What Is Postpartum Depression (PPD) In New Mothers?

Postpartum Depression, or PPD as it is more commonly referred to as, is defined as "an irritable, severely depressed mood" that can be seen in new mothers.[1]

Clinical studies have revealed that PPD affects up to 15% of mothers.[2] Recent research in the field has come to the finding that there are various biological as well as psychological factors that place an expectant mother at a higher risk for developing PPD after giving birth.

Studies have revealed that women at a higher risk for developing PPD include inner-city women as well as mothers of pre-term infants.[3]

Generally, many new mothers tend to get depressed after giving birth. With the focus shifting to another individual and the need to cope with the new erratic schedule, offering less time for sleeping, a majority of women go through the typical "baby blues" phase.

However, PPD is much serious than mere baby blues post-delivery. Depression following giving birth has been found to persist even beyond 7 months after delivery in certain women.[4]

A lengthy post-birth depressive period has been commonly associated with many social and relationship problems that a mother might encounter. Some mothers suffering from PPD have even been found to take recourse to alcohol abuse or smoking of tobacco.

Universal screening is established to be the recommended approach to be adopted for the detection of new mothers going through PPD.

Typically, PPD in women is under-recognized, and as a result, undertreated as well. PPD, when undiagnosed and untreated, can lead to certain adverse short-term as well as long-term effects on the development of the child involved.

While a certain extent of depression after giving birth is usually commonplace and generally no cause for concern, it is when things take a turn for the worse that medical intervention must be sought.

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Causes

Clinical trials and studies have revealed various factors linked with PPD in women which can be classified into 5 domains of risk factors that can be psychiatric, obstetric, hormonal or biological, social, or that of lifestyle. [5]

1. Psychological factors

A prior history of anxiety and depression is one of the major factors commonly associated with an increased risk of PPD.

The relationship between PPD and previous depression has been reported in many instances. Depression during pregnancy should not be overlooked, as it can be a powerful indicator of the mother developing postpartum depression eventually.

Generally, women with depression are more susceptible to the hormonal fluctuations that are a part and parcel of pregnancy.

Studies have come to the finding that a history of premenstrual syndrome [PMS] - ranging from moderate to severe - might be one of the key factors affecting the onset of PPD.[6]

Additionally, a negative attitude towards pregnancy or a history of sexual abuse in their past were also found to be predisposing factors of postpartum depression.
Further, low self-esteem with regard to the ability to handle parenting stress also contributes to PPD.

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2. Obstetric risk factors

Generally, it has been found that women with 2 or more children are at a higher risk of developing depression, owing to the higher psychological burden involved.

A risky pregnancy might also increase the risk of the pregnant woman developing PPD later. Risks during pregnancy - such as hospitalization while pregnant or the likelihood of an emergency caesarean section - might also increase the predisposition of a new mother to develop PPD.

Similarly, postpartum complications - like obstetric haemorrhages, meconium passage, low birth weight of the newborn etc. - might also lead to PPD in some situations.

3. Biological factors

There has been found to be a direct link between the age of the expectant mother and the risk of depression. While the highest level of depression has been reported in mothers in the age bracket of 19 years or below, the lowest rate of depression was seen in mothers that were comparatively older, that is, between the age of 31 to 35 years.[7]

In a study conducted on nearly 2,000 women at 2 to 12 weeks after giving birth, it was found that the more the maternal age and better maternal self-efficacy, the lower was the risk of developing PPD.

Higher glucose levels in pregnant women were also found to have a bearing on their risk of developing PPD.

Various other factors that might influence the risk of PPD include the levels of tryptophan, serotonin, oxytocin, and estrogen in the body of the pregnant woman.[8]

The relationship between thyroid dysfunction and PPD has not been clearly established as such.

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4. Social factors

By social support for the new mother is implied financial support, intelligence support, emotional support and empathy relations.

The onset of depression and various anxiety disorders in a new mother has been found to have a direct link with reduced social support for them.

5. Lifestyle

Factors related to the lifestyle of the mother - sleep pattern, physical activities, exercise, and food intake - might have a direct bearing of the mother developing depression after delivery.

The risk of PPD can be reduced by as much as 50% through the sufficient consumption of olive oil, fruits, vegetables, seafood, dairy products etc. [9]

An ecological study conducted on participants from 23 countries has found that increased consumption of seafood can bring down the risk of postpartum depression.

PPD has also been found to be connected with a reduced intake of selenium and zinc by the mother during the course of her pregnancy.

Exercise, through its positive effect on the mental conditions of an individual by the increase of endorphins and endogenous opioids, leads to the elimination of negative self-assessment along with boosting the self-confidence of the new mother.

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Symptoms

In medical parlance, there is a clear demarcation between postpartum blues, postpartum depression and postpartum psychosis. [10]

Most commonly seen in new mothers, postpartum blues is defined as a depressed mood that is typically experienced soon after giving birth. Approximately 50% to 70% of all women tend to develop postpartum blues following childbirth.[11]

Typically, postpartum blues surface in a new mother at around Day 3 or 4 after giving birth, disappearing and resolving on their own within 2 weeks. Postpartum blues, or baby blues, involve the mother going through common tell-tale signs such as poor concentration, fatigue, insomnia, crying spells, anxiety, and general depression.

Postpartum depression, a more serious condition than the 'blues', might have additional symptoms such as general irritability as well as a more severely depressed mood.

Rarest of them all, postpartum psychosis affects around 1 to 2 mothers per 1,000 deliveries. Postpartum psychosis has a wide range of associated features such as mania, thought disorders, severe depression, psychotic thoughts etc. This is a psychiatric emergency, requiring referral as well as hospitalization.

Treatments

Generally, mild depression in the mother after delivering their baby resolves on its own.

Psychiatric treatment is recommended for those developing a higher level of depression that might be accompanied with inadequate treatment response and/or other comorbid disorders.

Emergency mental health services might be required for women that develop severe PPD symptoms - disorganized behaviour, bizarre thoughts, thoughts of self-harm or even homicide.[12]

An important facet of successful treatment of PPD is the availability of a clinic-based depression care manager.

Upon successful identification of PPD, it is essential, to begin with, a treatment plan that is rapidly implemented. In case of delayed treatment, the patient might develop a lengthier illness, leading them to worsen symptoms, resistance to treatment, impaired functioning in their day-to-day life, and even suicide.

Antidepressants have been found to be effective in the treatment of PPD. Other changes that can be made for treating PPD in women is the introduction of nutrients and fatty acids supplements in the diet of the mother suffering from PPD.

Regular aerobic exercise might also help in controlling PPD.

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Prevention

• In view of the high morbidity of postpartum depression, the ideal course of action to minimize the risk of the mother developing PPD is by a focus on prevention.[13]
• It is essential to identify - even before their delivery - women at a heightened risk for developing postpartum mood disorders.
• The female with a previous history of depression and/or postpartum blues must be clearly identified during the course of their hospital admission at the time of delivery.
• Further, any woman that develops depression during the course of their pregnancy must be clearly identified and follow-ups provided. Such women require education as well as support on the treatments available before them.
• While certain such women might benefit from a consultation with a therapist, others might have to be referred to a psychiatrist instead. Others might even need antidepressants after delivery.
• In terms of the right treatment for women with PPD, pharmacological as well as a non-pharmacological line of treatment has proven effective in such settings with variable degrees of success.
• While a certain amount of depression in new mothers is quite commonplace and to be expected to a certain extent, the episode of postpartum depression in a woman can indeed be shortened by adopting the right measures.
• A simple change in the diet goes a long way. From increasing the intake of seafood during pregnancy to taking nutrient supplements post delivery, there is a lot that can be done to alleviate the stress that a new mother finds herself surrounded with.
• An increasing body of evidence points to the fact that postpartum women that develop depression and receive treatment have a much better mother-infant bonding experience when compared to those who do not seek treatment.
• PPD is women must not be overlooked or ignored. In the absence of the right intervention, the symptoms might get worse with time. Some women suffering from PPD have also been known to have gone to the extent of contemplating suicide or homicide.
• New mothers that go through depression might develop a range of mood and behaviour problems. Many women that suffer from PPD have also developed obesity later on.
• Even with the awareness of the existence of PPD, a wide majority of women worldwide miss out on treatment merely due to the absence of a proper follow-up after pregnancy. The ideal time for PPD screening is believed to be around 4 to 6 weeks after giving birth.[14]
• Routine screening of depression is an efficient and feasible method for improving the identification of patients that might be suffering from postpartum depression.
• Making a woman prone to PPD, biological and social factors are intertwined rings having a direct impact on each other that.
• Many environmental and biological factors - such as simple lifestyle changes - might help in the prevention of PPD through either directly or indirectly impacting the serotonin level in the brain.
• Additionally, various socioeconomic factors that might impact the mental health of the new mother can be dealt with.
• Programs targeted at the prevention of postpartum depression in women must focus on the interpersonal relationships that the individual enjoys, thereby increasing the cushion provided to the new mother through social protection.
• Tools designed for the prediction of postpartum depression should revolve around social and lifestyle factors, in addition to the physical health condition of the mother involved.

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