Postpartum depression, or postpartum psychosis, refers to depression symptoms occurring within six weeks of childbirth. Understanding PPD in detail helps comfort the mother.

Postpartum Depression

Humza Khizer

Overview

<p>Postpartum depression, or PPD, is a type of depression that is experienced by 1 out of 7 mothers after birth<sup><a href="#accordion">[3]</a></sup>. It is characterized by constant exhaustion, feeling empty, low, and even emotionless coupled with exhaustion and hopelessness.</p>

<p>After childbirth, it is common for women to experience baby blues. However, these baby blues are supposed to remain for an average of 2-3 days. During this period, women tend to experience mild depression, anxiety, and just generally low energy levels. There may be times when women have trouble sleeping. It is also common for women to question their ability to care for and provide for the baby.</p>

<p>Baby blues may sound similar, but are very different from postpartum depression where the feelings of sadness, anxiety, and hopelessness get so overwhelming that it affects the mother&rsquo;s daily activities, including taking care of the baby.&nbsp;&nbsp;</p>

<p>The best way to combat postpartum depression is to get treated in a timely manner. It does not only pose a threat to the mother but to the child as well. The symptoms may arise a month or a year after giving birth. It is recommended to seek professional help immediately for anyone with the symptoms.&nbsp;</p>

<div>&nbsp;</div>

<p>There are several types of mood-based disordered observed in parents after the birth of their child, which includes:<br />
&nbsp;</p>

<ul>
	<li>
	<h5><strong>Postpartum Blues</strong></h5>
	</li>
</ul>

<p>Postpartum blues are very common and normal in women after birth. Feeling low, sad, and anxious after childbirth for a few days up to a week is not something that requires immediate attention. Around 60% to 80% of women experience postpartum blues<sup><a href="#accordion">[4]</a></sup>. It is also classified as the mildest form of postpartum depression. Early diagnosis of PPB helps in avoiding the worsening of the condition and transitioning to postpartum depression.&nbsp;<br />
&nbsp;</p>

<ul>
	<li>
	<h5><strong>Postpartum Depression</strong></h5>
	</li>
</ul>

<p>Postpartum depression is often a progressive form of postpartum blues<sup><a href="#accordion">[4]</a></sup>. The impact of postpartum depression is not just limited to mothers, but may also instill different socialization behaviors in babies as they grow up. With the condition affecting more than just one person, it is dire for the mother to get treatment immediately before transitioning towards severe clinical depression characterized by feelings of failure<sup><a href="#accordion">[2]</a></sup>.<br />
&nbsp;</p>

<ul>
	<li>
	<h5><strong>Postpartum Psychosis&nbsp;</strong></h5>
	</li>
</ul>

<p>This is one of the most severe forms of postpartum-related mental illnesses and is meant to be treated as a medical emergency. 1 in 500 mothers suffers from postpartum psychosis<sup><a href="#accordion">[9]</a></sup>. It is also called puerperal psychosis or postnatal psychosis. Mothers experience symptoms within 2 weeks after giving birth. The symptoms include hallucinations, delusions, manic episodes, low mood, restlessness, feeling fearful, etc. In postpartum psychosis, mothers are a threat to themselves as well as their babies due to homicidal tendencies.&nbsp;<br />
&nbsp;</p>

<ul>
	<li>
	<h5><strong>Postpartum Depression In Men</strong></h5>
	</li>
</ul>

<p>PPD in men is commonly overlooked and not much research is done on it, but it does exist and can present its symptoms in men in a year. There are no established parameters, but it is most often characterized by irritability and depression. The biggest risk factor behind PPD in men is a history of <a href="https://www.merisehat.pk/disease/depression" target="_blank">depression</a>, financial restrictions, and hormonal changes<sup><a href="#accordion">[7]</a></sup>.</p>

<div>&nbsp;</div>

Signs And Symptoms

<p>Symptoms tend to vary from person to person, based on their history. These symptoms can range from mild to severe, making it hard to detect or differentiate from postpartum blues. These are the most common symptoms experienced by women suffering from postpartum depression:<br />
&nbsp;</p>

<ul>
	<li>Hopelessness</li>
	<li>Anhedonia</li>
	<li>Insomnia or hypersomnia</li>
	<li>Having thoughts of harming yourself or the baby</li>
	<li>Fatigue</li>
	<li>Severe mood swings</li>
	<li>Improper appetite</li>
	<li>Self-isolation</li>
	<li>Lower libido</li>
	<li>Lack of interest in the baby<br />
	&nbsp;</li>
</ul>

<p>These are some other symptoms that are not common after childbirth, but go hand-in-hand with severe cases of depression:</p>

<ul>
	<li>Random breakdowns</li>
	<li>Anger and irritability&nbsp;</li>
	<li>Trouble making decisions and concentrating</li>
	<li>Thinking you do not want your baby</li>
</ul>

<p>Seek help immediately if any of these symptoms prevail after childbirth. PPD is best treated as early as possible.</p>

<div>&nbsp;</div>

Causes

<p>Many signs link postpartum depression to the severe change in hormones and the sharp drop in levels of estrogen and progesterone. which is increased ten folds during pregnancy<sup><a href="#accordion">[12]</a></sup>.&nbsp;The effect of the drop of these hormones is much similar to the mood swings experienced during menstruation but at a smaller level as compared to the hormone levels during pregnancy.</p>

<p>For women who have had depression at any time in their lives, it is normal for the depression to resurface or further lead to postpartum depression. Several emotional factors come into play as well, including self-doubt regarding the mother&rsquo;s ability to raise the child, in case if the pregnancy was unplanned, if the baby got sick, etc., all factor into causing PPD. Several external factors like the mother&rsquo;s financial situation, overall support from the family, any stressful event including the death of a loved one, etc., can also be the reason behind your PPD.&nbsp;</p>

<p>If taken a deeper dive into the cause, underlying issues like hypothalamic-pituitary axis and thyroid dysfunction may contribute towards the cause. The issue is not solely estrogen and progesterone-based but serotonin receptors, monoamine oxidase A (MAO-A), and gamma-aminobutyric acid (GABA) also play a vital role in causing PPD<sup><a href="#accordion">[14]</a></sup>. Dropped levels of estrogen after birth have a similar impact on serotonin levels and receptors directly. An indirect impact on MAO-A levels is also recorded due to estrogen, whereas progesterone is responsible for the negative impact on GABA-A receptors. The impact on MAO-A levels is also translated further indirectly into altered levels of norepinephrine and dopamine levels. These hormonal shifts contribute a lot to PPD in individuals<sup><a href="#accordion">[14]</a></sup>.</p>

<div>&nbsp;</div>

<p>Postpartum screening is highly recommended by the American Academy of Pediatrics (AAP). There are multiple tools out there including antenatal and postnatal screening for depression.</p>

<p>Universal screening with the Edinburgh Postnatal Depression Scale (EPDS) is the most commonly used screening tool for the identification of women with PPD. EPDS is a 10-item questionnaire<sup><a href="#accordion">[8]</a></sup>. The test is a quick assessment of the patient&rsquo;s condition over the past week and can be scored quickly. Each response has a score of 0 to 3 and a total score of 12 or greater indicates the need for a more in-depth assessment of the situation. EPDS is usually employed after 2 months of postpartum checkups<sup><a href="#accordion">[15]</a></sup>. However, it is not necessarily a confirmed diagnosis of the problem. It is considered more of an initiating step to get a better idea of the mother&rsquo;s condition and the severity of the problem.</p>

<p>Center for Epidemiologic Studies of Depression instrument (CES-D), the Postpartum Depression Screening Scale (PDSS), and the Patient Health Questionnaire (PHQ-9) are some other validated tools that are used for PPD screening.</p>

<div>&nbsp;</div>

Diagnosis

<p>Postpartum depression is diagnosed through regular visits to your doctor. The doctor may ask a series of questions to assess your mental condition and the severity of your PPD. The diagnosis will be targeted towards determining if the issue is of short-term baby blues, or of a more serious matter like postpartum depression or even postpartum psychosis. Your physician may order a few blood tests to determine if an underactive thyroid is worsening your symptoms.&nbsp;</p>

<p>At least 5 of the symptoms must be present including anhedonia or a depressed mood for a diagnosis of PPD. The occurrence of the symptoms is ideally within a 2-week period, but in several cases, PPD can be observed months after giving birth<sup><a href="#accordion">[14]</a></sup>. A detailed history of the patient&rsquo;s mental health is crucial to identify any past occurrences of depression or depressive episodes, as well as in ensuring that restlessness, insomnia, fatigue etc. are not just the usual signs that occur while taking care of an infant, especially for new mothers.</p>

<p>The diagnostic criteria for PPD are the same as the ones used for Major Depressive Episodes (MDE) defined by the Diagnostic and Statistical Manual (DSM-IV). The most crucial aspect is the differentiation between postpartum blues, which is considered normal at this stage, and postpartum depression and postpartum psychosis, which is considered a medical emergency as it endangers the infant<sup><a href="#accordion">[17]</a></sup>.</p>

<div>&nbsp;</div>

Treatment

<p>When it comes to treatments, there is a wide range of options to choose from. Your physician may opt for more than one type of treatment for faster and more effective recovery from PPD:<br />
&nbsp;</p>

<ul>
	<li>
	<h5><strong>Psychotherapy</strong></h5>
	</li>
</ul>

<p>Cognitive Behavioural therapy (CBT) is one of the most common ways to combat PPD<sup><a href="#accordion">[3]</a></sup>. The therapy consists of identifying certain destructive behaviors, the thought process that influences those behaviors, and how to control them<sup><a href="#accordion">[11]</a></sup>.&nbsp;CBT aims towards replacing your destructive behaviors and thoughts with something more productive, realistic, and positive. When it comes to PPD, psychotherapy is ideal for women with mild to moderate symptoms. Psychotherapy is oftentimes coupled with pharmacotherapy to deliver more promising results. However, it is preferred to solely stick to psychotherapy in cases of women who are breastfeeding to avoid the use of antidepressants as they may have an impact on the infant. Other types of psychotherapy employed for the treatment of PPD include interpersonal therapy and non-directive counseling along with improving peer and partner support to help the mother<sup><a href="#accordion">[17]</a></sup>.&nbsp;<br />
&nbsp;</p>

<ul>
	<li>
	<h5><strong>Pharmacotherapy</strong></h5>
	</li>
</ul>

<p>New mothers are always cautious about using any medicines&nbsp;but in case of moderate to severe symptoms, pharmacotherapy and the use of the right and safe medication aid in speeding up the healing process. And has a vital impact on the overall treatment<sup><a href="#accordion">[17]</a></sup>.&nbsp;The use of antidepressants is solely dependent on the severity of the issue. Selective Serotonin Re-uptake Inhibitors (SSRIs) are the top choice of drugs for treating PPD. SSRIs like paroxetine, sertraline, and fluoxetine have shown promising results in multiple clinical trials<sup><a href="#accordion">[14]</a></sup>.<br />
Tricyclic antidepressants (TCAs) including nortriptyline and imipramine have shown positive results in PPD cases, but they are considered as second-line medications due to the risk of overdose. Additionally, the use of antidepressants while breastfeeding is considered to be safe to some extent, but there is no long-term data that backs this claim or proves otherwise. Women who are new to antidepressants are suggested sertraline and paroxetine due to their low excretion concentration in breast milk.<br />
Hormonal therapy is also an effective approach to treat PPD since it is directly related to the drastic drop in the levels of estrogen and progesterone. Transdermal estradiol has been used in several clinical trials that have shown some success, but it is too early to consider it as a safe form of treatment.&nbsp;<br />
&nbsp;</p>

<ul>
	<li>
	<h5><strong>Electroconvulsive Therapy (ECT)</strong></h5>
	</li>
</ul>

<p>In cases of severe PPD, electroconvulsive therapy is recommended especially in cases of PPD that transition towards postpartum psychosis<sup><a href="#accordion">[12]</a></sup>.&nbsp;ECT is also recommended for women who do not respond to pharmacologic treatments, especially antidepressants. The treatment and the use of ECT are the same as in major depressive episodes. The biggest concern mothers have often while ECT, is being put under anesthesia. The process involves electrical stimulation of the brain. ECT has proven to be effective in overall 80% of the patients that have been subjected to it. The treatment is recognized by American Psychiatric Association, the American Medical Association, and several other organizations all over the world<sup><a href="#accordion">[10].</a></sup><br />
&nbsp;</p>

<ul>
	<li>
	<h5><strong>Bright Light Therapy</strong></h5>
	</li>
</ul>

<p>Bright Light Therapy was initially used as a treatment for seasonal affective disorder, but it has proven to be useful in the case of PPD with no known complications or severe side effects. The only limitation is the lack of extensive data that supports this treatment as a vital option for PPD. However, for the smaller-scale studies that have been conducted so far with regard to bright light therapy as a treatment for PPD, the results have been promising showing drastic improvement in the patient&rsquo;s condition<sup><a href="#accordion">[17]</a></sup>.</p>

<div>&nbsp;</div>

<p>If postpartum depression is left untreated, it can cause a series of problems that are not just limited to the mother but also has an impact on the child and the family as a whole.</p>

<p>In the case of mothers, PPD can last for over a year if left untreated, and can even get worse and go into the realm of postpartum psychosis. Even treated PPD poses the risk of having future depressive episodes<sup><a href="#accordion">[13]</a></sup>.</p>

<p>For fathers, a mother&rsquo;s PPD can trigger their depression as well. Postpartum depression in fathers is often regarded as an episode of major depressive disorder (MDD). Despite there being no established criteria for men, it can surface over a year<sup><a href="#accordion">[7]</a></sup>.</p>

<p>When it comes to infants, they are the ones that are severely affected if the mother is going through PPD that is left untreated. Such babies tend to develop behavioral changes and emotional issues which results in slower development. Infants have been known to have eating problems, sleeping issues, tend to cry excessively, and may even develop ADHD<sup><a href="#accordion">[1]</a></sup>.</p>

<div>&nbsp;</div>

<p>Your entire lifestyle comes into play when it comes to risk factors that negatively impact the condition. Here are some of the risk factors that affect postpartum depression:<br />
&nbsp;</p>

<ul>
	<li>History of mental illness especially <a href="https://www.merisehat.pk/disease/depression" target="_blank">depression</a>, <a href="https://www.merisehat.pk/disease/anxiety" target="_blank">anxiety,&nbsp;</a>and <a href="https://www.merisehat.pk/disease/bipolar-disorder" target="_blank">bipolar disorder</a>.&nbsp;</li>
	<li>Prevalence of postpartum depression in previous pregnancies</li>
	<li>Stressful or sad past events that occurred in the previous year, including miscarriage, loss of a job, etc.&nbsp;</li>
	<li>The baby has health issues or special needs</li>
	<li>The pregnancy was unplanned or the mother had more than one baby (twins, triplets, etc.)</li>
	<li>Financial issues or lack of any financial support</li>
	<li>Issues with your spouse or any support system that you may have&nbsp;</li>
	<li>The process of pregnancy was risky i.e., involved a cesarean section or a longer hospitalization period</li>
	<li>Umbilical cord prolapse &ndash; This is an uncommon stressful event that often leads to loss of oxygen to the fetus, and may even result in stillbirths in many cases</li>
	<li>Social factors involving a history of sexual abuse and domestic violence may have an impact on the mother developing PPD</li>
	<li>Lack of Vitamin B6 &ndash; Vitamin B6 is responsible for converting into tryptophan and eventually into serotonin.&nbsp;</li>
	<li>Lack of physical activity, poor eating and sleeping habits, and practices that decrease your self-esteem are major factors that influence or trigger PPD.&nbsp;</li>
</ul>

<div>&nbsp;</div>

<p>Postpartum depression can be avoided if preventive measures are taken early during pregnancy. This is crucial, especially for mothers who have a history of mental illness (mainly depression, anxiety, bipolar disorder) or have had PPD in previous pregnancies. Keeping close contact with your doctor can help in identifying any early signs or symptoms of possible PPD<sup><a href="#accordion">[12]</a></sup>. It is best to be mindful that while PPD may be prevented through the right measures, mothers are still vulnerable to postpartum blues. The following measures can be taken to decrease the chances of developing PPD:<br />
&nbsp;</p>

<ul>
	<li>Getting adequate physical activity</li>
	<li>Monitoring your sleep habits and improving them wherever possible</li>
	<li>Avoiding alcohol and smoking altogether or reducing the intake at the very least</li>
	<li>Eating&nbsp;on time and consuming a well-balanced diet&nbsp;</li>
	<li>Having the right emotional support system and also some kind of support to take care of your baby for you to have a break now and then</li>
</ul>

<div>&nbsp;</div>

<p>With PPD getting so common in mothers, a lot of research is being done on understanding the condition itself. New research published in Molecular Psychiatry by researchers from the UNC School of Medicine found out that the B-cells in women with PPD were very different from mothers who do not have PPD. B-cells are a massive part of the immune system, especially during pregnancy, but during the postpartum period, the immune system is supposed to go back to normal. However, such a case is not observed in women with PPD<sup><a href="#accordion">[6]</a></sup>.</p>

<p>Another recent research published in the Journal of Women&rsquo;s Health carried out by scientists from the University of Massachusetts, USA found out that breastfeeding your child improves the mother&rsquo;s mental health and can have a positive impact on PPD. With around 34 studies out of 52 suggesting a strong relationship between breastfeeding and PPD, the impact of it is commendable. However, a problem lies in mothers who have set expectations from breastfeeding, especially in cases where those expectations are not met, they may even worsen PPD. Mothers who are unable to breastfeed due to uncomfortable sensations, pain, poor lactation, or external factors including obligations like employment, it is common for their PPD to get worse due to guilt and stress. Breastfeeding is known to create a healthy bond between the infant and the mother and is even associated with improving the infant&rsquo;s immune system while reducing any risks of pediatric cancer<sup><a href="#accordion">[5]</a></sup>.</p>

<div>&nbsp;</div>

Key Points

<ul>
	<li>It is common to experience some type of postpartum <a href="https://www.merisehat.pk/disease/depression" target="_blank">depression</a>, especially in the form of postpartum blues.</li>
	<li>Postpartum depression is not just prevalent in women, but men can also experience it within a year of having the baby.</li>
	<li>Women and men with a previous history of <a href="https://www.merisehat.pk/disease/depression" target="_blank">depression</a>, <a href="https://www.merisehat.pk/disease/anxiety" target="_blank">anxiety,&nbsp;</a>and<a href="https://www.merisehat.pk/disease/bipolar-disorder" target="_blank"> bipolar disorder</a> are most susceptible to PPD.</li>
	<li>Untreated PPD can worsen into psychosis or even go to severe stages where the mother poses a threat to herself.&nbsp;</li>
	<li>There are several treatments out there depending on the severity of the condition, ranging from psychotherapy, and&nbsp;pharmacotherapy to other types of treatment that include electroconvulsive therapy (ECT) and bright light therapy.</li>
	<li>Measures including physical activity, maintaining a stress-free environment, and the right diet can aid in reducing the chances of occurrence of PPD.</li>
</ul>

<div>&nbsp;</div>

[1] Yusra Azhar, W. S., 2021. Postpartum Depression.

[2] Reindolf Anokye, E. A. A. B.-A. E. I. O. a. A. G. A., 2018. Prevalence of postpartum depression and interventions utilized for its management. [Online]

[3] Pietrangelo, A., 2022. Everything You Need to Know About Postpartum Depression: Symptoms, Treatments, and finding help.

[4] Narashimhaiah G Manjunath, G. V. a. R., 2011. Postpartum Blue is Common in Socially and Economically Insecure Mothers.

[5] Megan Yuen, O. J. H. G. A. M. B. C. N. C. C. K. L. A. G. L. M. N. B. a. T. A. M. S., 2022. The Effects of Breastfeeding on Maternal Mental Health: A Systematic Review.

[6] Guintivano, J., Aberg, K.A., Clark, S.L. et al. Transcriptome-wide association study for postpartum depression implicates altered B-cell activation and insulin resistance. Mol Psychiatry 27, 2858–2867 (2022).

[7] Scarff JR. Postpartum Depression in Men. Innov Clin Neurosci. 2019;16(5-6):11-14.

[8] Health, M. C. f. W. M., 2008. Identifying Postpartum Depression: A Three Question Screening Tool.

[9] Postpartum Psychosis. NHS choices.

[10] Association, A. P., 2019. What is Electroconvulsive Therapy (ECT)?.

[11] Cherry, K., 2022. What Is Cognitive Behavioral Therapy (CBT)?.

[12] Postpartum depression: Causes, symptoms & treatment. Cleveland Clinic

[13] Postpartum depression. Mayo Clinic

[14] DelRosario, G. A. M. P.-C., Chang, A. C. M. P.-C. & Lee, E. D. B., 2013. Postpartum depression: Symptoms, diagnosis, and treatment approaches.

[15] Eberhard-Gran M, E. A. T. K. O. S. S. S., 2001. Review of validation studies of the. Acta Psychiatr Scand, pp. 243-249.

[16] Fitelson, Sarah Kim, Baker A, Leight K. Treatment of post-partum depression: a review of clinical, psychological and pharmacological options. Int J Womens Health. 2011;3:1-14

[17] Fitelson E, K. S. B. A. L. K., 2010. Treatment of postpartum depression: clinical, psychological and pharmacological options.. Int J Womens Health, pp. 1-14.