ROLE OF FAMILY IN POST-PARTUM DEPRESSION: A CASE REPORT

INTRODUCTION

Post-partum depression is a serious form of clinical depression related to pregnancy and childbirth which is often confused with the milder “baby blues” that typically go away after a week or two. The ICD-10, permits the classification of mental and behavioural disorders associated with the puerperium (F53) only if they onset within six weeks and if they cannot be classified elsewhere (WHO, 1992). The DSM-IV, with an even shorter onset specifier of four weeks. Ironically, in this system, specific features of postnatal mood disorder are acknowledged in the text (e.g., fluctuating course and mood lability, delusions including the baby at risk of infanticide, disinterest in the infant, guilt because of dissonance between the mother’s mood and society’s expectation of happiness, and less than optimum development of a mother/infant relationship) (APA, 1994).

Postpartum depression may be mistaken for baby blues at first but the signs and symptoms are more intense and last longer which may eventually interfere with the ability of a mother to bond and care for the baby and handle other daily tasks. Symptoms usually develop within the first few weeks after giving birth, but may begin earlier during pregnancy or later up to a year after birth (WebMed, 2020)

Postpartum depression signs and symptoms may include: depressed mood or severe mood swings, excessive crying, difficulty bonding with your baby, withdrawal from family and friends, loss of appetite or eating much more than usual, inability to sleep (insomnia) or sleeping too much, overwhelming fatigue or loss of energy, reduced interest and pleasure in activities you used to enjoy, intense irritability and anger, fear that you’re not a good mother, hopelessness, feelings of worthlessness, shame, guilt or inadequacy, diminished ability to think clearly, concentrate or make decisions, restlessness, severe anxiety and panic attacks, thoughts of harming yourself or your baby, recurrent thoughts of death or suicide (Mayoclinic, 2020, Canadianliving 2020). There are many causes of post-partum depression including rise of hormone levels while pregnancy, history of depression, stress and anxiety, difficult life events, unwanted pregnancy, financial issues, substance abuse, domestic violence, young age of the mother, lack of psycho-social support and care etc. (WebMed, 2020)

Postpartum depression can be prevented through educating the parents, maintain good sleep pattern and healthy nutritious diet, regular exercise, pregnancy yoga and meditation by avoiding making major life changes during or right after childbirth (Upadhyay et.al. 2017).  Sharing feelings and fears related to childbirth and care, Enlisting good support system during birth and aftercare of the mother and the baby. Preparing mother and her care givers well for childbirth. Building good emotional and psycho-social support group for ventilation of emotions and thoughts (Field, 2010). Asking for help if needed. Talking to them about how one is feeling and how life is changing rapidly each day after childbirth. Attending group therapy with new mothers under trained counsellors and therapists (O’hara & Swain,1996).

CASE DESCRIPTION

A twenty-eight years old, married, urban, middle class, Hindu, female contacted in the OPD of CIP for psychiatric help accompanied by her father and husband. Patient complaint of having irritability, low mood, crying to self, pessimistic views about future, lack of interest in daily activities and suicidal ideations for past eight months soon after the child birth. Patient denied to feed and take care of her new born and showed irresponsible and escapist behaviour. Onset of the illness was reported to be insidious with continuous course with deteriorating progress. Precipitating factors remained constant stress and anxiety as well as poor social support and marital conflict. Differential Diagnosis as per ICD-10 was kept: Post-partum depression without psychotic symptoms with adjustment disorder.

A brief cross-sectional history was taken while intervening with the patient with her husband and father, who was admitted for her treatment in (CIP). She was self-referred for her treatment and pharmacological intervention in CIP, OPD. Patient had poor marital adjustment and she was not able to carry her motherhood and marital responsibilities properly and was feeling overwhelmed, fatigued, insufficient, dissatisfied by her life with complaining behaviour. She used to become irritable and start crying whenever her mental conditions as well as psycho-social problems were discussed. She reported her difficult conditions, helplessness, hopelessness and death wishes during her assessment. 

Family composition was nuclear in type, consisting three members only. Index patient was the eldest daughter of three children staying with her parents after childbirth. Pre-morbidly patient was staying with her husband having problem in adjustment with his difficult temperament. Her father was a 59 years old businessman by profession. He cares for the patient and tries to fulfil her needs as per the requirement. But he is over-involved with the patient due to her financial problems and illness which has caused severe conflict with her husband. He is authoritative and impulsive in nature.

Patient’s mother was a 49 years old housewife. She has very warm and caring attitude towards her children. Due to over dependence of patient on her, she remains anxious and helpless. Patient’s elder brother was a 26 years old businessman. He was found very caring and supportive towards patient. He is married and patient shared conflicting relation with her sister-in-law. Patient’s younger brother has poor intellectual functioning and is unemployed. He holds a weak position in family but has limited relation with patient and other family members.

Patient’s family was in fifth developmental stage that is launching young children and moving on. The internal boundaries were open, semi permeable and disengaged. The external boundaries were semi-open and semi permeable. Power structure was in the hands of father who was nominal and functional head of the family. Decision making was autocratic as well as democratic at times.

The family belonged to sub-urban culture, religious and traditional belief system was found with moderately educated background with discriminatory attitude towards female members. They followed Hindu religion. There was mild level of stigma related to patient’s illness. The role performances were not adequately done and not distributed evenly, as patient was incapable of performing household tasks properly so her husband was overloaded due to increased burden of child care, his work as well as patient care with all household chores. He had psychological and emotional burden due to patient’s illness and her uncooperative nature towards him. There was unclear, indirect and insufficient communication between patient and her spouse and other family members. Affective involvement was based on need and interest.

Expressed emotions were found high from father and the husband adding to the distress of the patient. Attitude of the family towards patient’s illness was negative as the parents had poor and inadequate knowledge regarding patient’s condition. They have given poor attention and care to the distress caused to the patient due to her illness. Husband and father of the patient have negative temperament and critical view towards the patient. Family support system was not found adequate. Family history of any psychiatric illness was found nil. Living conditions of the patient was found satisfactory.

Psycho-social formulation included poor support from husband and family members, discrimination, critical comments and dissatisfaction from husband and father, financial dependency of the patient on family of origin, stress and physical and psychological burden due to childbirth and poor self-coping, struggle with self-insufficiency and poor problem-solving process, insufficiency and carelessness in managing house hold tasks and inadequacy in taking care of her new born and adjusting to the new role responsibilities.

Management plans included establishment of rapport with the patient and her family members and building therapeutic alliance, Psycho-education to the patient and her spouse as new parents, enhancing coping mechanisms and decision-making skills of the patient, resource mobilization for psycho-social and financial support, reducing stress of intra-personal and interpersonal conflicts, Family Therapy and providing guidance for self-care and child-care

FAMILY THERAPY INTERVENTIONS

After developing a strong rapport with the patient and her caregivers. The therapeutic alliance was easily built up. It was found that the patient’s mood remained low and she was crying most of the times and while assessment there was high self-consciousness. The patient was psycho-educated regarding the mood disorders and its implication on her health and other activities. The symptoms of post-partum depression were described and the course of mood disorders was also explained to her. The role of medication in depression and its side effects were explained. The patient’s condition was assessed with the help of her family members. Then psycho-education was given to them regarding her condition and illness. The symptoms and etiology of the depressive episodes were explained. The importance of caring her physical and mental health was also explained. The psycho-social factors of potential stressors were identified and the ways to reduce stress were also discussed. The family members agreed for each intervention and promised to cooperate in all possible ways. 

After assessment it was clear that the core problem was critical comments by husband about the inefficiency of the patient. He was very critical and discouraging towards the patient and had poor affective involvement with her. He had adequate relation with all the family members except the patient causing a lot of dissatisfaction and distress in her. Both father and husband were counselled together and separately in order to reach important conclusion for the patient’s optimal care, resolving family issues, roles and in reducing critical comments and dissatisfaction level. Along with better future prospects were discussed for the improvement of the patient as a new mother and new roles, also building up her confidence and positive self-image.

The coping mechanism was strengthened as patient was told that she has dependency on her own family members and relatives so far and therefore, for betterment she needs to strengthen her coping skills and enhance her strategies to handle the house hold responsibilities and child care techniques. The decision-making skills were also strengthened through the life skill training. She was detailed how decision making is important for her better life. She was assisted in taking decisions on various issues and the ways to take decision were taught like sharing her opinions with her spouse, identifying the pros and cons of the decisions, its feasibility and limitations. Putting thought to each decision and matter was emphasized. She herself reported that she was feeling good about her confidence, her roles, responsibility bearing and self-sufficiency in her decision-making skills. 

Information regarding her better future prospects were discussed to engage the patient in positive tasks and improve her personality with self-confidence. Different ways and methods for playing effective roles as a homemaker, wife and mother were suggested. She was told not to fully depend on her parents for her future decisions and plans. She was told to prepare herself for every type of events going to come in the future beforehand, for the betterment of herself and her family. 

Patient’s husband was given individual counselling in which the effective care-giving and controlled behaviour with patient was focused. He was told to sympathetically and patiently deal with the patient and be cooperative and encouraging for the efforts she has been taking for improvement in her roles and tasks. He was also suggested to wishfully handle her problems with combined efforts and give her special attention and support in child-care routine activities. The areas of dissatisfaction and criticism were effectively dealt by providing adequate knowledge and suggestions to the spouse of the patient. Problems of sexual sphere were also resolved consciously.

Pre-discharge counselling was done in which importance of follow-ups and medications were explained. Caregivers as well as the patient were told to come for next follow up. The side-effects profile and medicine dosage were explained in details.

DISCUSSION

Postpartum psychiatric disorders can be divided into three categories: postpartum blues; postpartum psychosis and postpartum depression. Postpartum blues, with an incidence of 300 750 per 1000 mothers globally, may resolve in a few days to a week, has few negative sequelae and usually requires only reassurance (Upadhyay et.al. 2017). Postpartum psychosis, which has a global prevalence ranging from 0.89 to 2.6 per 1000 births, is a severe disorder that begins within four weeks postpartum and requires hospitalization. Postpartum depression can start soon after childbirth or as a continuation of antenatal depression and needs to be treated (Di Florio et.al., 2013). The global prevalence of postpartum depression has been estimated as 100 150 per 1000 births (O’hara & Swain, 1996). Postpartum depression can predispose to chronic or recurrent depression, which may affect the mother infant relationship and child growth and development (Field, 2010). Children of mothers with postpartum depression have greater cognitive, behavioural and interpersonal problems compared with the children of non-depressed mothers (Cox, 2004). 

While postpartum depression is a considerable health issue for many women, the disorder often remains undiagnosed and hence untreated (Stewart et al., 2003). Scarcity of available mental health resources, inequities in their distribution and inefficiencies in their utilization are key obstacles to optimal mental health care especially in lower resource countries. Addressing these issues is therefore a priority for health care providers and government (Fisher et al., 2012). The care-giving of a new mother and a new-born should be dealt affectively through educating the immediate care providers, family members and the spouses (Baron, et al., 2016).

Despite the launch of India’s national mental health programme in 1982, maternal mental health is still not a prominent component of the programme. Dedicated maternal mental health services are largely deficient in health-care facilities, and health workers lack mental health training. The availability of mental health specialists is limited or non-existent in peripheral health-care facilities (Saxena et.al., 2007).  Despite the growing number of empirical studies on postpartum depression in India, there is a lack of robust systematic evidence that looks not only at the overall burden of postpartum depression, but also its associated risk factors (WHO, 2015).

India is experiencing a steady decline in maternal mortality, which means that the focus of care in the future will shift towards reducing maternal morbidity, including mental health disorders (Saxena et.al., 2007). Furthermore, there is currently no screening tool designated for use in clinical practice and no data are routinely collected on the proportion of perinatal women with postpartum depression (WHO, 2015). 

CONCLUSION

Family plays pivotal role in the care-giving of a new mother and her child. The added responsibilities and coping with the sudden physical, psychological, emotional and financial challenges of the new parents could be overwhelming. There should be pre-parental counselling for the new parents and assisted help should be managed prior to the child birth. Parenting is a huge responsibility and holistic care of a mother is required to combat with post-partum depression. Health workers and counselors could play efficient role in providing psycho-education and post pregnancy counselling to the new parents and their families.

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