Postpartum depression is the most common psychiatric complication of childbirth. Postpartum depression, or PPD, affects 1 in 7 women and is under-diagnosed and under-treated. It has negative effects for women, families and children. This article will discuss who is at risk for PPD, what causes PPD and how to know if you may have PPD.
Postpartum Depression: Listen to this artcile
Women have a lifetime prevalence of depression that is 1.5-3 times higher than that of men, which is in part due to the number of women who experience depression during childbearing years. During pregnancy 7-12% of women experience depression and after birth an estimated 15% of women experience postpartum depression (PPD). To make matters worse, women are reluctant to seek treatment and only 18% of those with depression during pregnancy or postpartum take antidepressants. Women with untreated PPD have increased marital difficulties, impaired cognitive abilities, and are more likely to commit infanticide or abuse their children. Two primary risk factors are depression during pregnancy and family history of depression.
Who is at risk for postpartum depression?
Risk factors for PPD include: lack of social support, domestic violence, history of sexual abuse, sadness of baby’s gender, low vitamin B6 levels, risky pregnancy, stressful delivery (emergency c-section, meconium passage, umbilical cord prolapse, preterm or low birth weight infant), decreased sleep, reduced physical activity, and history of anxiety and depression and premenstrual mood symptoms (PMS).
Some women may be more sensitive to hormonal changes
There is also evidence that some women are more sensitive to hormonal fluctuations in general.
Women go through many reproductive events in life: menarche, the premenstrual phase, hormonal contraceptive use, pregnancy, postpartum, and menopause. There are some women who are more susceptible to physical, psychological and sexual symptoms of these hormonal shifts throughout their lifetime, not just in one reproductive event. These women could have Hormonal Sensitivity Syndrome.
Evidence shows that women who have heavy periods, a history of depression, or PMS are more likely to experience negative side effects with oral contraceptives.
Similarly, women who have a history of depression, mood symptoms with oral contraceptives, or PMS are more likely to experience PPD. These findings show that certain women are more likely to experience negative symptoms when these reproductive events occur i.e. large hormonal changes, thus these women may be more sensitive to the hormonal shifts. These trends continue if we look at menopause as well, and the majority of research shows a link between depressed mood across multiple reproductive events.
Women who experience PMS, negative side effects for oral contraceptive use, or have a history of depression should be educated about the signs of PPD and followed up more closely after birth as they are at higher risk.
First-time mother or subsequent birth?
Depression and anxiety are more common in first-time mothers. For second-time mothers who do experience depression it tends to be less severe and they touch their infants more that first-time mothers who are depressed. This makes sense, the unknown is stressful and once you have had a newborn and know a bit what to expect this period becomes more manageable.
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First pregnancy vs second pregnancy
If you are preparing for baby 2 you probably have lots of questions. Like when to tell your toddler about the new baby and if labor is going to be faster this time. But before you get to those detials all women who are pregnant with a toddler must be aware of CMV.
What causes postpartum depression?
We don’t know. Genetics, hormones, psychological and social life stressors all play a role, although we aren’t exactly sure how. Research has shown that women with PPD have reduced hormonal levels (oxytocin and prolactin) and higher stress but it is unclear if the depression causes the physiological changes or the other way around.
Hormonal impacts of the stress response and breastfeeding
Stress Response
Cortisol & the HPA axis
Hormonal fluctuations are certainly involved in depression, but we do not yet completely understand how. Research has looked at different hormones to try to find a connection. We know that stress causes PPD and PPD causes stress. Cortisol and the HPA axis are both involved in our bodies stress response, but there is little evidence for cortisol causing PPD.
So what about the HPA axis? Research does show that breastfeeding decreases stress via the HPA axis. Women who breastfeed have a diminished HPA response to external stressors after suckling, meaning that something stressful can happen but the HPA axis doesn’t respond “as much” and they don’t feel stressed.
Women with PPD do not show this diminished HPA response to stressors, but they are also less likely to breastfeed so the full picture is not clear.
Breastfeeding
Oxytocin & Prolactin
These two hormones are important for breastfeeding and for mood regulation. Here again, like stress and PPD, we can see a relation but not a directional cause. Women with PPD are less likely to breastfeed and they have reduced prolactin levels. However, because some of the advantages of breastfeeding is that it increases prolactin levels, improves mood, and reduces stress it is not clear which comes first – the low prolactin levels or the depression.
The story is similar with oxytocin, we can’t quite work out the cause and the effect. Women with low levels of oxytocin in their blood during the 3rd trimester are more likely to show depressive symptoms during pregnancy and develop PPD.
Women with PPD and unwanted early weaning also show low levels of oxytocin. The failure to lactate and the onset of postpartum depression often occur at the same time complicating the story of the chicken or the egg.
How do I know if I have postpartum depression?
Some women wonder if they are just experiencing the “baby blues” or if it could be PPD. The baby blues are feelings of sadness, tearfulness, anxiety, irritability, and insomnia that decrease over the first two weeks after delivery. This affects an estimated 30-75% of women.
Postpartum depression normally occurs within 6 weeks after delivery. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM–5), PPD is diagnosed when at least 5 of the following 9 symptoms are present almost every day for at least 2 weeks. Depressed mood (#1) or loss of interest (#2) must be present.
- Depressed mood (subjective or observed) is present most of the day
- Loss of interest or pleasure, most of the day
- Insomnia or hypersomnia
- Psychomotor retardation or agitation
- Worthlessness or guilt
- Loss of energy or fatigue
- Suicidal ideation or attempt and recurrent thoughts of death
- Impaired concentration or indecisiveness
- Change in weight or appetite (weight change 5% over 1 month)
Women with PPD can have other psychiatric symptoms such as panic attacks, obsessions, or compulsions. An estimated 41-57% of women with PPD experience obsessive-compulsive thoughts.
If you think you may have PPD, see your physician now, for yourself and for your family. Persistence of maternal depression can increase the risk of children developing anxiety, depression and disruptive disorders and is associated with lower cognitive functioning and behavioural problems in children. There are medications and treatment for all women, including those who breastfeed.
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