User:Adelat8/Postpartum depression

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Postpartum Depression[edit]

Not to be confused with Postpartum blues. For other types of depression, see Mood disorder.

Postpartum depression (PPD), also called postnatal depression, is a type of mood disorder associated with pregnancy[1]. Symptoms may include extreme sadness, low energy, anxiety, crying episodes, irritability, and changes in sleeping or eating patterns.[1] Symptoms typically start between one week and one month after childbirth or miscarriage, but may occur anytime either during pregnancy. Many women commonly experience postpartum blues, a brief period of worry or unhappiness after delivery, however postpartum depression should be suspected if symptoms are severe and last over two weeks.[2][3]

While the exact cause of PPD is unclear, it is believed to be causes by a combination of physical, emotional, genetic, and social factors.[4] 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.

Postpartum depression affects roughly 15% of women after childbirth.[5] Among those at risk, providing psychosocial support such as community assistance and companionship may be protective in preventing PPD. Treatments for PPD may include therapy and medications.[6][7]

Signs and Symptoms[edit]

Symptoms of PPD can occur any time in the first year following childbirth.[8] Typically, a diagnosis of postpartum depression is considered once signs and symptoms persist for at least two weeks.[9]

Emotional[edit]

  • Persistent sadness, anxiousness or "empty" mood[8]
  • Severe mood swings[9]
  • Frustration, irritability, restlessness, anger[10][8]
  • Feelings of hopelessness or helplessness[8]
  • Guilt, shame, worthlessness[10][8]
  • Low self-esteem[8]
  • Numbness, emptiness[8]
  • Exhaustion[8]
  • Inability to be comforted[8]
  • Trouble bonding with the baby[9]
  • Feeling inadequate in taking care of the baby[8][10]
  • Thoughts of self-harm or suicide[11]

Behavioral[edit]

  • Lack of interest or pleasure in usual activities[8][9]
  • Low libido[12]
  • Changes in appetite[8]
  • Fatigue, decreased energy[9] and motivation[10]
  • Poor self-care[9]
  • Social withdrawal[8]
  • Insomnia or excessive sleep[8][9]
  • Worry about harming self, baby, or partner[10]

Start and Duration of Symptoms[edit]

Postpartum depression usually begins between two weeks to a month after delivery.[13] A study done at an inner-city mental health clinic has shown that 50% of postpartum depressive episodes there began prior to delivery.[14] Therefore, in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders 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.[15] Postpartum depression can also occur in women who have suffered a miscarriage.[16]

Causes[edit]

While the causes of PPD are not understood, a number of factors have been suggested to increase the risk.[17] These risk factors can be broken down into two categories, biological and psychosocial.[18] However, these factors do not increase risk for postpartum depression, they are only correlate with PPD. This correlation does not mean these factors are causal.[19]

Biological Risk Factors[edit]

Certain biological risk factors include the administration of oxytocin to induce labor, chronic illnesses such as diabetes or Addison's disease, as well as hypothalamic-pituitary-adrenal dysregulation (which controls hormonal responses), inflammatory processes like asthma or celiac disease, and genetic disposition 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.[20] 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.[21]

Psychosocial Risk Factors[edit]

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.[18] Women with fewer resources indicate a higher level of postpartum depression and stress than those women with more resources, such as financial.[22]

Psychosocial Risk Factors

Other Risk Factors[edit]

Rates of PPD have been shown to decrease as income increases. 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. Women with fewer resources may be more likely to have an unintended or unwanted pregnancy, increasing risk of PPD.[22]

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.[33]

Sexual orientation has also been studied as a risk factor for PPD. In a 2007 study found that postpartum depression is more common among lesbian women than heterosexual women, which can be attributed to lesbian women's higher depression prevalence. 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.[34]

Diagnosis[edit]

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.[35]

Criteria[edit]

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. The criteria include at least five of the following nine symptoms, within a two-week period:[35]

  • 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[edit]

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.[2] Symptoms typically resolve within two weeks. Symptoms lasting longer than two weeks are a sign of a more serious type of depression.[3]

Postpartum psychosis is a more severe form of postpartum mood disorder, occurs in about 1 to 2 per 1,000 women following childbirth.[36] Postpartum psychosis often requires hospitalization, where treatment is antipsychotic medications, mood stabilizers, and in cases of strong risk for suicide, electroconvulsive therapy.[37]

Birth-Related/Postpartum Post Traumatic Stress Disorder[38]

Although birth-related posttraumatic stress disorder is not recognized in the DSM-5, there is extensive research being conducted to bring awareness to the posttraumatic stress disorder symptoms one could experience following childbirth. [39]A crucial element in diagnosing postpartum posttraumatic stress disorder following childbirth is when there is a real or perceived trauma before, during, or following childbirth, which is not always required when it comes to diagnosing someone with postpartum depression.[40] This real or perceived traumatic event that could happen before, during, or following labor and delivery could be toward the baby, mother, or both.[41] Further research and development are needed to create a more accurate assessments and screening tools that can differentiate among posttraumatic stress disorders, postpartum/childbirth-related posttraumatic stress disorder, and postpartum depression so that the most adequate treatment interventions and options can be implemented as quickly as possible.

Screening[edit]

Screening for postpartum depression is critical as up to 50% of cases go undiagnosed in the US, emphasizing the significance of comprehensive screening measures.[42] In the US, the American College of Obstetricians and Gynecologists suggests healthcare providers consider depression screening for perinatal women.[43] Additionally, the American Academy of Pediatrics recommends pediatricians screen mothers for PPD at 1-month, 2-month and 4-month visits.[44] However, many providers do not consistently provide screening and appropriate follow-up.[43][45]

The Edinburgh Postnatal Depression Scale, a standardized self-reported questionnaire, may be used to identify women who have postpartum depression. If the new mother scores 13 or more, she likely has PPD and further assessment should follow.[46] Healthcare providers may also take a blood sample to test if another disorder is contributing to depression during the screening.[47]

Depending on one's cultural background, symptoms of postpartum depression may manifest differently, and non-Westerners being screened in Western countries may be misdiagnosed because their screening tools do not account for cultural diversity.[48]

Prevention[edit]

Psychosocial or psychological intervention after childbirth help reduce the risk of postnatal depression. These interventions included home visits, telephone-based peer support, and interpersonal psychotherapy.[49] Support is an important aspect of prevention, as depressed mothers commonly state that their feelings of depression were brought on by "lack of support" and "feeling isolated."[50]

In couples, emotional closeness and global support by the partner protect against both perinatal depression and anxiety.[51] Further factors such as communication between the couple and relationship satisfaction have a protective effect against anxiety alone.[52]

Preventative treatment with antidepressants may be considered for those who have had PPD previously. However, the evidence supporting such use is weak.[53]

Management[edit]

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.[54]

Talk Therapy[edit]

Both individual social and psychological interventions appear equally effective in the treatment of PPD.[55] Social interventions include individual counseling and peer support, while psychological interventions include cognitive behavioral therapy (CBT) and interpersonal therapy (IPT).[56] Interpersonal therapy (IPT) has shown to be effective in focusing specifically on the mother and infant bond.[57] Support groups and group therapy options focused on psychoeducation around postpartum depression have been shown to enhance the understanding of postpartum symptoms and often assist in finding further treatment options.[58]

Other forms of therapy, such as group therapy, home visits, counseling, and ensuring greater sleep for the mother may also have a benefit.[4] While specialists trained in providing counseling interventions often serve this population in need, results from a recent systematic review and meta-analysis found that nonspecialist providers, including lay counselors, nurses, midwives, and teachers without formal training in counseling interventions, often provide effective services related to perinatal depression and anxiety.[59]

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.[60]

Medication[edit]

Some evidence suggests that mothers with PPD will respond similarly to people with major depressive disorder. There is low-certainty evidence which suggests that selective serotonin reuptake inhibitors (SSRIs) are effective treatment for PPD.[61]The first-line anti-depressant medication of choice is sertraline, an SSRI, as very little of it passes into the breast milk and, as a result, to the child.[4]

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.[56] However, there is some controversy with this form of treatment because estrogen should not be given to people who are at higher risk of blood clots, which include women up to 12 weeks after delivery.[62] Additionally, none of the existing studies included women who were breastfeeding. However, there is some evidence that the use of estradiol patches might help with PPD symptoms.[5]

In 2019, the FDA approved brexanolone, a synthetic analog of the neurosteroid allopregnanolone, for use intravenously in postpartum depression. Allopregnanolone levels drop after giving birth, which may lead to women becoming depressed and anxious.[63] Some trials have demonstrated an effect on PPD within 48 hours from the start of infusion.[64] Other new allopregnanolone analogs under evaluation for use in the treatment of PPD include zuranolone and ganaxolone, but are only available to those at certified health care facilities with a health care provider who can continually monitor the patient.[64]

Electroconvulsive therapy[edit]

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. Tentative evidence supports the use of repetitive transcranial magnetic stimulation (rTMS).[65]

Other medications and supplements[edit]

It is unclear if acupuncture, massage, bright lights, or taking omega-3 fatty acids are useful.[66]

Resources for Postpartum Depression[edit]

Postpartum Support International is the most recognized international resource for those with PPD as well as healthcare providers.[67] It brings together those experiencing PPD, volunteers, and professionals to share information, referrals, and support networks. Services offered by PSI include the website (with support, education, and local resource info), coordinators for support and local resources, online weekly video support groups in English and Spanish, free weekly phone conference with chats with experts, educational videos, closed Facebook groups for support, and professional training of healthcare workers.

Government-funded programs[edit]

The Infant and Early Childhood Mental Health Consultation (IECMH) center is a related technical assistance program that utilizes evidence-based treatments services in order to address issues of PPD.[68] The IECMH facilitates parenting and home visit programs, early care site interventions with parents and children and a variety of other consultation-based services.[69] The IECMH's initiatives seek to educate home visitors on screening protocols for PPD as well as ways to refer depressed mothers to professional help.

Links to other government-funded programs[edit]

Hotlines & Telephone Interviews[edit]

Hotlines, chat lines, and telephone interviews offer immediate, emergency support for those experiencing PPD. Telephone-based peer support can be effective in the prevention and treatment of postpartum depression among women at high-risk.[70] Established examples of telephone hotlines, available in English and Spanish, include:

However, hotlines can lack cultural competency which is crucial in quality healthcare, specifically for people of color. Calling the police or 911, specifically for mental health crises, is dangerous for many people of color. Culturally and structurally competent emergency hotlines are a huge need in PPD care.[71]

  • National Maternal Mental Health Hotline: 833-9-HELP4MOMS (43-5746)
  • Postpartum Support International: 800-944-4PPD (4773)
  • SAMHSA's National Hotline: 1-800-662-HELP (4357)

Self-care & Well-being Activities[edit]

Women demonstrated an interest in self-care and well-being in an online PPD prevention program. Self-care activities, specifically music therapy, are accessible to most communities and valued among women as a way to connect with their children and manage symptoms of depression. Well-being activities associated with being outdoors, including walking and running, were noted amongst women as a way to help manage mood.[72]

Postpartum Depression in Males[edit]

See also: Paternal depression

In men, postpartum depression is typically defined as "an episode of major depressive disorder (MDD) occurring soon after the birth of a child"[73] which affects 8 to 10% of fathers. Symptoms of postpartum depression in men may include extreme sadness, fatigue, anxiety, irritability, and suicidal thoughts, however, there are no set criteria for men to have postpartum depression.[73] Several studies show that men experience the highest levels of postpartum depression between 3–6 months postpartum and the cause may be distinct in males.[74][75] Postpartum depression in males has been notably 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. [76] 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. [74][77] Reduced paternal interaction can later lead to cognitive and behavioral problems in children.[78] 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.[79]

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