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Postpartum Depression

Incidence of Postpartum Depression

Postpartum depression (PD) has been shown to occur in approximately one in ten childbearing women and is thought to be considerably underdiagnosed. The peak incidence of clinical depression in general is 18 to 44 years which coincides with prime childbearing years as well. While the exact mechanism is unknown, most feel that fluctuating hormones play a significant role in PD.

Symptoms

PD is characterized by persistent feelings of depressed mood, loss of pleasure or interest, sleep disturbances, weight loss, lack of energy, agitation, feelings of worthlessness, diminished concentration, and thoughts of death or suicide. Unfortunately, many of these symptoms are difficult to tell apart from the more commonly experienced “baby blues” that occur within the first few days after delivery and generally resolve within the first two weeks. Not surprising, these symptoms can be of concern if persisting when a pilot returns to flying.

Symptoms of Postpartum Depression

  • Depressed Mood
  • Loss of Interest or Pleasure
  • Sleep Disturbances*
  • Unintended Weight Loss*
  • Lack of Energy*
  • Agitation
  • Feelings of Worthlessness or Guilt
  • Diminished Concentration or Indecisiveness*
  • Frequent Thoughts of Death or Suicide

*Denotes symptoms that can also occur with the “baby blues”

“Baby Blues” versus Depression

Studies have shown the “baby blues” are much more common occurring in 26 to 85 percent of pregnancies. These milder symptoms may involve tearfulness for no discernable reason, labile mood, increased sensitivity and irritability peaking four to five days after delivery. Unfortunately when not short-lived, these symptoms can blossom into clinical PD. In extreme cases, psychosis can even develop where delusions or hallucinations are present that often involve the baby such as thoughts that a baby may be possessed by a demon and should die. Because of the risk to the mother and the child, postpartum psychosis is a medical emergency.

Unlike “baby blues”, PD tends to last much longer unless appropriate treatment is sought out. Many mothers delay seeking help because of perceived societal pressures, shame, or fear. Moreover, many women feel they are “losing their mind” and are afraid of repercussions if they admit it. For aviators, the problem is even more pronounced from fear of adverse action jeopardizing future flying careers. Hopefully after reading this article, those fears can be alleviated.

Evaluation for Postpartum Depression

First and foremost, early detection of PD is key. Studies have shown that maternal depression can affect babies as young as three months of age showing regression in cognitive skills, language development, and attention patterns. One screening tool known as the Edinburgh Postnatal Depression Scale has been shown quite effective in identifying PD. Those aviators at greater risk are characterized in the following graph.

Aviators at Risk for PD

  • Previous PD
  • Other Past History of Depression or Substance Abuse
  • Family History of Mental Illness
  • Severe Premenstrual Dysphoric Disorder or “PMS”
  • Marriage or Relationship Difficulties
  • Financial Difficulties
  • A Weak Support Group of Family or Friends
  • Other Concurrent Stressful Life Events
  • Young Maternal Age

Treatment and FAA Impact

Treatment for PD typically involves talk therapy, antidepressants, or a combination of the two. While routine marital counseling or visits to clergy are not reportable, other visits to healthcare professionals should be reported on the FAA medical application. Specifics on how to report such visits can be found on our website. Most importantly, pilots should not sacrifice their well-being in an attempt to maintain their medical certificate. Even if antidepressants are temporarily needed, a pilot can get a Special Issuance or waiver to return to flying once the meds are no longer required for control. You may also want to discuss with your doctor or midwife the possible use of non-traditional therapies and nutritional supplements such as St. John’s Wort, Tryptophan – 5-HTP, and S-Adenosylmethionine (SAM). Some studies have shown effectiveness of these supplements in treating the symptoms of depression and mood disorder. The substances are not regulated by the FDA, and are not required to be reported on your medical application. However, you must remember to report all visits to healthcare providers on your application, and be sure not to start medications or supplements without first discussing with your healthcare provider since some supplements have the potential for being passed to your baby in breast milk.

The Special Issuance process for history of PD or for PD that previously required medications is essentially the same. If medications were used, before consideration the FAA would like to see that the pilot has remained stable at least 60 days off the antidepressants depending on how long they were required for control. A detailed, typed, clinical narrative is crucial. It should address treatments including medication dosages (if any), start and stop dates of therapy, response, and future prognosis. If delays occur it’s generally due to inadequate information from the treating clinician. The narrative should be carefully scrutinized to make sure all of the Aeromedically significant issues are fully addressed to prevent delays in processing. If the package is complete the first time around, an airman can typically expect an answer in 3-5 weeks from the Aeromedical Certification Division of the FAA.

Current FAA policy also allows use of certain antidepressants for pilots and air traffic controllers in very specific circumstances. The antidepressant medications Celexa (citalopram), Prozac/Sarafem (fluoxetine), Zoloft (sertraline), Lexapro (escitalopram), Wellbutrin (buproprion) Extended or Sustained Release, Pristiq (desvenlafaxine), Cymbalta (duloxetine), and Effexor (venlafaxine) are now waiverable once on a single same dosage therapy for at least 6 months (this was reduced from 1 year in early 2014 and controllers were added to the policy in Mar 2017).  In addition to the required waiting period for stabilization, the FAA requires cognitive testing and oversight by a psychiatrist. This program requires a specially trained AME to serve as the Individual Medical Sponsor or IMS.  Please refer to our article on “Depression” for more information or talk with an AMAS physician.

Helpful Tips

  • Find someone to share your feelings with.
  • Try to get enough rest. Nap when the baby naps.
  • Do what you can and leave the rest! Consider hiring assistance for childcare, household chores, errands, etc.
  • Don’t spend excessive amounts of time alone.
  • Consider keeping a diary to “let it all out”. Later reading can reemphasize the progress you’ve made.
  • Spend time alone with husband or partner.
  • Talk with other mothers to learn from their experiences.
  • Join a support group for women with similar concerns.

Conclusion

For your baby’s sake, your family’s well-being, and your personal health, do not hesitate to seek help if needed. Our website lists some of the resources available to you. Should you find you do need help, make sure to get advice and assistance from an experienced Aviation Medical Examiner or an Aerospace Medicine physician to quickly get you back in the air. Our physician staff is available to assist you with this and any aeromedical certification issue.

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