Pharmacists Should Counsel Women About Post-Traumatic Stress Disorder Due to Childbirth
Posttraumatic stress disorder is seldom associated with happy and wondrous events like childbirth. In fact, many people find it hard to believe—or outright refuse to consider—that post-traumatic stress disorder due to childbirth actually exists. Sadly, it’s all too real.
Any type of trauma experienced during delivery can trigger this persistent disorder, which may subsequently interfere with the mom’s ability to bond with her new baby or to share in the family’s joy. It’s essential to recognize childbirth-related PTSD so you can educate patients about its existence, guide treatment decisions and help women survive this difficult condition.
Diagnostic Criteria for Post-Traumatic Stress Disorder
Posttraumatic stress disorder (PTSD) is a pathological anxiety disorder triggered by exposure to a traumatic event. As it relates to childbirth, PTSD is a relatively new field of study, but it should be on your radar so you can be a source of information for a new mom who’s struggling with unexplainable reactions. The DSM-5 diagnostic criteria used to evaluate all cases of PTSD include:1
Criterion A (one required) – The person was exposed to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence in one of the following ways:
- Direct exposure
- Witnessing the trauma
- Learning that a relative or close friend was exposed to a trauma
- Indirect exposure to aversive details of the trauma, often in the course of professional duties such as happens to first responders
Criterion B (one required) – The traumatic event is persistently re-experienced in the following ways:
- Recurrent and intrusive thoughts of the event
- Recurrent nightmares
- Flashbacks and other dissociative reaction—person feels or acts as if the event is recurring.
- Intense emotional distress after exposure to cues that symbolize the event.
- Physical reactivity after exposure to traumatic reminders
Several other diagnostic criteria cover issues like avoiding trauma-related stimuli and negative thoughts or feelings that began after the trauma. Another important criterion defines behavioral issues that began at or worsened after the trauma:
Criterion E (two required):
- Irritability or aggression
- Risky or destructive behavior
- Heightened startle reaction
- Difficulty concentrating
- Difficulty sleeping
Finally, to be diagnosed with PTSD the symptoms must last more than one month and create significant distress or functional impairment. For example, it may interfere with the ability to take care of the baby, go to work or socialize.
Difference Between Postpartum Depression and PTSD
Childbirth-related PTSD is sometimes confused with postpartum depression, so it’s important to recognize the differences between the two. Postpartum depression, which affects 1 in 8 women, manifests in classic depressive symptoms like sadness, lack of interest in daily activities, insomnia, and fatigue.2 Women with postpartum depression do not experience symptoms unique to PTSD such as intrusive memories and flashbacks. While women with PTSD may become depressed, they tend to feel on edge or as if danger is around the corner, and they avoid anything or anyone that reminds them of the trauma.
In women with postpartum depression:3
- 85 percent experience relatively mild depression that resolves in a few weeks.
- 10 to 15 percent develop persistent and disabling major depression.
Prevalence rates related to PTSD are estimated as follows:4
- Overall mean prevalence of about 3 to 4 percent—range of 1 to 7 percent5
- Full-fledged PTSD due to health difficulties in the mother and/or child and/or stillbirth—20 to 25 percent.
- Partial PTSD symptoms following a traumatic delivery—26 to 41 percent.
- Emotional distress following childbirth without difficulties—2.8 to 5.6 percent have PTSD at six weeks postpartum
Risk Factors for Post-Traumatic Stress Disorder Due to Childbirth
The factors that trigger PTSD following childbirth vary for each person. Overall emotional health, the accessibility of medical treatment, and support during and immediately after the traumatic event all have an impact. The following events are most likely to cause PTSD:
- Depression during pregnancy – strongly predictive of PTSD risk
- Health complications during pregnancy
- Emotional or subjective distress—fear of labor, feeling ill-prepared for delivery or helpless
- Extreme pain during delivery
- Lack of support from partner and/or medical staff
- Premature birth
- Complications with mother or child during and/or after delivery
- Unplanned Cesarean section, vacuum extraction or forceps delivery
- Infant placed in neonatal intensive care
- Postpartum hemorrhage
Health professionals, family, and friends expect new parents to have a serious emotional reaction to trauma like stillbirth, hemorrhage and physical complications with the mother or child. However, other items on the list, like fear of labor and pain during delivery, are often viewed as typical for childbirth, not events that should cause PTSD. Unfortunately, attitudes like that reflect stigma and misunderstanding, which prevent those with PTSD from seeking help. Remember that each woman’s emotional response, resilience and ability to cope is different.
Current Treatment Options for PTSD
Since few studies have explored treatment efficacy specifically for childbirth-related PTSD, treatment follows the same protocol as for any other type of posttraumatic stress, which means a combination of medications to control physiological symptoms and psychotherapy that gives the patient an opportunity to work through their emotional reactions.
In addition to anxiety management and relaxation techniques, nonpharmacological options include:
- Cognitive behavioral therapy (CBT) – The most effective treatment as it helps patients challenge recurrent thoughts and memories associated with the trauma.6 One study found that CBT for PTSD following childbirth was also effective when provided over the Internet.7
- Eye movement desensitization and reprocessing (EMDR) – EMDR is also considered first line treatment. In therapist-controlled phases, patients are directed to think about specific memories while performing eye or hand movements.8 The process is believed to enhance the brain’s processing system, which leads to resolution of emotional distress and cognitive insight.
Medical therapy – Different drugs are used to target specific symptoms, but first line treatment usually includes antidepressants and beta-blockers. In addition to monitoring for interactions with other drugs and herbal supplements, pharmacists should ask women if they’re breastfeeding and ensure medications aren’t contraindicated:
- Selective serotonin reuptake inhibitors – sertraline and paroxetine approved to reduce PTSD symptoms
- Tricyclic antidepressants – amitriptyline and imipramine are effective for PTSD but not FDA-approved
- Monoamine oxidase inhibitors – for patients who can’t tolerate or don’t respond to antidepressants
- Benzodiazepines – relieve anxiety and irritability in patients with PTSD
- Beta-blockers – propranolol to control hyperarousal
- Anticonvulsants – off-label to control impulsivity
- Atypical antipsychotics – off-label to help stop nightmares and flashbacks
- Alpha-2 adrenergic agonists – clonidine may be considered to relieve hyperarousal and to stop nightmares
Pharmacists Should Reach Out to Women with PTSD
Many new moms with PTSD don’t understand their emotions and thoughts. They may mistake them as a form of postpartum depression or they may ignore their symptoms thinking they’re just learning to adjust to a new baby. Even worse—PTSD may interfere with parenting if the baby serves to trigger traumatic memories. Their future health relies on getting help as soon as possible, which has a better chance of happening when pharmacists recognize the signs and offer a few minutes of time to educate the patient and recommend they seek a doctor’s advice.
Pharmaceutica North America provides prescription drug products such as diclofenac sodium and lidocaine ointment, and a diverse line of high-quality active pharmaceutical ingredients, including medications that may help women with PTSD. Contact us today to talk about how we can support your pharmaceutical needs.
- “PTSD and DSM-5,” December 2016, http://www.ptsd.va.gov/professional/PTSD-overview/dsm5_criteria_ptsd.asp ↩
- “Depression Among Women,” August 2016, https://www.cdc.gov/reproductivehealth/depression/ ↩
- “Postpartum Depression,” June 2016, http://reference.medscape.com/article/271662-overview ↩
- “Emotional Distress Following Childbirth: An Intervention to Buffer Depressive and PTSD Symptoms,” May 2015, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4873107/ ↩
- “Postpartum Depression and Posttraumatic Stress Disorder,” accessed January 2017, http://psychcentral.com/lib/postpartum-depression-post-traumatic-stress-disorder/ ↩
- “Managing Posttraumatic Stress Disorder in an Outpatient Setting,” November 2015, https://www.uspharmacist.com/article/managing-posttraumatic-stress-disorder-in-an-outpatient-setting ↩
- “Internet-Provided Cognitive Behaviour Therapy of Posttraumatic Stress Symptoms Following Childbirth – a Randomized Controlled Trial,” June 2016, https://www.ncbi.nlm.nih.gov/pubmed/27152849 ↩
- “What is EMDR Therapy?” accessed January 2017, http://www.emdr.com/frequent-questions/ ↩