Postpartum depression

Postpartum depression (PPD), also called postnatal depression, is a type of mood disorder associated with childbirth, which can affect both sexes.[1][3] Symptoms may include extreme sadness, low energy, anxiety, crying episodes, irritability, and changes in sleeping or eating patterns.[1] Onset is typically between one week and one month following childbirth.[1] PPD can also negatively affect the newborn child.[4][2]

Postpartum depression
Other namesPostnatal depression
SpecialtyPsychiatry
SymptomsExtreme sadness, low energy, anxiety, changes in sleeping or eating patterns, crying episodes, irritability[1]
Usual onsetA week to a month after childbirth[1]
CausesUnclear[1]
Risk factorsPrior postpartum depression, bipolar disorder, family history of depression, psychological stress, complications of childbirth, lack of support, drug use disorder[1]
Diagnostic methodBased on symptoms[2]
Differential diagnosisBaby blues[1]
TreatmentCounselling, medications[2]
Frequency~15% of births[1]

While the exact cause of PPD is unclear, the cause is believed to be a combination of physical, emotional, genetic, and social factors.[1][5] These may include factors such as hormonal changes and sleep deprivation.[1][6] Risk factors include prior episodes of postpartum depression, bipolar disorder, a family history of depression, psychological stress, complications of childbirth, lack of support, or a drug use disorder.[1] Diagnosis is based on a person's symptoms.[2] While most women experience a brief period of worry or unhappiness after delivery, postpartum depression should be suspected when symptoms are severe and last over two weeks.[1]

Among those at risk, providing psychosocial support may be protective in preventing PPD.[7] This may include community support such as food, household chores, mother care, and companionship.[8] Treatment for PPD may include counseling or medications.[2] Types of counseling that have been found to be effective include interpersonal psychotherapy (IPT), cognitive behavioral therapy (CBT), and psychodynamic therapy.[2] Tentative evidence supports the use of selective serotonin reuptake inhibitors (SSRIs).[2]

Postpartum depression affects roughly 15% of women after childbirth.[9][10] Moreover, this mood disorder is estimated to affect 1% to 26% of new fathers.[3] Postpartum psychosis, a more severe form of postpartum mood disorder, occurs in about 1 to 2 per 1,000 women following childbirth.[11] Postpartum psychosis is one of the leading causes of the murder of children less than one year of age, which occurs in about 8 per 100,000 births in the United States.[12]

Signs and symptoms

Symptoms of PPD can occur any time in the first year postpartum.[13] Typically, a diagnosis of postpartum depression is considered after signs and symptoms persist for at least two weeks.[14]

Emotional
  • Persistent sadness, anxiousness or "empty" mood[13]
  • Severe mood swings[14]
  • Frustration, irritability, restlessness, anger[13][15]
  • Feelings of hopelessness or helplessness[13]
  • Guilt, shame, worthlessness[13][15]
  • Low self-esteem[13]
  • Numbness, emptiness[13]
  • Exhaustion[13]
  • Inability to be comforted[13]
  • Trouble bonding with the baby[14]
  • Feeling inadequate in taking care of the baby[13][15]
  • Thoughts of self-harm or suicide[16]

Behavioural

Cognition
  • Diminished ability to make decisions and think clearly[15]
  • Lack of concentration and poor memory[15]
  • Fear that you can not care for the baby or fear of the baby[13]
  • Worry about harming self, baby, or partner[14][15]

Onset and duration

Postpartum depression onset usually begins between two weeks to a month after delivery.[18] A study done at an inner-city mental health clinic has shown that 50% of postpartum depressive episodes there began prior to delivery.[19] Therefore, in the DSM-5 postpartum depression is diagnosed under "depressive disorder with peripartum onset", in which "peripartum onset" is defined as anytime either during pregnancy or within the four weeks following delivery. PPD may last several months or even a year.[20] Postpartum depression can also occur in women who have suffered a miscarriage.[21] For fathers, several studies show that men experience the highest levels of postpartum depression between 3–6 months postpartum.[22]

Parent-infant relationship

Postpartum depression can interfere with normal maternal-infant bonding and adversely affect acute and longterm child development. Postpartum depression may lead mothers to be inconsistent with childcare.[23] These childcare inconsistencies may include feeding routines, sleep routines, and health maintenance.[23]

In rare cases, or about 1 to 2 per 1,000, the postpartum depression appears as postpartum psychosis.[11] In these, or among women with a history of previous psychiatric hospital admissions,[24] infanticide may occur. In the United States, postpartum depression is one of the leading causes of annual reported infanticide incidence rate of about 8 per 100,000 births.[2]

Causes

The cause of PPD is not well understood. Hormonal changes, genetics, and major life events have been hypothesized as potential causes.

Evidence suggests that hormonal changes may play a role.[25] Hormones which have been studied include estrogen, progesterone, thyroid hormone, testosterone, corticotropin releasing hormone, endorphins, and cortisol.[6] Estrogen and progesterone levels drop back to pre-pregnancy levels within 24 hours of giving birth, and that sudden change may cause it.[26] The use of synthetic oxytocin, a birth-inducing drug, has been linked to increased rates of postpartum depression and anxiety.[27]

Fathers, who are not undergoing profound hormonal changes, can also have postpartum depression.[28] The cause may be distinct in males.

Profound lifestyle changes that are brought about by caring for the infant are also frequently hypothesized to cause PPD. However, little evidence supports this hypothesis. Mothers who have had several previous children without suffering PPD can nonetheless suffer it with their latest child.[29] Despite the biological and psychosocial changes that may accompany pregnancy and the postpartum period, most women are not diagnosed with PPD.[30][31] Many mothers are unable to get the rest they need to fully recover from giving birth. Sleep deprivation can lead to physical discomfort and exhaustion, which can contribute to the symptoms of postpartum depression.[32]

Risk factors

While the causes of PPD are not understood, a number of factors have been suggested to increase the risk:

Of these risk factors a history of depression, and cigarette smoking have been shown to have additive effects.[34] Some studies have found a link with low levels of DHA in the mother.[45]

These above factors are known to correlate with PPD. This correlation does not mean these factors are causal. Rather, they might both be caused by some third factor. Contrastingly, some factors almost certainly attribute to the cause of postpartum depression, such as lack of social support.[46] The relationship between breastfeeding and PPD is not clear.[47]

Women with fewer resources indicate a higher level of postpartum depression and stress than those women with more resources, such as financial. Rates of PPD have been shown to decrease as income increases.[48] Women with fewer resources may be more likely to have an unintended or unwanted pregnancy, increasing risk of PPD. Women with fewer resources may also include single mothers of low income. Single mothers of low income may have more limited access to resources while transitioning into motherhood.

Studies have also shown a correlation between a mother's race and postpartum depression. African American mothers have been shown to have the highest risk of PPD at 25%, while Asian mothers had the lowest at 11.5%, after controlling for social factors such as age, income, education, marital status, and baby's health. The PPD rates for First Nations, Caucasian and Hispanic women fell in between.[48]

Migration away from a cultural community of support can be a factor in PPD. Traditional cultures around the world prioritize organized support during postpartum care to ensure the mother's mental and physical health, wellbeing, and recovery.[8]

One of the strongest predictors of paternal PPD is having a partner who has PPD, with fathers developing PPD 50% of the time when their female partner has PPD.[49]

Sexual orientation[50] has also been studied as a risk factor for PPD. In a 2007 study conducted by Ross and colleagues, lesbian and bisexual mothers were tested for PPD and then compared with a heterosexual sample group. It was found that lesbian and bisexual biological mothers had significantly higher Edinburgh Postnatal Depression Scale scores than did the heterosexual women in the sample.[51] These higher rates of PPD in lesbian/bisexual mothers may reflect less social support, particularly from their families of origin and additional stress due to homophobic discrimination in society.[52]

A correlation between postpartum thyroiditis and postpartum depression has been proposed but remains controversial. There may also be a link between postpartum depression and anti-thyroid antibodies.[53]

Violence

A meta-analysis reviewing research on the association of violence and postpartum depression showed that violence against women increases the incidence of postpartum depression.[54] About one-third of women throughout the world will experience physical or sexual violence at some point in their lives.[55] Violence against women occurs in conflict, post-conflict, and non-conflict areas.[55] It is important to note that the research reviewed only looked at violence experienced by women from male perpetrators, but did not consider violence inflicted on men or women by women. Further, violence against women was defined as "any act of gender-based violence that results in, or is likely to result in, physical, sexual, or psychological harm or suffering to women".[54] Psychological and cultural factors associated with increased incidence of postpartum depression include family history of depression, stressful life events during early puberty or pregnancy, anxiety or depression during pregnancy, and low social support.[51][54] Violence against women is a chronic stressor, so depression may occur when someone is no longer able to respond to the violence.[54]

Diagnosis

Criteria

Postpartum depression in the DSM-5 is known as "depressive disorder with peripartum onset". Peripartum onset is defined as starting anytime during pregnancy or within the four weeks following delivery. There is no longer a distinction made between depressive episodes that occur during pregnancy or those that occur after delivery.[56] Nevertheless, the majority of experts continue to diagnose postpartum depression as depression with onset anytime within the first year after delivery.[35]

The criteria required for the diagnosis of postpartum depression are the same as those required to make a diagnosis of non-childbirth related major depression or minor depression. The criteria include at least five of the following nine symptoms, within a two-week period:[56]

  • Feelings of sadness, emptiness, or hopelessness, nearly every day, for most of the day or the observation of a depressed mood made by others
  • Loss of interest or pleasure in activities
  • Weight loss or decreased appetite
  • Changes in sleep patterns
  • Feelings of restlessness
  • Loss of energy
  • Feelings of worthlessness or guilt
  • Loss of concentration or increased indecisiveness
  • Recurrent thoughts of death, with or without plans of suicide

Differential diagnosis

Postpartum blues
Main article: Postpartum blues

Postpartum blues, commonly known as "baby blues," is a transient postpartum mood disorder characterized by milder depressive symptoms than postpartum depression. This type of depression can occur in up to 80% of all mothers following delivery.[57] Symptoms typically resolve within two weeks. Symptoms lasting longer than two weeks are a sign of a more serious type of depression.[58] Women who experience "baby blues" may have a higher risk of experiencing a more serious episode of depression later on.[59]

Psychosis

Postpartum psychosis is not a formal diagnosis, but is widely used to describe a psychiatric emergency that appears to occur in about 1 in a 1000 pregnancies, in which symptoms of high mood and racing thoughts (mania), depression, severe confusion, loss of inhibition, paranoia, hallucinations and delusions begin suddenly in the first two weeks after delivery; the symptoms vary and can change quickly.[60] It is different from postpartum depression and from maternity blues.[61] It may be a form of bipolar disorder.[62] It is important not to confuse psychosis with other symptoms that may occur after delivery, such as delirium. Delirium typically includes a loss of awareness or inability to pay attention.[59]

About half of women who experience postpartum psychosis have no risk factors; but a prior history of mental illness, especially bipolar disorder, a history of prior episodes of postpartum psychosis, or a family history put some at a higher risk.[60]

Postpartum psychosis often requires hospitalization, where treatment is antipsychotic medications, mood stabilizers, and in cases of strong risk for suicide, electroconvulsive therapy.[60]

The most severe symptoms last from 2 to 12 weeks, and recovery takes 6 months to a year.[60] Women who have been hospitalized for a psychiatric condition immediately after delivery are at a much higher risk of suicide during the first year after delivery.[63]

Screening

In the US, the American College of Obstetricians and Gynecologists suggests healthcare providers consider depression screening for perinatal women.[64] Additionally, the American Academy of Pediatrics recommends pediatricians screen mothers for PPD at 1-month, 2-month and 4-month visits.[65] However, many providers do not consistently provide screening and appropriate follow-up.[64][66] For example, in Canada, Alberta is the only province with universal PPD screening. This screening is carried out by Public Health nurses with the baby's immunization schedule.

The Edinburgh Postnatal Depression Scale, a standardized self-reported questionnaire, may be used to identify women who have postpartum depression.[67] If the new mother scores 13 or more, she likely has PPD and further assessment should follow.[67]

Healthcare providers may take a blood sample to test if another disorder is contributing to depression during the screening.[68]

Prevention

A 2013 Cochrane review found evidence that psychosocial or psychological intervention after childbirth helped reduce the risk of postnatal depression.[69][70] These interventions included home visits, telephone-based peer support, and interpersonal psychotherapy.[69] Support is an important aspect of prevention, as depressed mothers commonly state that their feelings of depression were brought on by "lack of support" and "feeling isolated."[71]

Across different cultures, traditional rituals for postpartum care may be preventative for PPD, but are more effective when the support is welcomed by the mother.[72]

In couples, emotional closeness and global support by the partner protect against both perinatal depression and anxiety. Further factors such as communication between the couple and relationship satisfaction have a protective effect against anxiety alone.[73]

In those who are at risk counselling is recommended.[74] In 2018, 24% of areas in the UK have no access to perinatal mental health specialist services.[75]

Preventative treatment with antidepressants may be considered for those who have had PPD previously. However, as of 2017, the evidence supporting such use is weak.[76][77]

Treatments

Treatment for mild to moderate PPD includes psychological interventions or antidepressants. Women with moderate to severe PPD would likely experience a greater benefit with a combination of psychological and medical interventions.[78] Light aerobic exercise has been found to be useful for mild and moderate cases.[79][80]

Therapy

Both individual social and psychological interventions appear equally effective in the treatment of PPD.[81] Social interventions include individual counseling and peer support, while psychological interventions include cognitive behavioral therapy (CBT) and interpersonal therapy (IPT).[82] Other forms of therapy, such as group therapy, home visits, counseling, and ensuring greater sleep for the mother may also have a benefit.[13][5]

Internet-based cognitive behavioral therapy (iCBT) has shown promising results with lower negative parenting behavior scores and lower rates of anxiety, stress, and depression. iCBT may be beneficial for mothers who have limitations in accessing in person CBT. However, the long term benefits have not been determined.[83]

Medication

A 2010 review found few studies of medications for treating PPD noting small sample sizes and generally weak evidence.[82] Some evidence suggests that mothers with PPD will respond similarly to people with major depressive disorder.[82] There is evidence which suggests that selective serotonin reuptake inhibitors (SSRIs) are effective treatment for PPD.[84] The first-line anti-depressant medication of choice is sertraline, an SSRI, as very little of the it passes into the breast milk and, as a result, to the child.[5] However, a recent study has found that adding sertraline to psychotherapy does not appear to confer any additional benefit.[85] Therefore, it is not completely clear which antidepressants, if any, are most effective for treatment of PPD, and for whom antidepressants would be a better option than non-pharmacotherapy.[84]

Some studies show that hormone therapy may be effective in women with PPD, supported by the idea that the drop in estrogen and progesterone levels post-delivery contribute to depressive symptoms.[82] However, there is some controversy with this form of treatment because estrogen should not be given to people who are at higher risk of blood clots, which include women up to 12 weeks after delivery.[86] Additionally, none of the existing studies included women who were breastfeeding.[82] However, there is some evidence that the use of estradiol patches might help with PPD symptoms.[9]

In 2019, the FDA approved brexanolone, a synthetic analog of the neurosteroid allopregnanolone, for use intravenously in postpartum depression. Allopregnanolone levels drop after giving birth, which may lead to women becoming depressed and anxious.[87] Some trials have demonstrated an effect on PPD within 48 hours from the start of infusion.[88] Other new allopregnanolone analogs under evaluation for use in the treatment of PPD include SAGE-2017 and ganaxolone.[9]

Brexanolone has risks that can occur during administration, including excessive sedation and sudden loss of consciousness, and therefore has been approved under the Risk Evaluation and Mitigation Strategy (REMS) program.[89] The mother is to enrolled prior to receiving the medication. It is only available to those at certified health care facilities with a health care provider who can continually monitor the patient. The infusion itself is a 60-hour, or 2.5 day, process. People's oxygen levels are to be monitored with a pulse oximeter. Side effects of the medication include dry mouth, sleepiness, somnolence, flushing and loss of consciousness. It is also important to monitor for early signs of suicidal thoughts or behaviors.[89]

Breastfeeding

Antidepressant medications are generally considered safe to use during breastfeeding.[32] Most antidepressants are excreted in breast milk. However, there are limited studies showing the effects and safety of these antidepressants on breastfed babies.[90] Regarding allopregnanolone, very limited data did not indicate a risk for the infant.[91]

Other

Electroconvulsive therapy (ECT) has shown efficacy in women with severe PPD that have either failed multiple trials of medication-based treatment or cannot tolerate the available antidepressants.[78] Tentative evidence supports the use of repetitive transcranial magnetic stimulation (rTMS).[92]

As of 2013 it is unclear if acupuncture, massage, bright lights, or taking omega-3 fatty acids are useful.[93]

Epidemiology

Postpartum depression is found across the globe, with rates varying from 11% to 42%.[94] Around 3% to 6% of women will experience depression during pregnancy or shortly after giving birth.[59] About 1 in 750 mothers will have postpartum depression with psychosis and their risk is higher if they have had postpartum episodes in the past.[59]

History

Prior to the 19th century

Western medical science's understanding and construction of postpartum depression has evolved over the centuries. Ideas surrounding women’s moods and states have been around for a long time,[95] typically recorded by men. In 460 B.C., Hippocrates wrote about puerperal fever, agitation, delirium, and mania experienced by women after child birth.[96] Hippocrates' ideas still linger in how postpartum depression is seen today.[97]

A woman who lived in the 14th century, Margery Kempe, was a Christian mystic.[98] She was a pilgrim known as "Madwoman" after having a tough labor and delivery.[98] There was a long physical recovery period during which she started descending into "madness" and became suicidal.[98] Based on her descriptions of visions of demons and conversations she wrote about that she had with religious figures like God and the Virgin Mary, historians have identified what Margery Kempe was suffering from as "postnatal psychosis" and not postpartum depression.[99][100] This distinction became important to emphasis the difference between postpartum depression and postpartum psychosis. A 16th century physician, Castello Branco, documented a case of postpartum depression without the formal title as a relatively healthy woman who suffered from melancholy after childbirth, remained insane for a month, and recovered with treatment.[97] Although this treatment was not described, experimental treatments began to be implemented for postpartum depression for the centuries that followed.[97] Connections between female reproductive function and mental illness would continue to center around reproductive organs from this time all the way through to modern age, with a slowly evolving discussion around "female madness".[95]

19th century and after

With the 19th century came a new attitude about the relationship between female mental illness and pregnancy, childbirth, or menstruation.[101] The famous short story, The Yellow Wallpaper, was published by Charlotte Perkins Gilman in this period. In the story, an unnamed woman journals her life when she is treated by her physician husband, John, for hysterical and depressive tendencies after the birth of their baby.[102] Gilman wrote the story to protest societal oppression of women as the result of her own experience as a patient.[103] Her tale is likely to have resonated with many women because female hysteria was a common medical diagnosis at the time, having arisen many centuries earlier as the first mental disorder attributed to specifically women.[95] Hysterical neurosis was not removed from the DSM until 1980, whereas postpartum depression continues to be excluded as a unique "distinct disorder" and was only added into the fourth edition as a "course modified" in 1994.[104] Thus, in the 19th century, the idea of female hysteria was often conflated and confused with symptoms of postpartum depression, all in connection with the prevailing mindset that women were weak and vulnerable to mental illness.[95]

Also during the 19th century, gynecologists embraced the idea that female reproductive organs, and the natural processes they were involved in, were at fault for "female insanity."[105] Approximately 10% of asylum admissions during this time period are connected to “puerperal insanity,” the named intersection between pregnancy or childbirth and female mental illness.[106] It wasn't until the onset of the twentieth century that the attitude of the scientific community shifted once again: the consensus amongst gynecologists and other medical experts was to turn away from the idea of diseased reproductive organs and instead towards more "scientific theories" that encompassed a broadening medical perspective on mental illness.[105]

Society and culture

Malay culture holds a belief in Hantu Meroyan; a spirit that resides in the placenta and amniotic fluid.[107] When this spirit is unsatisfied and venting resentment, it causes the mother to experience frequent crying, loss of appetite, and trouble sleeping, known collectively as "sakit meroyan". The mother can be cured with the help of a shaman, who performs a séance to force the spirits to leave.[108]

Some cultures believe that the symptoms of postpartum depression or similar illnesses can be avoided through protective rituals in the period after birth. These may include offering structures of organized support, hygiene care, diet, rest, infant care, and breastfeeding instruction.[109] The rituals appear to be most effective when the support is welcomed by the mother.[72] Globalization and migration can disconnect women from their traditional communities of maternal support, which can be positive or negative depending on the traditions and on the mother's wishes.

Some Chinese women participate in a ritual that is known as "doing the month" (confinement) in which they spend the first 30 days after giving birth resting in bed, while the mother or mother-in-law takes care of domestic duties and childcare. In addition, the new mother is not allowed to bathe or shower, wash her hair, clean her teeth, leave the house, or be blown by the wind.[110]

In the US, the Patient Protection and Affordable Care Act included a section focusing on research into postpartum conditions including postpartum depression.[111] Some argue that more resources in the form of policies, programs, and health objectives need to be directed to the care of those with PPD.[112]

The stigma of mental health - with or without support from family members and health professionals - often deters women from seeking help for their PPD.[113] When medical help is achieved, some women find the diagnosis helpful and encourage a higher profile for PPD amongst the health professional community.[114]

Media

Certain cases of postpartum mental health concerns received attention in the media and brought about dialogue on ways to address and understand more on postpartum mental health. Andrea Yates, a former nurse, became pregnant for the first time in 1976.[115] After giving birth to five children in the coming years, she suffered severe depression and had many depressive episodes. This led to her believing that her children needed to be saved, and that by killing them, she could rescue their eternal souls. She drowned her children one by one over the course of an hour, by holding their heads under water in their family bathtub. When called into trial, she felt that she had saved her children rather than harming them and that this action would contribute to defeating Satan.[116]

This was one of the first public and notable cases of postpartum psychosis,[115] which helped create dialogue on women's mental health after childbirth. The court found that Yates’ was experiencing mental illness concerns, and the trial started the conversation of mental illness in cases of murder and whether or not it would lessen the sentence or not. It also started a dialogue on women going against “maternal instinct” after childbirth and what maternal instinct was truly defined by.[116]

Yates' case brought wide media attention to the problem of filicide,[117] or the murder of children by their parents. Throughout history, both men and women have perpetrated this act, but study of maternal filicide is more extensive

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See also

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