Postpartum Depression

**Postpartum depression** (**PPD**), also called **postnatal depression**, is a type of clinical depression which can affect both sexes after childbirth. Women get PPD when they have mental illnesses, Symptoms may include sadness, low energy, changes in sleeping and eating patterns, reduced desire for sex, crying episodes, anxiety, and irritability. While many women experience self-limited, mild symptoms postpartum, postpartum depression should be suspected when symptoms are severe and have lasted over two weeks.

Although a number of risk factors have been identified, the causes of PPD are not well understood. Hormonal change is hypothesized to contribute as one cause of postpartum depression. The emotional effects of postpartum depression can include sleep deprivation, anxiety about parenthood and caring for an infant, identity crisis, a feeling of loss of control over life, and anxiety due to lack of support from a romantic or sexual partner.[1] Many women recover with treatment such as a support group, counseling, or medication, or even getting stabilized.

About 0.5% to 61% of women will experience depression after delivery.[4] Postpartum psychosis occurs in about 1–2 per thousand women following childbirth.[5] Among men, in particular new fathers, the incidence of postpartum depression has been estimated to be between 1% and 25.5%.[6] In the United States, postpartum depression 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.

## Signs and symptoms

Symptoms of PPD can occur any time in the first year postpartum.[9] These symptoms include, but are not limited to:

* Sadness
* Hopelessness
* Low self-esteem
* Guilt
* A feeling of being overwhelmed
* Sleep and eating disturbances/patterns
* Inability to be comforted
* Exhaustion
* Emptiness
* Inability to experience pleasure from activities usually found enjoyable
* Social withdrawal
* Low or no energy
* Becoming easily frustrated
* Feeling inadequate in taking care of the baby
* Decreased sex drive
* Occasional or frequent anxiety

### Onset and duration

Postpartum depression usually begins between two weeks to a month after delivery.[12] Recent studies have shown that fifty percent of postpartum depressive episodes actually begin prior to delivery.[13] 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.[14] Postpartum depression can also occur in women who have suffered a miscarriage.[15]

### Parent-infant relationship

Postpartum depression can interfere with normal maternal-infant bonding and adversely affect child development. Postpartum depression may lead mothers to be inconsistent with childcare.[16] Children of mothers with PPD have been found to have higher rates of emotional problems, behavioral problems, psychiatric diagnoses (such as oppositional defiant disorder and conduct disorder), and hyperactivity.[17][18]

In rare cases, or about 1 to 2 per 1,000, the postpartum depression appears as postpartum psychosis which may adversely affect the infant's health.[5] In these, or among women with a history of previous psychiatric hospital admissions,[19] 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.[7][20]

## 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. Hormones which have been studied include estrogen, progesterone, thyroid hormone, testosterone, corticotropin releasing hormone, and cortisol.[21]

Fathers, who are not undergoing profound hormonal changes, can also have postpartum depression.[22] 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.[23] Additionally, most women experience profound lifestyle changes with their first pregnancy, yet most do not suffer PPD.[*citation needed*]

### Risk factors

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

* Prenatal depression or anxiety
* A personal or family history of depression/mental illness
* Moderate to severe premenstrual symptoms
* Maternity blues
* Birth-related psychological trauma
* Birth-related physical trauma
* Previous stillbirth or miscarriage
* Formula-feeding rather than breast-feeding
* Cigarette smoking
* Low self-esteem
* Childcare or life stress
* Low social support
* Poor marital relationship or single marital status
* Low socioeconomic status
* Infant temperament problems/colic
* Unplanned/unwanted pregnancy
* Elevated prolactin levels
* Oxytocin depletion

Of these risk factors, formula-feeding, a history of depression, and cigarette smoking have been shown to have additive effects.[25]

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.[28]

Not surprisingly, women with fewer resources indicate a higher level of postpartum depression and stress than those women with more financial resources. Rates of PPD have been shown to decrease as income increases.[29] Women with fewer resources may be more likely to have an unintended or unwanted pregnancy, increasing risk of PPD. Single mothers of low income may have fewer resources to which they have access while transitioning into motherhood.

Studies have also shown a correlation between a mother's race and postpartum depression. For race, African American mothers have been shown to have the highest risk of PPD at 25%, while Asians 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.[29]

Sexual orientation[30] 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. 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.[31] 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.[32]

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.[33]

### 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.[34] About one-third of women throughout the world will experience physical and/or sexual violence at some point in their lives.[35] Violence against women occurs in conflict, post-conflict, and non-conflict areas.[35] 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".[34] 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.[31][34] Violence against women is a chronic stressor, so depression may occur when someone is no longer able to respond to the violence.[34]

## 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.[36] Nevertheless, the majority of experts continue to diagnose postpartum depression as depression with onset anytime within the first year after delivery.[26]

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:[36]

* 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[edit]

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.[37] Symptoms typically resolve within two weeks. Symptoms lasting longer than two weeks are a sign of more serious depression.[38]

#### Psychosis

Postpartum psychosis is a 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 set in begin suddenly in the first two weeks after delivery; the symptoms vary and can change quickly.[39] It is different from postpartum depression and from maternity blues.[40] It may be a form of bipolar disorder.[41]

About half of women who experience it 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, are at a higher risk.[39]

It often requires hospitalization, where treatment is antipsychotic medication, mood stabilizers, and in cases of strong risk for suicide, electroconvulsive therapy.[39]

The most severe symptoms last from 2 to 12 weeks, and recovery takes 6 months to a year.[39] 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.[42]

## Screening

In the US, the American College of Obstetricians and Gynecologists suggests healthcare providers consider depression screening for perinatal women.[43] Additionally, the American Academy of Pediatrics recommends pediatricians screen mothers for PPD at 1-month, 2-month and 4-month visits.[44] However, many providers do not consistently provide screening and appropriate follow-up.[43] 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.[45] If the new mother scores 13 or more, she likely has PPD and further assessment should follow.[45]

## Prevention

A 2013 Cochrane review found evidence that psychosocial or psychological intervention after childbirth helped reduce the risk of postnatal depression.[46][47] These interventions included home visits, telephone-based peer support, and interpersonal psychotherapy.[46] 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."[48]

A major part of prevention is being informed about the risk factors, and the medical community can play a key role in identifying and treating postpartum depression. Women should be screened by their physician to determine their risk for acquiring postpartum depression. Also, proper exercise and nutrition appear to play a role in preventing postpartum, and depressed mood in general.

## Treatment

A variety of treatment options exist for PPD, and treatment may include a combination of therapies. If the cause of PPD can be identified, treatment should be aimed accordingly. If a woman with PPD does not feel she is being taken seriously, or is being recommended a treatment plan with which she is not comfortable, she may wish to seek a second opinion.[9]

### Non-pharmacological therapy

Both individual social and psychological interventions appear effective in the treatment of PPD.[49] Other forms of therapy, such as group therapy and home visits, are also effective treatments.[9] Internet-based cognitive behavioral therapy has been developed and tested, and has shown promising results with lower negative parenting behavior scores in those who participated. It is unclear if acupuncture, massage, bright lights, or taking omega-3 fatty acids are useful.[50]

### Medication

There is evidence which suggests that selective serotonin reuptake inhibitors (SSRIs) are effective treatment for PPD.[51] However, the quality of the evidence is low given it is based on very few studies and patients. It remains unclear which antidepressants are most effective for treatment of PPD, and for whom antidepressants would be a better option than non-pharmacotherapy.[51] A recent study has found that adding sertraline, a specific SSRI, to psychotherapy does not appear to confer an additional benefit.[52]

## Epidemiology

### Mothers

According to the National Institutes of Mental Health, studies show that the childbearing years are when a woman is most likely to experience depression in her lifetime. Approximately 15% of all women will experience postpartum depression following the birth of a child.[54]

### Fathers

In the past, developmentalists have underestimated the importance of a father's interactions with the child in early development.[17] However, researchers have recently found that father involvement in early life has significant effects on subsequent child development. These studies include infants' exposure to paternal depression and its repercussions on the child's development.[55]

Research on postpartum depression have mostly focused on mothers, but studies have shown that fathers also pose a risk of experiencing postpartum depression, though a lower prevalence than in mothers.[55] Compared to mothers, fathers face lower levels of anxiety towards fatherhood and typically take part less in direct care for the child, reducing their susceptibility to PPD.[56] In addition, researchers have depicted a positive correlation between maternal postnatal depression and paternal depression, most likely due to factors such as marital satisfaction, a strong predictor for PPD.[55] Some studies propose that maternal depression plays a causal role in the development of postnatal depression in fathers.[55]

Furthermore, the prevalence of PPD in fathers inversely correlates with socioeconomic status, in which the PPD in fathers increased as socioeconomic status declined.[56] Similarly, unemployed fathers also demonstrated greater vulnerability to developing PPD.[56]

Several negative development outcomes in children have been associated with paternal depression. In a cross-sectional study, pre-school children, three to five years of age, who faced paternal depression as infants developed increased behavioral problems relating to conduct and hyperactivity.[17] In other words, paternal depression in early life places the child at a higher risk for developing behavioral issues, especially in early childhood.[55] The results of the study also indicated a higher incidence of behavioral problems, as a result of paternal postpartum depression, in boys than in girls.[17] Generally, boys more sensitively responded to the father's parenting, explaining the increased tendency of the boys to develop behavioral issues.[17]

The study proposes several explanations for the development of behavioral issues. Similar to maternal depression, fathers experiencing depression find it more difficult to care for their children and to fulfill their roles and responsibilities in the family. As a result, early interaction between the father and the child may decrease.[17] Also, indirect causes of depression, such as marital stress and tension, could also be a factor in the increase in behavior problems.[17]

Prevention and treatment for parental postnatal depression follow the same guidelines as in maternal depression. Awareness through consulting services by doctors and nurses of postpartum depression, baby care, and the attachment and relationship between the parents and the child will provide fathers with the necessary information to avoid depression.[56]

## Society and culture

Malay culture holds a belief in Hantu Meroyan; a spirit that resides in the placenta and amniotic fluid.[57] 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.[58] Some cultures believe that the symptoms of postpartum depression or similar illnesses can be avoided through protective rituals in the period after birth. 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.[59]