Postpartum Depression
OVERVIEW
One in seven parents will experience postpartum depression (PPD).[1] This type of depression occurs after an individual gives birth[2] and usually occurs within a six-week period after childbirth.[3] In some cases, the onset of depression can happen earlier in the pregnancy, and in such cases, it is referred to as peripartum depression.[4] While each parent’s journey is unique, for most new parents PPD can last up to a year.[5] All new parents, regardless of whether they gave birth or not, are susceptible to PPD.[6]
SIGNS & SYMPTOMS
There are a diverse range of symptoms for PPD, with the presentation of symptoms highly dependent on the severity of one’s PPD. Symptoms include:[7]
Depressed mood
Major mood swings
Insomnia or sleeping too much
Feelings of hopelessness, worthlessness, guilt, and/or shame
An overwhelming fear of not being a “good” parent
Repeated thoughts of death or suicide
Anxiety attacks
Withdrawal from loved ones
Major changes in eating patterns
Difficulties forming emotion and physical bonds with their baby
Less interested in activities that were once pleasurable
Self-harm or harm to baby
The overwhelming concern for one’s child and towering doubt in one’s abilities to be a parent is referred to as “caring concern”.[8] This combination of concern and doubt often leads to heightened feelings of guilt and instances of self-blame.[9]
When discussing PPD, the impact of the illness on the infant should also be considered. Since PPD hinders a parent’s ability to emotionally bond with their child, parents with PPD are less likely to pick up on important infant cues and more likely to express negative emotions, such as hostility and frustration, when engaging with their infant.[10] According to a study conducted by Walker et al. (2007), such interactions have a negative impact on the infant’s cognitive and socioemotional development.[11] These infants present weaker cognitive abilities and are at higher risk for future behavioral issues.[12] They are also at risk for various psychopathologies, such as anxiety and other affective disorders.[13] Regarding physical consequences, infants may have trouble sleeping and eating and are also more susceptible to obesity.[14]
CAUSES
While the main cause behind PPD still remains a mystery, scientists have found that PPD is fueled by a complex combination of various biopsychosocial factors. Beginning with the biological factors, during pregnancy a mother’s estrogen and progesterone levels skyrocket.[15] However, immediately after giving birth, their levels dramatically drop.[16] By the third day postpartum, hormone levels return to the normal pre-pregnancy levels.[17] The drastic fluctuation in hormones is believed to be one of the contributing factors to PPD symptoms, particularly the major mood swings and depressive episodes.[18]
Several social and psychological factors are also believed to lead to PPD. Some of these factors include major changes to one’s body (e.g., weight gain and weight loss), a lack of sleep, changes to one’s relationship with their partner, and the onset of new parenting stressors.[19]
RISK FACTORS
Although not every parent will experience PDD, certain risk factors increase a parent’s chances of developing PDD. Some of these risk factors include:[20-21]
History of depression or anxiety
Previous instances of PPD (those who have had PPD before are 30% more likely to have it again during subsequent pregnancies)
Familial history of depression or PPD
A lack of sleep
Ambivalence about the baby
Social risk factors include:[22]
Lack of a support network
Domestic violence or history of sexual abuse
Smoking during pregnancy
The type of birth also weighs heavily on one’s likelihood of developing PPD, with the following situations increasing a parent’s risk of PPD:[23]
A risky pregnancy
Emergency cesarean section
Hospitalization during pregnancy
Preterm or low birth weight
Having a child with special needs
DIAGNOSIS & CLASSIFICATIONS
Although some parents may not go on to develop a pathological level of depression, nearly all new parents will experience some form of depression post-birth. This is referred to as the postpartum “baby blues”, which typically occurs during the first two to three days post-birth and lasts for approximately two weeks.[24] New parents with the baby blues may experience mood swings, crying episodes, increased anxiety, and difficulty sleeping.[25] The baby blues is a normal part of the adjustment to postpartum life, with 80% of parents experiencing them.[26]
As for PPD, an average of 15% of all parents will go on to develop it.[27] In particular, approximately 4% of partners experience symptoms of PPD in the first year following birth.[28] In fathers, PPD is sometimes referred to as paternal postpartum depression.[29] PPD encompasses all the symptoms of the baby blues but at a more extreme level and typically lasts up to a year.[30] Within PPD, feelings of depression, anxiety, guilt, and shame are heightened and episodes of insomnia, crying, and panic become more frequent.[31]
In rare occasions, PPD can worsen, developing into postpartum psychosis. Postpartum psychosis is an extreme form of PPD that often causes severe anxiety, agitation, confusion, hopelessness, and shame. Parents with postpartum psychosis experience paranoia, hallucinations, and delusions.[32]
To screen for these various types of postpartum illnesses, healthcare workers can utilize the Edinburgh Postnatal Depression Scale.[33] The assessment consists of ten questions that inquire about recent episodes of anxiety and depression. The parent is asked to check the response that best reflects what they’ve been feeling in the last seven days. Examples of positive and negative measures in the scale include: (1) I have been able to laugh and see the funny side of things and (2) I have blamed myself unnecessarily when things went wrong. The higher one’s score computes to, the more likely it is that they are experiencing postpartum depression.
TREATMENT & PREVENTION
The treatment plan for PPD is dependent on the severity of the illness. For mild forms of PPD, the first line of treatment is psychotherapy. Specifically, cognitive behavioral therapy (CBT) is the most recommended therapy for patients with PPD.[34] In CBT, patients work with their therapists to constructively change their thought patterns and behaviors, helping them become more aware of distorted and negative thinking habits.[35] The American Psychiatric Association also recommends attending support groups, as such groups can directly address feelings of loneliness.[36] If psychotherapy is not effective, doctors usually recommend patients taking medication.[37] While various medications can be prescribed for PPD, SSRIs and SNRIs are the two most common antidepressants prescribed to patients with PPD. SSRIs and SNRIs have been proven to minimize symptoms of anxiety and depressive disorders. Other medications include Bupropion (or Wellbutrin), which blocks the reuptake of various neurotransmitters, such as dopamine and norepinephrine, and tricyclic antidepressants (TCAs), which are another form of antidepressants.[38]
If medication and psychotherapy are not effective enough, both as separate forms of treatment and in conjunction, the next course of treatment would be electroconvulsive therapy (ECT).[39] This is a noninvasive treatment that involves sending electrical currents through the brain, resulting in a purposefully-induced seizure. The electrical currents utilized in ECT are believed to alter the neural activity in the brain, resulting in minimized anxiety and depression symptoms.
Apart from the above treatments, lifestyle changes are highly recommended to minimize symptoms of PPD.[40] The Cleveland Clinic recommends getting adequate sleep, eating healthily, visiting friends and family, and surrounding oneself with a supportive network.[41]
In addition to minimizing symptoms, there are several changes someone can adopt to potentially prevent the onset of PPD. Some of these changes include:[42]
Limiting visitors when the baby first arrives home
Asking for help
Sleeping when your baby sleeps
Exercising
Keeping in touch with loved ones
Making time for you and your partner
Knowing that bad days are completely normal
If you are exhibiting signs and symptoms of PPD, please contact a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support. Additionally, your primary care provider, obstetrician, or your baby’s pediatrician can work with you to find the best treatment option for you and your family.
Contributed by: Adithi Jayaraman
Editor: Jennifer (Ghahari) Smith, Ph.D.
references
1 Mughal, S., Azhar, Y., & Siddiqui, W. (2022, October 7). Postpartum Depression. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519070/
2 Ibid.
3 Ibid.
4 Mayo Clinic. (2022, November 24). Postpartum Depression - Symptoms and Causes. Mayo Clinic; Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/postpartum-depression/symptoms-causes/syc-20376617
5 Cleveland Clinic. (2022, April 12). Postpartum Depression: Types, Symptoms, Treatment & Prevention. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/9312-postpartum-depression
6 Ibid.
7 Mayo Clinic (2022)
8 Morgan, J. K., Santosa, H., Fridley, R. M., Conner, K. K., Hipwell, A. E., Forbes, E. E., & Huppert, T. J. (2021). Postpartum Depression Is Associated With Altered Neural Connectivity Between Affective and Mentalizing Regions During Mother-Infant Interactions. Frontiers in Global Women’s Health, 2. https://doi.org/10.3389/fgwh.2021.744649
9 Ibid.
10 Leight, K., Fitelson, E., Kim, S., & Baker, A. (2010). Treatment of post-partum depression: a review of clinical, psychological and pharmacological options. International Journal of Women’s Health, 3(3), 1–14. https://doi.org/10.2147/ijwh.s6938
11 Walker SP, Wachs TD, Gardner JM, et al. International Child Development Steering Group Child development: risk factors for adverse outcomes in developing countries. Lancet. 2007;369(9556):145–157.
12 Leight et al., (2010)
13 Ibid.
14 Ibid.
15 Cleveland Clinic (2022)
16 Ibid.
17 Ibid.
18 Ibid.
19 Ibid.
20 Mughal et al., (2022)
21 Cleveland Clinic (2022)
22 Mughal et al., (2022)
23 Ibid.
24 Mayo Foundation for Medical Education and Research. (2022, November 24). Postpartum depression. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/postpartum-depression/symptoms-causes/syc-20376617
25 Ibid.
26 Ibid.
27 Mayo Clinic. (2015). Postpartum Depression: What You Need to Know. In YouTube. https://www.youtube.com/watch?v=fBYYr_kEjmo
28 Cleveland Clinic (2022)
29 Ibid.
30 Ibid.
31 Ibid.
32 Morgan et al., (2021)
33 Ibid.
34 Torres, F. (2020, October). Psychiatry.org - What is Peripartum Depression (formerly Postpartum)? Psychiatry.org. https://www.psychiatry.org/patients-families/Peripartum-Depression/What-is-Peripartum-Depression
35 Mayo Clinic. (2019, March 16). Cognitive behavioral therapy. Mayoclinic.org; Mayo Clinic. https://www.mayoclinic.org/tests-procedures/cognitive-behavioral-therapy/about/pac-20384610
36 Torres (2020)
37 Ibid.
38 Ibid.
39 Cleveland Clinic (2022)
40 Mughal et al., (2022)
41 Cleveland Clinic (2022)
42 Ibid.