Postnatal depression

Postpartum depression (PPD), also called postnatal depression, is a type of mood disorder associated with childbirth, which can affect both sexes. Symptoms may include extreme sadness, low energy, anxiety, crying episodes, irritability, and changes in sleeping or eating patterns. Onset is typically between one week and one month following childbirth. PPD can also negatively affect the newborn child.

While the exact cause of PPD is unclear, the cause is believed to be a combination of physical, emotional, genetic, and social factors. These may include factors such as hormonal changes 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 have been found to be effective include interpersonal psychotherapy (IPT), cognitive behavioral therapy (CBT), and psychodynamic therapy. Tentative evidence supports the use of selective serotonin reuptake inhibitors (SSRIs).

Postpartum depression affects roughly 15% of women after childbirth. Moreover, this mood disorder is estimated to affect 1% to 26% of new fathers. Postpartum psychosis, a more severe form of postpartum mood disorder, 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 any time in the first year postpartum.The Boston Women's Health Book Collective: Our Bodies Ourselves, pages 489–491, New York: Touchstone Book, 2005 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 swingsWebMD: Understanding Post Partum Depression
* 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

fMRI 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 is 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 anterior cingulate cortex, striatum, orbitofrontal cortex, and insula in mothers with PPD when viewing images of their own 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 there began prior to delivery. Therefore, in the DSM-5 postpartum depression is diagnosed under "depressive disorder with peripartum onset", in which "peripartum onset" is defined as anytime either during pregnancy or within the four weeks following delivery. PPD may last several months or even a year. Postpartum depression can also occur in women who have suffered a miscarriage. For fathers, several studies show that men experience the highest levels of postpartum depression between 3–6 months postpartum.

Parent-infant relationship

Postpartum depression can interfere with normal maternal-infant bonding and adversely affect acute and longterm child development. Postpartum depression may lead mothers to be inconsistent with childcare. These childcare inconsistencies may include feeding routines, sleep routines, and health maintenance.

In rare cases, or about 1 to 2 per 1,000, the postpartum depression appears as postpartum psychosis. In these, or among women with a history of previous psychiatric hospital admissions, infanticide may occur. In the United States, postpartum depression is one of the leading causes of annual reported infanticide incidence rate of about 8 per 100,000 births.

According to research published in the ''American Journal of Obstetrics and Gynecology'', children can experience the effects of postpartum depression. If a mother experiences postpartum depression that goes untreated, it can have adverse effects on her children. When a child is in infancy, these problems can include unusual amounts of crying (colic) and not having normal sleeping patterns. These problems can have a cyclical effect, meaning that they can further agitate the mother's postpartum depression and can even lead to the mother further developing postpartum depression. These cyclical effects can affect the way the mother maintains her relationship with her child. These can include the stopping of breastfeeding, as well as negative emotions such as withdrawal, disengagement, and even hostility. If a mother develops a hostile relationship, it can lead to extreme outcomes such as infanticide.

As the child grows older, postpartum depression can lead to the child experiencing irregularities in cognitive processes, behaviors, and emotions. In addition to these abnormalities, children who grew up around postpartum depression also are susceptible to developing violent tendencies.

Postpartum Depression in Fathers

Paternal postpartum depression has not been studied as intently as its maternal counterpart. However, postpartum depression affects 8 to 10% of fathers. In men, postpartum depression is typically defined as "an episode of major depressive disorder (MDD) occurring soon after the birth of a child". 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 increase risk of suicide, while also limiting healthy infant-father attachment. Men who experience PPD can exhibit poor parenting behaviors, 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 experience problems with internalizing and externalizing behaviors, indicating that paternal postpartum depression can have long-term consequences. Furthermore, if children as young as two are not frequently read to, this negative parent-child interaction can have a harmful impact on their expressive vocabulary.

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 have observed that women with PPD have more dramatic changes in HPA axis activity, however directionality of specific hormone increases or decreases remain mixed. Hormones which 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.

Fathers, who are not undergoing profound hormonal changes, can also have postpartum depression. The cause may be distinct in males.

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.

Risk factors

While the causes of PPD are not understood, a number of factors have been suggested to increase the risk. These risks can be broken down into two categories, biological and psychosocial:

Biological

* Administration of labor-inducing medication synthetic oxytocin
* Chronic illnesses caused by neuroendocrine irregularities
* Genetic history of PPD
* Hormone irregularities
* Inflammatory illnesses (irritable bowel syndrome, fibromyalgia)
* Cigarette smoking

The risk factors for postpartum depression can be broken down into two categories as listed above, biological and psychosocial. Certain biological risk factors include the administration of oxytocin to induce labor. Chronic illnesses such as diabetes, or Addison's disease, as well as issues hypothalamic-pituitary-adrenal dysregulation (which controls hormonal responses), inflammatory processes like asthma or celiac disease, and genetic vulnerabilities such as a family history of depression or PPD. Chronic illnesses caused by neuroendocrine irregularities including irritable bowl syndrome and fibromyalgia typically put individuals at risk for further health complications. However, it has been found that these diseases do not increase risk for postpartum depression, these factors are known to correlate with PPD. This correlation does not mean these factors are causal. Cigarette smoking has been known to have additive effects. Some studies have found a link between PPD and low levels of DHA (an omega-3 fatty acid) in the mother. A correlation between postpartum thyroiditis and postpartum depression has been proposed but remains controversial. There may also be a link between postpartum depression and anti-thyroid antibodies.

Psychosocial

* Prenatal depression or anxiety
* A personal or family history of depression
* Moderate to severe premenstrual symptoms
* Stressful life events experienced during pregnancy
* Postpartum blues
* Birth-related psychological trauma
* Birth-related physical trauma
* History of sexual abuse
* Childhood trauma
* Previous stillbirth or miscarriage
* Formula-feeding rather than breast-feeding
* Low self-esteem
* Childcare or life stress
* Low social support
* Poor marital relationship or single marital status
* Low socioeconomic status
* A lack of strong emotional support from spouse, partner, family, or friends
* Infant temperament problems/ colic
* Unplanned/unwanted pregnancy
* Breastfeeding difficulties
* Maternal age, family food insecurity and violence against women

The psychosocial risk factors for postpartum depression include severe life events, some forms of chronic strain, relationship quality, and support from partner and mother. There is a need for more research in regard to the link between psychosocial risk factors and postpartum depression. Some psychosocial risk factors can be linked to the social determinants of health. Women with fewer resources indicate a higher level of postpartum depression and stress than those women with more resources, such as financial.

Rates of PPD have been shown to decrease as income increases. Women with fewer resources may be more likely to have an unintended or unwanted pregnancy, increasing risk of PPD. Women with fewer resources may also include single mothers of low income. Single mothers of low income may have more limited access to resources while transitioning into motherhood. These women already have fewer spending options, and having a child may spread those options even further. Low-income women are frequently trapped in a cycle of poverty, unable to advance, affecting their ability to access and receive quality healthcare to diagnose and treat postpartum depression.

Studies have also shown a correlation between a mother's race and postpartum depression. African American mothers have been shown to have the highest risk of PPD at 25%, while Asian mothers had the lowest at 11.5%, after controlling for social factors such as age, income, education, marital status, and baby's health. The PPD rates for First Nations, Caucasian and Hispanic women fell in between.

Migration away from a cultural community of support can be a factor in PPD. Traditional cultures around the world prioritize organized support during postpartum care to ensure the mother's mental and physical health, wellbeing, and recovery.

One of the strongest predictors of paternal PPD is having a partner who has PPD, with fathers developing PPD 50% of the time when their female partner has PPD.

Sexual orientation has also been studied as a risk factor for PPD. In a 2007 study conducted by Ross and colleagues, lesbian and bisexual mothers were tested for PPD and then compared with a heterosexual sample group. It was found that lesbian and bisexual biological mothers had significantly higher Edinburgh Postnatal Depression Scale scores than did the heterosexual women in the sample. Postpartum depression is more common among lesbian women than heterosexual women, which can be attributed to lesbian women's higher depression prevalence. Lesbian women have a higher risk of depression because they are more likely to have been treated for depression and to have attempted or contemplated suicide than heterosexual women. These higher rates of PPD in lesbian/bisexual mothers may reflect less social support, particularly from their families of origin and additional stress due to homophobic discrimination in society.

There is a call to integrate both a consideration of biological and psychosocial risk factors for PPD when treating and researching the illness.

Violence

A meta-analysis reviewing research on the association of violence and postpartum depression showed that violence against women increases the incidence of postpartum depression. About one-third of women throughout the world will experience physical or sexual violence at some point in their lives. Violence against women occurs in conflict, post-conflict, and non-conflict areas. The research reviewed only looked at violence experienced by women from male perpetrators. Further, violence against women was defined as "any act of gender-based violence that results in, or is likely to result in, physical, sexual, or psychological harm or suffering to women". Psychological and cultural factors associated with increased incidence of postpartum depression include family history of depression, stressful life events during early puberty or pregnancy, anxiety or depression during pregnancy, and low social support. Violence against women is a chronic stressor, so depression may occur when someone is no longer able to respond to the violence.

Diagnosis

Criteria

Postpartum depression in the DSM-5 is known as "depressive disorder with peripartum onset". Peripartum onset is defined as starting anytime during pregnancy or within the four weeks following delivery. There is no longer a distinction made between depressive episodes that occur during pregnancy or those that occur after delivery. Nevertheless, the majority of experts continue to diagnose postpartum depression as depression with onset anytime within the first year after delivery.

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

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.

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 different from postpartum depression and from maternity blues. It may be a form of bipolar disorder. 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.

Birth-Related/Postpartum Posttraumatic Stress Disorder

Although birth-related posttraum