Postpartum Depression

What Causes Postpartum Depression?

Doctors and researchers have not yet determined exactly what causes postpartum depression, and several likely factors lead to the onset of the disorder in most cases. Causes also likely vary from mother to mother. The most likely causes include:

• Hormonal changes. During pregnancy, a woman’s body produces high levels of the hormones estrogen and progesterone. After birth, the level of these hormones drops quickly, and the change in hormone levels is a likely cause of changes in mood and energy levels. Some women may be more than typically sensitive to hormonal changes, leading to postpartum depression.
• Environmental factors. Life after childbirth is physically stressful, and new mothers are likely to suffer from too little sleep, inadequate nutrition, and other strains that cause fatigue and physical aches and pains. Under this stress, new mothers may be more vulnerable to the mood fluctuations that characterize postpartum depression.
• Emotional factors. Significant life changes that come in the wake of childbirth may also induce emotional stress that can exacerbate the physical stresses the mother is experiencing.

Is Postpartum Depression Hereditary?

Researchers have not yet identified a definitive link between the onset of postpartum depression and a family history of the disorder, but there is some evidence that there may be a genetic or familial connection to the condition.

• One study found that women with a sister who had experienced postpartum depression were almost four times as likely to develop the disorder than women with no affected sibling.
• Another study found that 42% of women with a family history of postpartum depression developed the disorder after their first pregnancy. In contrast, the study found that only 15% of women without a family history developed the condition.
• Studies of twins have found a significant heritability rate, ranging from 25% to 54%. This suggests that there could be a genetic basis for developing the disease, and research is ongoing to identify a specific gene or genes responsible.

How Is Postpartum Depression Detected?

Spotting postpartum depression early is not easy because the symptoms of the disorder mimic the less severe symptoms of common postpartum blues, and the physical symptoms often have discernible causes that are a normal part of having a new baby. However, if the symptoms are recognized and addressed early enough, it may be possible to prevent them from progressing beyond a relatively mild state into full-blown postpartum depression. Early diagnosis also helps to rule out the unlikely possibility of postpartum psychosis.

The early indications of postpartum depression include:

• Persistent sadness or low mood. Hormonal changes after childbirth can cause mood swings even under normal circumstances, but sadness that lasts for weeks or that grows more intense over time may be a warning sign for postpartum depression.
• Disruption in sleep patterns. Having a new baby in the house is disruptive to a new mother’s sleep patterns, but if you have trouble sleeping even when the baby is asleep or being cared for by someone else or want to sleep much more than necessary, take note.
• Mental fogginess. Postpartum depression can get in the way of your ability to focus, make decisions, or engage emotionally with your everyday routine.
• Withdrawal from pleasurable activities. Like major depression, postpartum depression can make you want to stay away from social situations or interactions with loved ones. It can also make it difficult to take part in activities you used to enjoy.
• Worries about your parenting abilities. Doubts about your ability to handle the responsibilities of motherhood are normal, but if these worries are persistent and frequent, they may be a danger sign.
• Thoughts of harming yourself or your baby. These thoughts can be a sign of severe postpartum depression or even postpartum psychosis. If you have them, you should seek professional medical help immediately.

How Is Postpartum Depression Diagnosed?

Diagnosis of postpartum depression typically begins with a physical assessment followed by a psychological evaluation. First, doctors will usually make an effort to rule out medical conditions that could be causing the physical and mental symptoms. After these potential physical conditions have been ruled out will the diagnostic process move on to possible psychological causes.

Diagnostic steps may include:

• A physical exam. This exam is aimed at ruling out physical conditions that could be causing the symptoms.
• Blood and laboratory tests. These tests look at the patient’s blood chemistry for issues such as thyroid function that could be causing depressive symptoms. Screenings for drugs and alcohol may also be conducted to rule out symptoms caused by substance abuse.
• Psychological assessments. These assessments may take the form of questionnaires or talk sessions with a mental health professional to assess the patient’s mood, mental state, and mental health history. Family members or caregivers may also be asked to participate in these assessments.

The psychological assessment results will be compared to the diagnostic criteria for postpartum depression in the Diagnostic and Statistical Manual of Mental Disorders. The DSM does not recognize postpartum depression as a disorder distinct from major depression, so the diagnostic process will look for symptoms of depression that occur during pregnancy or within four weeks after childbirth.

A mental health professional will look for these indications of depression:

• Depressed mood
• Loss of interest in pleasurable activities
• Change in weight or appetite
• Sleep disruptions
• Lethargy or restlessness
• Fatigue
• Feelings of worthlessness or guilt
• Problems with concentration or decision-making
• Recurrent thoughts of death or suicide, or a suicide attempt

The professional will also look for signs that the symptoms have caused impairment, that they’re persistent and frequent, and that they aren’t consistent with another disorder, such as bipolar disorder.

How Is Postpartum Depression Treated?

The treatment prescribed for postpartum depression depends on the severity of the symptoms, the patient’s medical history, and any underlying physical conditions that contribute to the symptoms of the disorder. Often, the treatment for postpartum depression includes antidepressant medication, psychotherapy, or both.

Medication

Antidepressants, including popular selective serotonin reuptake inhibitors (SSRIs), are often used to treat postpartum depression. In general, these medications are considered safe for new mothers to use, but breastfeeding mothers should be aware that some amount of the drug(s) may be transmitted to the baby in breast milk. You should discuss the medication’s potential risks with your doctor, especially if you’re breastfeeding, and weigh the risks against the benefits before you begin treatment.

In addition to SSRI antidepressants, which may take weeks to have an effect, a new fast-acting drug called brexanolone has recently been approved for use in moderate to severe cases of postpartum depression. The drug is given via an intravenous infusion in a supervised setting and typically takes effect in less than three days.

Psychotherapy

The most common therapeutic approaches used to treat postpartum depression are cognitive behavioral therapy (CBT) and interpersonal therapy (IPT). CBT focuses on helping the patient identify a pattern of harmful thoughts and construct strategies and solutions for dealing with them that don’t interfere with functionality. IPT helps the patient to understand the challenges in interpersonal relationships and find solutions to the problems.

Treatment for Postpartum Blues

Postpartum blues’ common symptoms may be helped by paying attention to them and taking steps to lessen their impact. New mothers should make every effort to get as much rest as possible, get help from loved ones, make time for self-care, and avoid alcohol and other recreational drugs. If symptoms persist or get worse, seek professional help.

Treatment for Postpartum Psychosis

In the unlikely event that the symptoms rise to the level of postpartum psychosis, treatment is much more aggressive and usually requires hospitalization. Medications used include antipsychotics, mood stabilizers, and benzodiazepines. In some cases, typically when other treatments have not been effective, electroconvulsive therapy (ECT) helps control symptoms.

How Does Postpartum Depression Progress?

With early detection and proper treatment, the prognosis for postpartum depression is good, with most sufferers seeing a reduction or elimination of symptoms after following a treatment plan. Without treatment, however, symptoms may increase in severity and persistence. In many cases, relatively mild symptoms that fit the definition of postpartum blues progress to symptoms of postpartum depression. Untreated postpartum depression may progress to a major depressive episode that fits the definition of clinical depression and last for months or longer.

How Is Postpartum Depression Prevented?

Some women are especially at risk of developing postpartum depression. For example, women who have experienced the disorder at least once have about a 50% chance of experiencing it again during subsequent pregnancies. Women who have experienced major depression outside of pregnancy also seem to be at increased risk; some research suggests that women who have experienced depression generally have between a 30% and 50% chance of experiencing depressive episodes during pregnancy or soon after giving birth.

Some preventative treatments have shown promise in preventing the onset of the disorder in women at risk.

• Preventative medication. One study looked at the effectiveness of prophylactic treatment with SSRI antidepressants in women with a history of postpartum depression. The study results suggested that the treatment was effective at preventing a recurrence of the disorder.
• Behavioral techniques. A therapeutic process called Practical Resources for Effective Postpartum Parenting (PREPP) has also shown preventative promise. The approach encourages behaviors that help the mother get rest, decrease the baby’s fussiness, and strengthen the bond between mother and child.

Postpartum Depression Caregiver Tips

As is the case with major depression and other depressive disorders, those who care for sufferers of postpartum depression are at risk for developing depression themselves. Caregivers for someone with postpartum depression should consider these tips to help the sufferer and themselves to deal with the disorder:

• Learn as much as possible about the disorder.
• Don’t expect the sufferer to get better on their own.
• Seek out appropriate professional treatment for the sufferer.
• Do everything possible to support the sufferer in the pursuit of treatment.
• Be supportive of the sufferer and acknowledge any improvements.
• Find a support group for caregivers.
• Take time away from the sufferer when possible.

Many people with postpartum depression also suffer from other brain and mental health-related issues, a condition called co-morbidity. Here are a few of the disorders commonly associated with postpartum depression:

• Many people with postpartum depression also suffer from depression in addition to their postpartum symptoms.
• About two-thirds of people with postpartum depression have a co-existing anxiety disorder.
• Some people with postpartum depression also may be diagnosed with bipolar disorder.

Postpartum Depression Brain Science

Decades ago, researchers discovered that some of the chemicals produced when the body breaks down hormones such as progesterone seem to help neurons in the brain function properly. The researchers also found that the level of one of these compounds, called allopregnanolone, fluctuated in women during their menstrual cycle and pregnancy. Specifically, a woman’s allopregnanolone level increases during pregnancy and then drops after childbirth. This led scientists to suspect that allopregnanolone played a role in postpartum blues and depression.

The result of this research was the development of brexanolone, a drug that mimics allopregnanolone and that shows promise in alleviating the symptoms of postpartum depression. The FDA approved Brexanolone as a treatment for moderate to severe postpartum depression in March 2019.

Postpartum Depression Research

Title: PREPP: Preventing Postpartum Depression (PREPP)

Stage: Recruiting

Principal investigator: Catherine Monk, PhD

Columbia University

New York, NY

The primary aim of this study is to determine if a behavioral intervention targeting maternal caregiving of young infants can increase infant sleep and reduce fuss/cry behavior, and thereby (1) reduce the incidence and/or severity of postpartum maternal depression and (2) improve the quality of the mother-infant interaction and subsequent child development. Specifically, the study team will investigate: (1) the effectiveness of the intervention compared to usual care; (2) if the effects of the intervention can be detected in the assessments of the quality of mother-infant interaction; (3) if there are prenatal and/or postnatal biomarkers that can help identify infants whose behavior is more likely to play a role in their mothers’ depression; (4) if these markers differentiate which infants will be most responsive to the intervention(s); and (5) if assessments of brain function at birth and 4-6 weeks of age provide biological nodal points for identifying the effects of the intervention on infant brain development. Participants will be recruited during their 2nd trimester. They will be randomly separated into one of two groups: a group that receives coaching in parenting techniques (4 in-person coaching sessions and 1 phone session) or one that receives treatment as usual. 

Title: Accelerated iTBS for Post Partum Depression

Stage: Recruiting

Contact: Constance Guille, MD

Medical University of South Carolina

Charleston, SC

This is an open-label study designed to investigate the feasibility and tolerability of a novel TMS treatment protocol to treat depression in women with postpartum depression. It is known that TMS can effectively treat depression. The FDA-approved protocol lasts 6 weeks and is not feasible for many women with post-partum depression. The investigators are investigating a 3-day treatment for depression which may be more acceptable for this population. The investigators further hope to characterize the ant-depressant effect of this protocol to design a larger trial.

Title: Ketamine to Prevent PPD After Cesarean (PoCKet)

Stage: Recruiting

Contact: David T. Monks, MBChB FRCA 

Washington University School of Medicine

St. Louis, MO

The investigators plan to randomize participants to receive ketamine or placebo control subcutaneously or by 40-minute intravenous infusions and follow them up for 42 days to assess the incidence of postpartum depression. This feasibility pilot study is designed to explore the adequacy of the study procedures and tolerability of the interventions.