The Unusual Suspects: How to Become an Elite Detective in the Hunt for PPD Risk Factors

23 Nov The Unusual Suspects: How to Become an Elite Detective in the Hunt for PPD Risk Factors

When you ask a woman who has Postpartum Depression what her pregnancy was like, she is likely to tell you that she wasn’t doing too well back then but that when she sought help, she was just reassured that everything was “normal”.

When you carefully review her history, however, you may find that there have been warning signs that could have helped to flag her as a woman at risk for PPD.

The Edinburgh Prenatal Depression Scale (EPDS) has been widely recognized and used as a screening and diagnostic tool by health-care professionals. But whereas the EPDS is an excellent tool for detecting active and current depression, it is lacking in identifying risk for future depression. So how can we, as care providers, do a better job in detecting and flagging women at risk for PPD?

Consider Nicole*, for example. She did not have symptoms of depression during pregnancy but became depressed postpartum. When you read her story, try to think of some warning signs that could have been noted by her care provider.

Nicole*: A Case Example
When Nicole came to see me for the first time, she was carrying her six-month-old baby in a carrier. She apologized for bringing the baby with her, explaining she did not have child-care that day. I assured her it was fine with me.

Later in session, though, she told me she had actually been taking care of her baby by herself since birth, with little respite. Her husband, Peter*, had been working long hours and was “never home.”

When he came home from work, her husband would usually state how tired he was, take a shower and inquire about dinner. He was a good husband, Nicole said; a good provider who never got angry at her, even when she didn’t have dinner ready or any groceries at home. He was happy to order in. No complaints.

When I inquired about Peter’s involvement with the baby and whether he sometimes took care of him, Nicole’s response was that Peter was “not good with babies” and, that he promised that he was going to “take the kid to Hockey when he was old enough to play.”

Nicole and Peter were new in town and did not have any family of friends close by. Nicole attended pre-natal classes while she was pregnant and met a couple of women she sometimes talked to on the phone. She did not participate in any mother-baby group because, she said, she was too exhausted and too moody to be able to pull herself together, pack a bag for the baby and get herself anywhere in time. Nicole was completely isolated and stated she had been feeling very lonely and sad. She said she had been feeling this way for months. I conducted a clinical interview and reviewed a couple of scales Nicole filled out. I determined that Nicole was moderately depressed.

Nicole did not have any history of depression or another mental illness and there was no known mental illness in her family. She was fairly satisfied in her marriage and the pregnancy was planned and wanted by both her husband and herself. During pregnancy, she did not experience any symptoms of depression and her score on the EPDS was non-clinical.

So how come Nicole developed Postpartum Depression? What did you think should have been noted and, should she have been flagged by her maternity care provided as being “at risk”? How would a care provider for pregnant women, such as a midwife, an ObGyn, a therapist, a family physician who provides maternity care or a doula come to realize that a pregnant woman might be at risk for Postpartum Depression despite a low score on the EPDS and being asymptomatic?

Care providers may want to look beyond the “usual suspects”, such as a history of mental illness, mental illness in the family of origin, an unplanned/unwanted pregnancy, young maternal age and poverty?

Uncommon Risk Factors
Below is a list of a few Unusual Suspects; risk factors which are likely to assist us in our assessment of a pregnant woman’s risk for developing PPD:

  • Unrealistic Expectations-Although it is helpful to have a positive attitude in life, expecting everything to be smooth, easy and intuitive for the mother and, that the new mother will have no problem providing all the baby care and perform the house chores single-handedly, may set her up for failure. These expectations are very much a part of the Myth of Motherhood that is a subtext in the discourse on motherhood in our society. When the new mother, her partner and others in her environment have these unrealistic expectations, the new mother may be at a high risk for developing PPD. A care provider may want to discuss postpartum expectations with their pregnant client.
  • Recent or planned transition or change-The transition to motherhood is, of course, a major one. Often pregnant couples plan another major transition at the same time, such as moving to a bigger space in a different neighborhood or city. Such changes might make sense on one level, for example, allowing for more space to accommodate the growing family, but they make little sense in terms of the level of stress entailed and the possibility of losing social connections and accessibility to services. Health care providers may wish to inquire about such recent or planned changes.
  • Lack of Postpartum Plan-Related to unrealistic expectations regarding motherhood is a lack of postpartum plan. Women, especially those having their first baby, are often much more focused on the birth plan than on a plan for the weeks and months postpartum. Questions such as who will provide support? Who is going to share the care for the baby with the mother? What about food preparation? What about house chores? Should be discussed in detail and pregnant women and their partners should be encouraged to make one in as great detail as possible.
  • Relationship distress-Whether the distress is in the relationship with the partner or another family member, it can add significantly to a new mother’s level of stress. Highly significant are the relationship with the partner and the new mother’s own mother. These have been identified as risk factors for depression in general and postpartum depression, in particular.
  • Being emotionally disconnected from the baby-most pregnant women, even first time mothers, think about the baby, are curious what the baby would look like, are moved when they see the baby’s ultrasound image, preparing for the baby (“nesting”), etc. A pregnant woman who seems to be disconnected from the baby, does not show interest in the baby or says she doesn’t feel anything toward the baby, should be flagged for PPD risk.
  • Receiving a diagnosis of baby abnormality-learning that your baby has a congenital malformation or another health concern is often devastating. Such diagnosis should serve as a serious warning sign for depression in pregnancy and in the postpartum period.

We should all keep in mind that about 15% of new mothers will develop Postpartum Depression.

The percentage is higher in disadvantaged populations and when the mother is a teen and has no partner or support. Many pregnant women who exhibit symptoms of depression or who have other risk factors are being underdiagnosed. Early diagnosis and monitoring can help a woman get the help she needs sooner. This would significantly help her, her baby and her family.

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*All names and personal details are altered to preserve clients’ privacy