not give us diagnostic accuracy, they do identify women with clinically significant symptoms who may benefit from treatment.
Distinguishing between postpartum depression and anxiety will help us to make better treatment recommendations. Women with milder symptoms may benefit from psychotherapy. While interpersonal therapy (IPT) benefits women with postpartum depression, we don’t really know how IPT works for OCD or generalized anxiety symptoms. In contrast, we have ample data from both postpartum and non-postpartum populations to indicate that cognitive-behavioral therapy (CBT) is an effective treatment for depression, OCD, and anxiety symptoms.
When it comes to pharmacotherapy, the antidepressants most commonly use to treat women with postpartum illness – serotonin uptake inhibitors (SSRIs and SNRIs) — are effective for the treatment of major depression, generalized anxiety disorder, and OCD. Bupropion is not as effective for managing anxiety symptoms and OCD. Women with comorbid depression and anxiety may also benefit from treatment with an anxiolytic medication, such as lorazepam (Ativan) or clonazepam (Klonopin), to help manage anxiety symptoms and sleep disturbance while waiting for the antidepressant to take effect.
While this question has not been adequately studied, it appears clinically that women with comorbid depression and anxiety may have more severe illness and may be more difficult to treat. According to current guidelines, it is recommended that women with more severe postpartum illness be treated with psychotherapy and medication. This may be particularly an issue with obsessional thoughts where symptoms are more refractive to treatment and CBT alone appears to be less effective than CBT plus medication.
Ruta Nonacs, MD PhD
Miller ES, Hoxha D, Wisner KL, Gossett DR. The impact of perinatal depression on the evolution of anxiety and obsessive-compulsive symptoms. Arch Womens Ment Health. 2015 Jun;18(3):457-61.
Wisner KL, Peindl KS, et al. (1999). Obsessions and compulsions in women with postpartum depression. J Clin Psychiatry 60(3): 176-80.