Lindsey Gottschalk, MSPH
After 9 long months of waiting, you are finally home with your baby, and you are… tired. Everything is new and exciting but also overwhelming. You are overjoyed but also feel sad, anxious, and irritable. What gives?
During the first few days after childbirth through the first few weeks some times months, it is incredibly common to experience this rollercoaster of moods and emotions. You may have heard this referred to as the “baby blues” or “postpartum blues.” The good news is that for most women who experience this, the baby blues are fleeting and not an indication of major depression.
But what about after that?
Baby blues or postpartum blues can transform into Postpartum depression.
Postpartum depression (PPD) is estimated to affect roughly 13-19% of women during the postpartum period, though estimates vary among studies and settings (1).
It is characterized by depressed mood, loss of interest in activities, and a host of other symptoms that last for a length of time (the diagnostic criteria specify 5 or more symptoms lasting at least 2 weeks) (2, 3).
It is distinguished from the baby blues as it lasts longer, disrupts daily activities, and may require treatment—it is not something that you should be expected to “just shake off” or “get over.”
PPD can feel particularly challenging because it is disruptive and causes significant issues while you are already adjusting to a multitude of changes in your surroundings and your body. You know that you want to be able to care for your little one and yourself, but you also might be feeling helpless or apathetic and unable to dig yourself out. Compounding this, you might still be experiencing physical pain from the delivery that affects your ability to do daily tasks, your mood, and your outlook on life and motherhood.
Pain as a risk factor for postpartum depression
While there are many risk factors for PPD that are commonly known, including previous episodes of major depressive disorder, lack of social support, and difficulty breastfeeding, one area of current exploration is the relationship between physical pain and PPD.
The relationship between pain and depression in the general population is well-established, having been observed and studied for several decades at this point (3, 4, 5). Pain—whether from an injury or as a symptom of another health condition—can contribute to depression; likewise, depression can manifest in physical pain, such as headaches or backaches (4, 5, 6).
Pain and fatigue are the most common issues experienced by women in the postpartum period (7). For most women, the pain gradually subsides; however, several women continue to experience pain months after delivery. Is it possible that childbirth-related pain—pain related to recovery from vaginal delivery or C-section—triggers or compounds PPD? Based on what we already know about the relationship between pain and depression, this is a reasonable hypothesis. The evidence on the relationship between pain and PPD is still limited, but is a growing area of interest for researchers with mounting evidence to suggest “yes.”
Acute pain is a sharp, severe pain that is directly related to an injury or medical procedure, and that usually goes away within weeks or months. A 2008 study suggests that acute pain after delivery is associated with both persistent postpartum pain and PPD (8). Women in the study that experienced acute pain 24 hours after delivery (both vaginal and C-section) were 2.5 times more likely to experience persistent pain at 8 weeks postpartum and 3 times more likely to have PPD than women who had reported mild pain after delivery (8).
In the same study, women with C-sections had more acute pain immediately after birth than women who delivered vaginally; however, by 8 weeks postpartum, the experience of persistent pain and PPD was the same regardless of the type of delivery (8). This study clearly indicates that persistent pain is related to an individual’s pain response and not the degree of the trauma of one type of delivery versus the other (8). In short, everyone experiences and recovers from pain differently.
In another study, women with perineal pain at 4-6 weeks postpartum had a higher risk of PPD at 4-6 weeks and 6 months compared with women that did not have any pain (9). Pain can interfere with the ability to return to normal, daily activities, and it can take a psychological toll on new mothers; this may help to explain one of the ways that pain impacts the development of depression (7, 9).
Researchers are currently investigating interventions performed during delivery that could better manage pain and trying to understand the complex ways in which pain and PPD interact (10). What’s clear is that there is a relationship between pain and depression, which extends to delivery-related pain, prolonged postpartum pain, and PPD. The American College of Obstetricians and Gynecologists (ACOG) acknowledges the relationship between untreated pain and PPD and has issued guidelines to providers for addressing and managing pain in the postpartum period (7). The recently updated guidelines from The American College of Obstetricians and Gynecologists (ACOG) suggests that mothers should be seen as early as 2 weeks postpartum and should be evaluated in several categories including mental and physical health (7). Please request your OBGYN for an appointment sooner than 6 weeks postpartum and go for the appointment.
Addressing pain and postpartum depression
So what can you do if you are experiencing pain and/or symptoms of PPD?
Talk to your healthcare provider. Contact them if you are experiencing any of the following:
Prolonged pain (either on the surgery site or any part of the body)
Pain in the Perineal/vaginal area.
Pain with penetration during sex.
Trouble taking care of your baby or completing daily tasks.
Thoughts of harming yourself or your baby.
Difficulty taking pleasure in activities or depressed feelings that have persisted or are getting worse
Many providers already screen for postpartum depression, as it is recommended by the United States Preventive Services Task Force (11). However, it is possible that you have not been screened since delivery or that your status has changed since you were last seen. You know your body best—let your provider know that you are experiencing symptoms of depression and physical pain.
Be upfront about your concerns. As hard as it is, don’t stay silent about any pain that you are experiencing, especially as it could be affecting your mental health and your ability to care for yourself and your baby. It is common to have difficulty discussing these topics, and you may even feel guilty, just talking about it. Remember that your provider is there to help you assess the problem and find a treatment solution that works for you.
Treatment Options:
Your provider will likely discuss options for treating the two conditions.
For Postpartum Depression:
Treatment options include psychotherapy, medication, or both simultaneously. If your PPD symptoms are mild, your provider might start by prescribing counseling and recommending lifestyle changes, such as modifications to your diet and physical activity. Medication can be a great option for treating depression, especially if symptoms are severe. Many newer antidepressants have fewer side effects than some of the older medications, and your provider will discuss options and try to find one that will work best for your individual body and lifestyle. While you might worry about starting medication for a long period of time, many people are eventually able to stop taking antidepressants after their symptoms have subsided slowly.
For pain:
You can expect your provider to start by prescribing Nonsteroidal Anti-inflammatory Drugs (NSAIDs), which are considered the first line of defense because they are often effective and are non-habit forming (7). Some of them can be safely taken while breastfeeding, but your provider should speak to you about the safety of taking your medications while nursing. Another course of treatment for postpartum pain is physical therapy; your provider can refer you to a PT who specializes in women’s health and the pelvic floor region. As these conditions are interrelated, treating your depression can help improve physical pain, and treating your pain can help improve symptoms of PPD.
For you:
Finally, enlist a support network, like a partner, friend, or family member, if possible. It’s hard enough being a new mother without dealing with pain or PPD, so get help where you can.
Conclusions
There is a well-established link scientific link between pain and depression, and delivery-related pain and postpartum depression are no exception. Experiencing a painful delivery and acute pain in the immediate postpartum period does not, however, mean that you will develop PPD. If you have acute pain after delivery or prolonged pain in the postpartum period, make pain management a top priority and self-monitor for signs of depression. Talk to your provider about how to manage both your pain and depression symptoms together. In many cases, improvement in one will help with the other.
References
1. O'Hara MW, McCabe JE. “Postpartum depression: current status and future directions.”
Annual Review of Clinical Psychology. March 2013. 9, pp 379-407. doi.org/10.1146/annurev-clinpsy-050212-185612
2. American Psychiatric Association. “Diagnostic and statistical manual of mental disorders (5th ed.).” 2013. doi: 10.1176/appi.books.9780890425596
3. Division of Reproductive Health, National Center of Chronic Disease Prevention and Health Promotion. “Depression During and After Pregnancy.” Centers for Disease Control and Prevention. May 2019. Available at: https://www.cdc.gov/reproductivehealth/features/maternal-depression/index.html
4. Bair MJ, Robinson RL, Katon W, & Kroenke K. “Depression and Pain Comorbidity.” Archives of Internal Medicine. November 10, 2003. Vol. 163, pp 2433-2445. doi: 10.1001/archinte.163.20.2433
5. Korff MV & Simon G. “The Relationship Between Pain and Depression.” The British Journal of Psychiatry. June 1996. Vol. 168, Supplement 30, pp 101-108. doi:10.1192/S0007125000298474
6. Romano J & Turner J. “Chronic pain and depression: does the evidence support a relationship?” Psychological Bulletin. 1985. Vol. 97, pp. 18-34
7. American College of Obstetricians and Gynecologists. “Postpartum pain management. ACOG Committee Opinion No. 742.” Obstetrics and Gynecology. May 18, 2018. Vol. 132. DOI: 10.1097/AOG.0000000000002683.
8. Eisenach JC, Pan PH, Smiley R, Lavand'homme P, Landau R, and Houle TT. “Severity of Acute Pain After Childbirth, but not Type of Delivery,
Predicts Persistent Pain and Postpartum Depression.” Pain. November 15, 2008; Vol. 140, Issue 1, pp 87–94. doi:10.1016/j.pain.2008.07.011.
9. Chang SR, Chen KH, Lee CN, Shyu MK, Lin MI, & Lin WA. “Relationships between perineal pain and postpartum depressive symptoms: A prospective cohort study.” International Journal of Nursing Studies. 2016. Vol. 59, pp 68-78. doi: 10.1016/j.ijnurstu.2016.02.012
10. Lim G, Farrell LM, Facco FL, Gold MS, Wasan AD. “Labor Analgesia as a Predictor for Reduced Postpartum Depression Scores: A Retrospective Observational Study.” Anesthesia & Analgesia. May 2018. Vol. 126, Issue 5, pp 1598-1605. doi:10.1213/ANE.0000000000002720
11. U.S. Preventive Services Task Force. “U.S. Preventive Services Task Force (USPSTF): Depression in Adults Screening.” U.S. Dept. of Health & Human Services, Agency for Healthcare Research and Quality. January 2016. Accessed at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/depression-in-adults-screening1
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