Postpartum Depression: Causes, Symptoms and Treatments
Experts are aware of some risk factors linked to postpartum depression(PPD). However, nobody is completely sure what causes it. Doctors say that PPD is effectively treatable, either with support groups and counseling, or such help combined with medication.
Contents of this article:
- What is postpartum depression?
- Postpartum depression prevalence
- Symptoms of postpartum depression
- Causes of postpartum depression
- Diagnosis of postpartum depression
- Treatment for postpartum depression
- Preventing postpartum depression
Fast facts on postpartum depression
Here are some key points about postpartum depression. More detail and supporting information is in the main article.
- PPD normally appears 4 to 6 weeks after giving birth
- Usually, there is no clear cause of the depression
- PPD affects approximately 1 in 7 new mothers
- An estimated 10% of fathers also experience PPD
- PPD appears to be more prevalent in urban areas
- Symptoms include feeling trapped, overwhelmed, a loss of appetite and reduced libido
- A significant proportion of mothers with postpartum depression does not tell people how they feel
- Sufferers often have thoughts about harming their baby, although this very rarely occurs
- A complicated labor can be a contributing factor to PPD
- PPD is considered a subtype of major depression.
What is postpartum depression?
Postpartum depression affects approximately 1 in 7 new mothers.
PPD, also known as postnatal depression (PND), is a type of depression that affects some women after having a baby. Typically, it develops within four to six weeks after giving birth, but can sometimes take several months to appear. Usually, there is no clear reason for the depression. The patient may experience fatigue, sadness, reduced libido, episodes of crying, irritability, anxiety, and irregular sleeping patterns.
There is absolutely no link between postpartum depression and not loving your baby. Postpartum depression is a clinical illness and not a character weakness. It is important that people with signs and symptoms see their doctor immediately.
Even though doctors and the general public are much more aware of postpartum depression today, a considerable number of women suffer in silence. A study carried out by 4Children, a UK charity, found that half of all women across the UK with postpartum depression do not see a healthcare professional about their problem.
Researchers from the Eastern Virginia Medical School, Norfolk, VA, found that approximately 10% of fathers experience postpartum or prenatal depression. They added that the highest rates are three to six months after childbirth.
Postpartum depression prevalence
Researchers from Northwestern Medicine reported in JAMA Psychiatry that postpartum depression affects approximately 1 in every 7 new mothers.
In their study, involving over 10,000 mothers, they also found that close to 22% of them had been depressed when they were followed up 12 months after giving birth.
Team leader, Dr. Katherine L. Wisner recommends that all pregnant women and new mothers be screened for depressive symptoms. She says:
“In the U.S., the vast majority of postpartum women with depression are not identified or treated even though they are at higher risk for psychiatric disorders. It’s a huge public health problem. A woman’s mental health has a profound effect on fetal development as well as her child’s physical and emotional development.”
Wisner and team discovered that:
- 19.3% of the women who had been screened for depression had considered hurting themselves
- A sizeable proportion of mothers who had screened positive for postpartum depression had had some kind of depression before, as well as an anxiety disorder
- Bipolar disorder is frequently diagnosed late. After giving birth a woman is at a much higher risk of episodes of mania.
A Canadian study found that postpartum depression is much more common in urban areas. After analyzing data from the 2006 Canadian Maternity Experiences Survey, the team from Women’s College Hospital, Centre for Addiction and Mental Health, St. Michael’s Hospital and the University of Toronto, Ontario, found a 10% risk of postpartum depression among women living in urban areas compared to a 6% risk for those in rural areas.
Symptoms of postpartum depression
Postpartum depression can affect mothers in several different ways. Below are some common signs and symptoms:
- A feeling of being overwhelmed
- A feeling of being trapped
- A feeling that it is impossible to cope
- A low mood that lasts for longer than a week
- A sensation of being rejected
- Crying a lot
- Feeling guilty
- Frequent irritability
- Headaches, stomachaches, blurred vision – signs of tension
- Lack of appetite
- Loss of libido
- Panic attacks
- Persistent fatigue
- Problems concentrating or focusing on things
- Reduced motivation
- Sleeping problems
- The mother lacks interest in herself
- A feeling of inadequacy
- Unexplained lack interest in the new baby
- Lack of desire to meet up or stay in touch with friends.
Postpartum depression has nothing to do with baby blues, which affects many women for a few days after giving birth. If the woman’s ability to go about her day-to-day life is significantly undermined, it is more likely she has postpartum depression.
For several possible reasons, a significant proportion of mothers with postpartum depression does not tell people how they feel. Partners, family and friends who are able to pick up on the signs of postpartum depression at an early stage should encourage her to get medical help as soon as possible.
Scary thoughts – some mothers may have thoughts about harming their child. Experts say this happens in about half of all patients with postpartum depression. The mother may also think about ending her life or harming herself. The mother and/or baby are very rarely harmed. However, having these thoughts are frightening and distressing.
Dr. Catharine Goodsteine, who works at the NYU Medical School, Obstetrics & Surgery OB-GYN, Downtown Women NYC, studies the difference between “baby blues” and postpartum depression, its symptoms and postpartum psychosis. She also investigates who are more likely to develop the condition.
Causes of postpartum depression
To date, no one knows what the exact causes of postpartum depression are.
Experts believe postpartum depression does not have just one cause but is probably the result of multiple factors. However, its causes are still an enigma – nobody is sure.
Depression is usually caused by either emotional and stressful events, or some biological factor which leads to an imbalance of brain chemicals (neurotransmitters), or both.
Dr. Peter J. Schmidt, an NIH investigator who studies how hormones affect women’s moods, said: “There are probably certain characteristics that increase vulnerability to the condition.” Dr. Schmidt added that women who have had postpartum depression before have a higher risk of another bout. “Other vulnerabilities may be related to events, like early-life trauma.”
The following potentially stressful events that may occur during pregnancy, childbirth or/and shortly afterward, could be contributory factors:
- Depression develops during pregnancy
- Excessive worry about the baby and the responsibilities of being a parent
- Complicated or difficult labor and childbirth
- A Brazilian study published in The Lancet found that psychological violence by the pregnant woman’s partner can raise the risk of her developing postpartum depression, regardless of whether or not there was any physical violence
- Lack of family support
- Worries about relationships
- Financial difficulties
- Loneliness, not having close friends and family around
- A history of mental health problems, such as depression, or a previous postpartum depression
- Health consequences following childbirth, such as urinary incontinence, anemia, changes in blood pressure, and alterations in metabolism. A Dutch study found that complications around the time of childbirth can raise the risk of postpartum depression
- Hormonal changes – after giving birth, estrogen and progesterone (hormones) levels may drop considerably, as may other hormones produced by the thyroid gland
- Lack of sleep – newborn babies can cry a lot at night and deprive parents of a lot of sleep.
- An unplanned or unwanted pregnancy. A study carried out at the University of North Carolina found that women with unintended or unplanned pregnancies were four times more likely to develop postpartum depression, compared to those who had wanted/planned to have a baby
- A UK study found that certain genes may have a positive or negative effect on postpartum depression risk, depending on a person’s environment
Breastfeeding difficulties – new mothers with breastfeeding difficulties in the first two weeks after the baby is born to have a higher risk of postpartum depression two months later, a study carried out at the University of North Carolina at Chapel Hill found.
Team leader, Stephanie Watkins, MSPH, MSPT, said “We found that women who said they disliked breastfeeding were 42 percent more likely to experience postpartum depression at two months compared to women who liked breastfeeding. We also found that women with severe breast pain at day one and also at two weeks postpartum were twice as likely to be depressed compared to women that did not experience pain with nursing.”
A person with a family history of depression has a higher risk of developing it themselves. However, nobody knows why this occurs in detail.
Women who have bipolar disorder have a higher risk of developing postpartum depression compared to other mothers.
Researchers at South London and Maudsley NHS Foundation Trust, England, found that postpartum depression can start during the pregnancy itself.
Diagnosis of postpartum depression
Postpartum depression is considered a subtype of major depression by DSM (Diagnostic and Statistical Manual of Mental Disorders). DSM is the standard classification of mental disorders used by doctors and psychologists in the USA – it is published by the American Psychiatric Association.
Postpartum depression can be diagnosed through the completion of a depression-screening questionnaire with a health care provider.
The DSM says that the signs and symptoms of major depression must have developed within four weeks of the baby being born (many experts say this period is too short).
A GP (general practitioner, primary care physician) and other health care professionals may ask the patient to complete a depression-screening questionnaire, The aim here is to rule out baby blues.
The doctor may also order some diagnostic tests, such as blood tests, to determine whether there are any hormonal problems, such as those caused by an underactive thyroid gland, or anemia.
According to the NHS (National Health Service), UK, a GP will probably ask the patient two questions:
- Have you been bothered by feeling down, depressed or hopeless during the past month
- Have you been bothered by taking little or no pleasure in taking part in activities that would usually make you happy?
A patient who answers “Yes” to both questions is much more likely to have postpartum depression.
The doctor may then ask the patient whether she feels she needs or wants help. Whether the doctor asks this will usually depend on how the first two questions were answered.
The NHS says that many mothers with no partner or close relative to help out with baby care might not want to answer openly because they fear they will be diagnosed with postpartum depression and will have the baby taken away from them.
UK authorities stress that this is most unlikely to happen. A baby is only taken away in very exceptional situations. Even in very severe cases where the mother has to be hospitalized in a mental health clinic, in the UK and most developed nations, she will usually have her baby next to her.
In most countries, a GP is trained to diagnose and treat postpartum depression. The doctor will probably try to determine what the signs and symptoms are so that the severity of the depression can be assessed (so that the best course of treatment can be decided upon).
The doctor will ask if the patient has:
- Sleeping problems
- Problems making decisions and concentrating
- Self-confidence problems
- Changes in appetite – this could be lack of appetite or eating more than usual (comfort eating)
- Fatigue, listlessness, reluctance to be involved in any physical activity
- Been feeling guilty
- Been self-critical
- Been having suicidal thoughts.
A patient who answers “yes” to three of the questions above probably has mild depression. In cases of mild depression, the mother is still able to go about her normal activities. The more “yes” answers there are, the higher the severity of depression, to “moderate” and finally “severe” depression.
A mother with moderate depression will find normal activities hard to do – but with the right help will probably cope. If she has severe depression she will not be able to function at all and will need extensive help from a dedicated mental health team.
Treatment for postpartum depression
Mothers who wonder whether they might have postpartum depression symptoms should get in touch with their doctor. In the UK and many other countries which offer universal healthcare, talking to a health visitor or midwife is also recommended.
Although postpartum depression is treatable and curable, recovery may sometimes take several months, and in some cases even longer.
The mother’s most important step on the road to treatment and recovery is to acknowledge the problem. Family, partner and close friends’ support can have a major impact on a faster recovery.
Experts say it is better for the mother to express how she feels to people she can trust, rather than bottling everything up inside. There is a risk partner and sometimes other loved ones may feel shut out, which can complicate things.
Self-help groups are useful because not only will the mother have access to useful data, she will also meet other mothers who share similar problems and symptoms. This may help her feel less isolated.
In moderate or severe postpartum depression the doctor may prescribe an antidepressant. These are supposed to help balance the chemicals in the brain that affect mood. Antidepressants may help with irritability, hopelessness, a feeling of not being able to cope, concentration, and sleeplessness. These medications tend to have good results and help the mother cope better and bond with her baby.
Antidepressants may take a few weeks to kick in. Patients who despair at experiencing no immediate results need to be reminded about this. Depending on how patients respond, the doctor may alter the medication’s dosage.
According to the NHS, between 50% and 70% of patients respond well to antidepressants within a few weeks. However, they do not work for everybody.
Antidepressants can be passed on to babies through breast milk. Nobody knows what the long-term risks are for the baby. According to some small studies, TCAs (tricyclic antidepressants), such as imipramine and nortriptyline are most likely the safest to take while breastfeeding a baby. If the mother has a history of heart disease, epilepsy, or severe depression with frequent suicidal thoughts she should not be prescribed TCAs.
Those who cannot take TCAs may be prescribed an SSRI (selective serotonin reuptake inhibitor), such as paroxetine or sertraline. The amount of paroxetine or sertraline that eventually gets into breast milk is minimal.
The mother should discuss feeding options with her doctor so that selecting the right treatment, which may include an antidepressant, is an informed choice decision.
Breastfeeding, apart from its nutritional benefits for the baby, also helps mother and child bond, and boosts the patient’s confidence in being a good mother.
Tranquilizers may be prescribed in cases of postnatal psychosis, where the mother may have hallucinations, suicidal thoughts and irrational behavior. However, in such cases, the medications should be used for a short time. Tranquilizers may cause loss of balance, memory loss, lightheadedness, drowsiness and confusion. Patients on tranquilizers may have impaired driving skills.
Often, a combination of talking therapies and drug treatments is the best course of action.
Studies have found that CBT (cognitive behavioral therapy) has a success rate of between 50% to 70% of patients with moderate postpartum depression – a similar rate to medication. For those with severe depression, where motivation is low, talking therapies alone are much less effective.
Most studies agree that the best results come from a combination of talking therapies with medication, also known as counseling and drugs.
Examples of talking therapies may include:
- Cognitive therapy – this type of therapy is based on the principle that a person’s thoughts can trigger depression. The patient is shown (taught) how her thoughts can have a harmful impact on her state of mind. The aim is to alter the patient’s thought patterns so that they become more positive
- Cognitive behavioral therapy (CBT) – this is a combination of behavioral therapy and cognitive therapy. The patient is shown how to change the way she thinks, behaves and feels
- Other therapies – these may include problem-solving therapy, interpersonal therapy, etc.
Severe postpartum depression – the patient may be referred to a team of specialists, including psychiatrists, psychologists, occupational therapists, and specialized nurses. If the doctor(s) feels that the patient is at risk of harming herself or her child, she may be hospitalized in a mental health clinic. In some cases, the baby may be cared for by the partner or family member while the mother is being treated.
In the UK, if the mother has nobody to help out, the team will usually find her a mother-and-baby mental health clinic so that the two can remain together. Initially, the baby may sleep in a separate room. As the mother improves, mother and baby spend more time together.
If the mother’s symptoms are very severe, she might benefit from electroconvulsive therapy (ECT). However, this is always a treatment of last resort – when all other options, such as medication and talking therapies, have failed.
ECT is applied under general anesthetic, plus drugs to relax the muscles. ECT is usually very effective in cases of very severe depression.
However, sometimes the improvements may be short-lived. There may be some side effects, such as headaches, and memory loss (usually short term, but not always). Memory is monitored closely after each ECT session. If doctors detect any sizeable memory loss, the treatment is stopped.
Preventing postpartum depression
The more a doctor knows during or even before a pregnancy about the patient’s medical and family history, the higher the chances are of preventing postpartum depression. The GP should be told about any previous episodes of depression or mental illness.
A study carried out at the School of Physiotherapy at the University of Melbourne, Victoria, Australia, found that a physical therapy exercise and health education program effectively reduced the risk of developing postpartum depression.
An article published in Methods of Information in Medicine reported on a Spanish study that found that 80% percent of cases of postpartum depression can be predicted by a new method involving artificial neuronal networks and a series of risk factors.
According to the National Health Service (UK), the following may help:
- Stay physically fit. Do regular exercise. Many women have reported benefits from exercise. However, a study published in The Lancet reported only a moderate effect of exercise in reducing symptoms of postpartum depression. The authors wrote that although some difference was noted, it was not statistically significant.
- Follow a well-balanced, healthy diet.
- Omega-3 fatty acids – scientists from the University of Montreal, Canada reported in the Canadian Journal of Psychiatry that women with low levels of omega-3 may be at a higher risk of developing postpartum depression. Team leader, Gabriel Shapiro, said “The literature shows that there could be a link between pregnancy, omega-3 and the chemical reaction that enables serotonin, a mood regulator, to be released into our brains. Many women could bring their omega-3 intake to recommended levels.”However, an article published in JAMA reported that fish oil capsules taken during pregnancy did not reduce postpartum depression risk.
- Rest – get at least 7 to 8 hours good quality sleep each night
- Blood sugar – eat frequently, don’t let your blood glucose levels drop too much by not eating for long periods
- Make lists – organize yourself so you are not rushing around and becoming frustrated at not achieving much. Try not to do too much; prioritize
- Be open – talk to close friends, partners, and family members about how you feel, and things you are worried about
- Get in touch with local help groups
- Remember that postpartum depression affects millions of women every year. It is not your fault.
Strong social support from families helps prevent postpartum depression – a team from UCLA National Institute of Mental Health found that levels of the placental corticotropin-releasing hormone (pCRH), a stress hormone released from the placenta, are lower among pregnant women with strong social support from their families.
Research team member, Jennifer Hahn-Holbrook, said: “Now we have some clue as to how support might ‘get under the skin’ in pregnancy, dampening down a mother’s stress hormone, and thereby helping to reduce her risk for postpartum depression.”