Postpartum Depression

Definition
Postpartum depression (PPD), also called postnatal depression, is a
type of mood disorder associated with childbirth, which can affect both sexes.
It usually begins between two weeks to a month after delivery.
Epidemiology
According to Shefaly Shorey et al(2018), The incidence of postpartum
depression was 12% while the overall prevalence of depression was 17%
among healthy mothers without a prior history of depression. The
Middle-East has the highest prevalence (26%) and Europe has the lowest
rate, which is 8%.
According to Postpartum Depression( as cited in
https://www.postpartumdepression.org/resources/statistics/ ) in 2019,
postpartum depression rates in Asian countries could be at 65% or
more among new mothers. Postpartum depression can affect people from all
races, ethnicities, cultures and educational or economic backgrounds.
 Approximately 10% of new fathers experience symptoms of depression
during the postpartum period.
 Half of men who have partners with postpartum depression will go on to
develop depression themselves.
 Women with a history of depression, anxiety disorders or serious mood
disorders are 30% to 35% more likely to develop postpartum depression.
 women of low socioeconomic status were 11 times more likely to develop
PPD symptoms than women of higher socioeconomic status

Etiology
The cause of PPD is not well understood. Hormonal changes, genetics, and
major life events have been hypothesized as potential causes.
Hormonal changes may play a role. Hormones which have been studied
include estrogen, progesterone, thyroid hormone, testosterone, corticotropin
releasing hormone, and cortisol.
Fathers, who are not undergoing profound hormonal changes, can also
have postpartum depression. The cause may be distinct in males.
Mothers who have had several previous children without suffering PPD can
nonetheless suffer it with their latest child.
Sleep deprivation of postpartum for a long time

Risk Factors

 Prenatal depression or anxiety

 A personal or family history of depression
  Moderate to severe premenstrual symptoms
 Stressful life events experienced during pregnancy
 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
 Low levels of DHA in the mother
 Sexual orientation(lesbian and bisexual mothers)
 Race(African American mothers have the highest risk of PPD)
 Domestic violence to puerperal

Signs& Symptoms

Some of the more common symptoms a woman may experience include:

 Feeling sad, hopeless, empty, or overwhelmed

 Crying more often than usual or for no apparent reason
 Worrying or feeling overly anxious
 Feeling moody, irritable, or restless
 Oversleeping, or being unable to sleep even when her baby is asleep
 Having trouble concentrating, remembering details, and making decisions
 Experiencing anger or rage
 Losing interest in activities that are usually enjoyable
 Suffering from physical aches and pains, including frequent headaches,
stomach problems, and muscle pain
 Eating too little or too much
 Withdrawing from or avoiding friends and family
 Having trouble bonding or forming an emotional attachment with her baby
 Persistently doubting her ability to care for her baby
 Thinking about harming herself or her baby.
Emotional

 Persistent sadness, anxiousness or "empty" mood

 Severe mood swings
 Frustration, irritability, restlessness, anger
 Feelings of hopelessness or helplessness
 Guilt, shame, worthlessness
 Low self-esteem
 Numbness, emptiness
 Exhaustion
 Inability to be comforted
 Trouble bonding with the baby
 Feeling inadequate in taking care of the baby
Behavioural

 Lack of interest or pleasure in usual activities

 Low or no energy
 Low libido
 Changes in appetite
 Fatigue, decreased energy and motivation
 Poor self-care
 Social withdrawal
 Insomnia or excessive sleep
Cognition

 Diminished ability to make decisions and think clearly

 Lack of concentration and poor memory
 Fear that you cannot care for the baby or fear of the baby
 Worry about harming self, baby, or partner

Diagnosis
Criteria
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:

 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
1. 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. Symptoms typically resolve within two weeks.
Symptoms lasting longer than two weeks are a sign of a more serious type of
depression. Women who experience "baby blues" may have a higher risk of
experiencing a more serious episode of depression later on.
2. 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. 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.
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.
Postpartum psychosis often requires hospitalization, where treatment
is antipsychotic medications, mood stabilizers, and in cases of strong risk for
suicide, electroconvulsive therapy.
The most severe symptoms last from 2 to 12 weeks, and recovery takes 6
months to a year. 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.
Screening
At present, the screening scales commonly used in the evaluation of
postpartum depression are:
1. Edinburgh Postpartum Depression Scale (EPDS)
It is the most widely used self-rating scale for primary health care screening.
This table contains 10 items, which are investigated 6 weeks after delivery. It
can indicate whether there is depressive disorder. If the new mother scores 13
or more, she likely has PPD and further assessment should follow.
But it can’t assess the severity of the disease.
2. Zung Self-rating Depression Scale (SDS)
This table includes 20 questions. It divides the degree of depression into
four grades. It has the advantage of not being influenced by age, economic
status and other factors. It is mainly used to measure the degree of depression
and the changes in treatment.
3. Baker Depression Inventory (BDI)
It is a questionnaire with 21 questions, which has good consistency and
repeatability in the diagnosis of postpartum depression, but the results of the
questionnaire are higher than those of other methods.
4. Hamilton Depression Scale (HAMD)
This table is simple, accurate and easy to master. It is the most frequently
used scale for clinical evaluation of depressive state. It lists 24 items of
depressive symptoms and scores them in 5 grades. But sometimes it is not
easy to distinguish it from anxiety disorder.
5. Symptom Checklist 90 (SCL90)
It can distinguish whether there are psychological symptoms or not. It can be
used to detect whether there are psychological disorders, what kind of
disorders and their severity. It is widely used in outpatient examination of
mental disorders and mental diseases.

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. Exercise has been found to be useful for mild and moderate
cases.
Talk Therapy
Both individual social and psychological interventions appear equally
effective in the treatment of PPD. Social interventions include individual
counseling and peer support, while psychological interventions
include cognitive behavioral therapy (CBT) and interpersonal
therapy (IPT). Other forms of therapy, such as group therapy and home visits,
are also effective treatments.
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.
Medication
 There is evidence which suggests that selective serotonin reuptake
inhibitors(SSRIs) are effective treatment for PPD. However, a recent study has
found that adding sertraline, an SSRI, to psychotherapy does not appear to
confer any additional benefit. 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.
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.
Breastfeeding
There are currently no antidepressants that are FDA approved for use
during lactation. Most antidepressants are excreted in breast milk. However,
there are limited studies showing the effects and safety of these
antidepressants on breastfed babies.
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.

Prevention
A 2013 Cochrane review found evidence that psychosocial or psychological
intervention after childbirth helped reduce the risk of postnatal
depression. These interventions included:
1. Home visits
2. Telephone-based peer support
3. Interpersonal psychotherapy.
4. Emotional closeness and global support by the partner protect against
both perinatal depression and anxiety.
5. Communication between the couple and relationship satisfaction
6. Avoid the risk factors. Women should be screened to determine their
risk for acquiring postpartum depression.
7. Proper exercise and nutrition appear to play a role in preventing
postpartum depression and depressed mood in general.

References:
1. https://en.wikipedia.org/wiki/Postpartum_depression
2. https://www.nimh.nih.gov/health/publications/postpartum-depression-fa
cts/index.shtml
3. "Postpartum Depression Facts". NIMH. Archived from the original on 21
June 2017. Retrieved 11 June 2017.
4. https://www.postpartumdepression.org/resources/statistics/
5. Shefaly Shorey et al(2018). Journal of Psychiatric Research,
ELSEVIER. Prevalence and incidence of postpartum depression among
healthy mothers: A systematic review and meta-analysis. Volume
104, Pages 235-248