Postpartum depression


Postpartum depression, also known as perinatal 'depression', is a mood disorder which may be experienced by pregnant or postpartum women. Symptoms include extreme sadness, low energy, anxiety, crying episodes, irritability, and extreme changes in sleeping or eating patterns. PPD can also negatively affect the newborn child.
Although the exact cause of PPD is unclear, it is believed to be due to a combination of physical, emotional, genetic, and social factors such as hormone imbalances and sleep deprivation. 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. Diagnosis is based on a person's symptoms. 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.
Among those at risk, providing psychosocial support may be protective in preventing PPD. This may include community support such as food, household chores, mother care, and companionship. Treatment for PPD may include counseling or medications. Types of counseling that are effective include interpersonal psychotherapy, cognitive behavioral therapy, and psychodynamic therapy. Tentative evidence supports the use of selective serotonin reuptake inhibitors.
Depression occurs in roughly 10 to 20% of postpartum women. Postpartum depression commonly affects mothers who have experienced stillbirth, mothers who live in urban areas, and adolescent mothers. Moreover, this mood disorder is estimated to affect 1% to 26% of new fathers. A different kind of postpartum mood disorder is postpartum psychosis, which is more severe and occurs in about 1 to 2 per 1,000 women following childbirth. 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.

Signs and symptoms

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

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
  • Thoughts of self-harm or suicide

    Behavioral

  • Lack of interest or pleasure in usual activities
  • Low libido
  • Changes in appetite
  • Fatigue, decreased energy and motivation
  • Poor self-care
  • Social withdrawal
  • Insomnia or excessive sleep
  • Worry about harming self, baby, or partner

    Neurobiology

studies indicate differences in brain activity between mothers with postpartum depression and those without. Mothers diagnosed with PPD tend to have less activity in the left frontal lobe and increased activity in the right frontal lobe when compared with healthy controls. They also exhibit decreased connectivity between vital brain structures, including the anterior cingulate cortex, dorsal lateral prefrontal cortex, amygdala, and hippocampus. Brain activation differences between depressed and nondepressed mothers are more pronounced when stimulated by non-infant emotional cues. Depressed mothers show greater neural activity in the right amygdala toward non-infant emotional cues as well as reduced connectivity between the amygdala and right insular cortex. Recent findings have also identified blunted activity in the anterior cingulate cortex, striatum, orbitofrontal cortex, and insula in mothers with PPD when viewing images of their infants.
More robust studies on neural activation regarding PPD have been conducted with rodents than humans. These studies have allowed for greater isolation of specific brain regions, neurotransmitters, hormones, and steroids.

Onset and duration

Postpartum depression onset usually begins between two weeks to a month after delivery. A study done at an inner-city mental health clinic has shown that 50% of postpartum depressive episodes began before delivery. In the Diagnostic and Statistical Manual of Mental Disorders PPD is not recognized as a distinct condition but rather a specific type of a major depressive episode. In the DSM-5, the specifier "with peripartum onset" can be applied to a major depressive episode if the onset occurred either during pregnancy or within the four weeks following delivery. The prevalence of postpartum depression differs across different months after childbirth. Studies done on postpartum depression amongst women in the Middle East show that the prevalence in the first three months of postpartum was 31%, while the prevalence from the fourth to twelfth months of postpartum was 19%. PPD may last several months or even a year.

Consequences on maternal and child health

Postpartum depression can interfere with normal maternal-infant bonding and adversely affect acute and long-term child development. Infants of mothers with PPD have higher incidences of excess crying, temperamental symptoms, and sleeping difficulties. Probems with sleeping in infants may exacerbate or be exacerbated by concurrent PPD in mothers. Maternal outcomes of PPD include withdrawal, disengagement, and hostility. Additional patterns observed in mothers with PPD include lower rates of initiation and maintenance of breastfeeding.
Children and infants of PPD-affected mothers experience negative long-term impacts on their cognitive functioning, inhibitory control, and emotional regulation. In cases of untreated PPD, violent behaviors and psychiatric and medical conditions in adolescence have been observed.
Suicide rates of women with PPD are lower than those outside of the perinatal period. Fetal or infant death in the first year postpartum has been associated with a higher risk of suicide attempt and higher inpatient psychiatric admissions.

Postpartum depression in fathers

Paternal postpartum depression is a poorly understood concept with a limited evidence-base. However, postpartum depression affects 8 to 10% of fathers. There are no set criteria for men to have postpartum depression. The cause may be distinct in males. Causes of paternal postpartum depression include hormonal changes during pregnancy, which can be indicative of father-child relationships. For instance, male depressive symptoms have been associated with low testosterone levels in men. Low prolactin, estrogen, and vasopressin levels have been associated with struggles with father-infant attachment, which can lead to depression in first-time fathers. Symptoms of postpartum depression in men are extreme sadness, fatigue, anxiety, irritability, and suicidal thoughts. Postpartum depression in men is most likely to occur 3–6 months after delivery and is correlated with maternal depression, meaning that if the mother is experiencing postpartum depression, then the father is at a higher risk of developing the illness as well. Postpartum depression in men leads to an increased risk of suicide, while also limiting healthy infant-father attachment. Men who experience PPD can exhibit poor parenting behaviors, and distress, and reduce infant interaction.
Reduced paternal interaction can later lead to cognitive and behavioral problems in children. Children as young as 3.5 years old may experience problems with internalizing and externalizing behaviors, indicating that paternal postpartum depression can have long-term consequences. Studies suggest that children raised by fathers experiencing depression or other mental illnesses have approximately a 33% to 70% higher risk of developing emotional or behavioral difficulties. Furthermore, if children as young as two are not frequently read to, this negative parent-child interaction can harm their expressive vocabulary. A study focusing on low-income fathers found that increased involvement in their child's first year was linked to lower rates of postpartum depression.

Adoptive parents

Postpartum depression may also be experienced by non-biological parents. While not much research has been done regarding post-adoption depression, difficulties associated with parenting post-partum are similar between biological and adoptive parents. Women who adopt children undergo significant stress and life changes during the postpartum period, similar to biological mothers. This may raise their chance of developing depressive symptoms and anxious tendencies. Postpartum depression presents in adoptive mothers via sleep deprivation similar to birth mothers, but adoptive parents may have added risk factors such as a history of infertility.

Issues for LGBTQ people

Additionally, preliminary research has shown that childbearing individuals who are part of the LGBTQ community may be more susceptible to prenatal depression and anxiety than cisgender and heterosexual people.
According to two other studies, LGBTQ people were discouraged from accessing postpartum mental health services due to societal stigma adding a social barrier that heteronormative mothers do not have. Lesbian participants expressed apprehension about receiving a mental health diagnosis because of worries about social stigma and employment opportunities. Concerns were also raised about possible child removal and a parent's diagnosis including mental illness. From the studies conducted thus far, although limited, it is evident that there is a much larger population that experiences depression associated with childbirth than just biological mothers.

Causes

The cause of PPD is unknown. Hormonal and physical changes, personal and family history of depression, and the stress of caring for a new baby all may contribute to the development of postpartum depression.
Evidence suggests that hormonal changes may play a role. Understanding the neuroendocrinology characteristic of PPD has proven to be particularly challenging given the erratic changes to the brain and biological systems during pregnancy and postpartum. A review of exploratory studies in PPD has observed that women with PPD have more dramatic changes in HPA axis activity, however, the directionality of specific hormone increases or decreases remain mixed. Hormones that have been studied include estrogen, progesterone, thyroid hormone, testosterone, corticotropin releasing hormone, endorphins, and cortisol. Estrogen and progesterone levels drop back to pre-pregnancy levels within 24 hours of giving birth, and that sudden change may cause it. Aberrant steroid hormone-dependent regulation of neuronal calcium influx via extracellular matrix proteins and membrane receptors involved in responding to the cell's microenvironment might be important in conferring biological risk. The use of synthetic oxytocin, a birth-inducing drug, has been linked to increased rates of postpartum depression and anxiety.
Estradiol, which helps the uterus thicken and grow, is thought to contribute to the development of PPD. This is due to its relationship with serotonin. Estradiol levels increase during pregnancy, then drastically decrease following childbirth. When estradiol levels drop postpartum, the levels of serotonin decline as well. Serotonin is a neurotransmitter that helps regulate mood. Low serotonin levels cause feelings of depression and anxiety. Thus, when estradiol levels are low, serotonin can be low, suggesting that estradiol plays a role in the development of PPD.
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 experiencing PPD can nonetheless experience it with their latest child. Despite the biological and psychosocial changes that may accompany pregnancy and the postpartum period, most women are not diagnosed with PPD. 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.