Postpartum depression

Symptoms Of Postpartum Depression 

After childbirth, a mother can experience a range of emotions, from joy and pleasure to sadness and crying bouts, mood swings, irritability, anxiety, being overwhelmed, appetite problems, etc. These mild depressive feelings are called "baby blues'' and may include the following:

• Having doubts that you can be a good mom
• Putting pressure on yourself to be a perfect mom
• Feeling that you’re no longer the person you were before you had your baby
• Feeling that you’re less attractive after having your baby
• Having no free time for yourself
• Feeling tired and moody because you aren’t sleeping well or getting enough sleep

Baby blues typically develop within two to three days of delivery, peak over the next few days, and tend to decrease over the first two weeks after delivery. 

While women experiencing baby blues tend to recover quickly, around one in seven women can develop postpartum depression (PPD). PPD tends to last longer and severely affects women's potential to return to normal function. The onset of postpartum major depression can occur either during pregnancy or in the four weeks following delivery. 

The symptoms of postpartum depression are similar to symptoms of depression and the duration and intensity can vary from person to person. The symptoms of postpartum depression may include:

• Depressed mood
• Loss of interest
• Agitation
• Anxiety
• Changes in sleep patterns or insomnia (lack of sleep)
• Change in appetite
• Feelings of worthlessness or guilt
• Loss of energy or fatigue
• Inability to concentrate or indecisiveness
• Recurrent thoughts of death, which may include thinking about or even planning suicide
• Change in weight or appetite (weight change 5% over 1 month)
• Patients may also experience delusions or hallucinations
  
  

Postpartum depression needs to be addressed as it interferes with women’s ability to care for themselves and the baby, poor maternal-infant bonds, failure of breastfeeding, negative parenting practices, marital discord, as well as worse outcomes concerning the child's physical and psychological development.

Causes Of Postpartum Depression

Postpartum depression is linked to the various chemical, social, and psychological changes that occur during childbirth. 

It has been found that changes or alterations in hormone levels during and after pregnancy are more likely to affect a woman's mood. However, all mothers experience these hormonal changes in their body during pregnancy, but only about 10–15% suffer from PPD (Postpartum Depression).

• The female reproductive hormones progesterone and estrogen are ten times more abundant during pregnancy.
  
  Within 48 hours following birth, the level of these hormones dramatically lowers. The levels usually return to their normal levels within three days following childbirth. The rapid changes in these reproductive hormones following delivery can be a potential stressor in susceptible women and lead to the onset of PPD.
  
  
• Oxytocin and prolactin hormones regulate the milk let-down reflex as well as the synthesis of breast milk. Low levels of these hormones, failure to lactate and unwanted early weaning are associated with PPD.

Risk Factors For Postpartum Depression

The time following the birth of a child is one of intense physiologic and psychological change for new mothers. There is no single cause of postpartum depression, but genetics, physical changes and emotional issues may play a role.

1. Age

• Having a child before the age of 20 years predisposes the woman to PPD

2. Genetics

• Having a family history of depression or postpartum depression

3. Emotional factors

• Lack of sleep makes it difficult to deal with even small issues. 

• Worried about being able to take care of a newborn. 

• Feelings of being less attractive, identity issues, or lack a sense of control over your life. 

• A poor relationship with one’s own mother.

• Stressful life events (eg, marital conflict, emigration, or the COVID-19 pandemic) during pregnancy or after delivery 

• Lack of emotional support from the partner or family

4. Social factors

• Lack of support from family or friends

• Unemployment, low income or lack of financial support

• Domestic violence, verbal abuse etc.

• Intimate partner violence and lifetime history of physical and/or sexual abuse

5. Psychological factors

• History of depression and anxiety, or depression during pregnancy

• A prior episode of PPD 

• Premenstrual syndrome (PMS)

• Unplanned pregnancy

• Fear of childbirth

• Negative attitude towards the baby

• The reluctance of the baby's gender

• Childcare stress such as inconsolable infant crying, difficult infant temperament, or infant sleep disturbance

• Body image dissatisfaction (preconception, antenatal, and/or postpartum)

6. Obstetric factors

• Complications during pregnancy, like premature birth, being pregnant with multiples, birth defects and pregnancy loss. 

• Previous miscarriage

7. Overall health status

• Poor perinatal health eg, obesity at the time of conception, pregestational or gestational diabetes, antenatal or postnatal hypertension, or infection following delivery

• Rapid alteration of reproductive or thyroid hormones post-delivery. This makes one feel tired, depressed, agitated etc.

8. Lifestyle choices

• Smoking or drinking excessive alcohol

• Less sunlight exposure. This can lead to a drop in serotonin and melatonin levels in the body and disrupt mood and sound sleep.

• Working late till night and getting up late or spending less time outdoors. This can disrupt the circadian rhythm and may trigger depression. 

Diagnosis Of Postpartum Depression (PPD)

There is no one specific test that can definitively diagnose PPD. Therefore, doctors diagnose this condition by gathering comprehensive medical, family, and mental health history along with an assessment of lifestyle habits:

1. Discussion of symptoms

The healthcare provider will ask about your symptoms, their duration, and severity. They will inquire about your mood, energy levels, sleeping patterns, appetite, and any thoughts of self-harm or harm to the baby.

2. Medical history and physical examination

The doctor will ask questions about symptoms and medical histories including drug and alcohol history, smoking habits, and all prescription and over-the-counter-drug medications.

They may also request blood tests to rule out other causes of depression.

3. Psychological assessment

The most commonly used screening tool for PPD is the Edinburgh Postnatal Depression Scale (EPDS). It is a simple 10-item questionnaire, including a question on suicidal ideation.

Patients must have an EPDS cutoff score of 13 or higher in order to be considered at risk for PPD.

This screening test provides the basis for additional clinical tests to rule out other psychiatric illnesses.

Prevention Of Postpartum Depression

Postpartum depression may not be entirely preventable. However, knowing the symptoms of postpartum depression can help you manage the condition and get treatment sooner if necessary. The following tips can help prevent postpartum depression to some extent:

• Keep in touch with family and friends, don’t isolate yourself before your baby is born
• Take antenatal and postnatal educational classes
• Have an arrangement for childcare in place so you can take a break
• Maintaining a balanced diet and try to get some exercise and fresh air every day
• Avoid alcohol and caffeine
• Getting adequate sleep and general rest
• Reducing alcohol intake or avoiding it altogether
• Your doctor can prescribe medical counseling and even some medicine even during pregnancy if you feel any kind symptoms associated with depression.
• After delivery, the doctor might recommend an early postpartum checkup to look for symptoms associated with depression.

Additionally, psychological and psychosocial methods help prevent PDP. It includes interpersonal therapy and cognitive behavioral therapy (helps to modify negative patterns of behavior) during and after pregnancy may reduce the risk of postpartum depression in those at an increased risk of developing it.

Note: If you have a history of depression or if you are taking an antidepressant, tell your ob-gyn or health care professional early in your prenatal care.

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Doctor To Visit

If you think you may be depressed or not feeling yourself, you should contact a healthcare professional such as-

• General physician
• Psychiatrist
• Obstetrician and gynecologist

Immediately contact your OB/GYN or primary care doctor or psychiatrist to discuss treatment and address your physical symptoms like: 

• The symptoms last longer than two weeks.
• You are unable to manage daily tasks or behave properly.
• You've considered hurting your baby or yourself.
• Most of the day, you feel incredibly nervous, afraid, and panicked.
• If you have any physical conditions, especially any kind of mental health condition, let your doctor know. You must also disclose all current medications you are taking, including OTC, herbal, and other supplements with dosage information.

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Treatment Of Postpartum Depression

Management of PPD involves a non-pharmacological and pharmacological component.  Non-pharmacological treatment is usually the first line of treatment and if need be followed by pharmacological treatment.

A. Non Pharmacological treatment 

Psychotherapy helps to talk through your concerns with a psychiatrist, psychologist or other mental health professional. This involves sessions which help a patient understand and deal with feelings of anxiety, modify behavior, and improve responses to particular situations.

The two most commonly used psychotherapies that have been found to be beneficial are:

• Interpersonal therapy (IPT) -This approach focuses on improving the symptoms of depression and mood disorders. In this, a therapist emphatically engages the patient to work on their communication with others and solve their issues.
  
  
• Cognitive behavioural therapy (CBT)- This psychological therapy helps teach the patient various coping skills to manage difficult situations. It helps the patient to change their thoughts about a particular situation and the behavioral component further helps them to change their reactions to any situation.
  

For mild to moderate postpartum depression psychotherapy is an effective treatment. Psychotherapy can also be used as adjunct therapy with medications for moderate to severe postpartum depression.

B. Pharmacological Treatment

A combination of therapy and antidepressant drugs is recommended for women with moderate to severe depression.

Antidepressant medications include- 

1. Selective serotonin reuptake inhibitors-  SSRIs are the first choice of drugs, which includes Citalopram, escitalopram, fluoxetine, paroxetine, sertraline etc. 

2. Serotonin-norepinephrine reuptake inhibitors (SNRIs)- If SSRIs are not effective, then SNRIs are prescribed. These include desvenlafaxine, duloxetine, venlafaxine etc.

3. Other medications- It may require a combination of medicines such as antidepressants, antipsychotic medicines, mood stabilizers and benzodiazepines  to control your signs and symptoms. Examples include diazepam, lorazepam, bupropion etc.

NOTE: Many women are worried about exposing their children to these medications via breastfeeding. While the risk of breastfeeding while taking a serotonin reuptake inhibitor is relatively low, it is important for lactating women to discuss the benefits of breastfeeding and the risks of antidepressant use during lactation with their healthcare provider. It is best that all apprehensions are adequately addressed and an informed decision is made.

Have a lot of questions and doubts regarding antidepressants?

Here are 8 things about antidepressants you need to know.

C. Other Treatment options

• Transcranial magnetic stimulation (TMS)- This treatment is an alternative option for women who do not want to take antidepressants while breastfeeding or for those who haven't responded to psychotherapy and antidepressants. It is a non-invasive procedure in which a coil placed against the scalp sends brief magnetic pulses to stimulate and activate nerve cells in the brain.
  
  
• Electroconvulsive therapy (ECT)- For patients with severe PPD or postpartum psychosis who do not respond to medications, ECT may be recommended. Previously called electroshock therapy or shock treatment, it involves inducing seizures by placing electrodes on the person's head while the person is fully sedated. ECT seems to cause changes in brain chemistry that can reduce the symptoms of psychosis.
  
  Many studies have suggested ECT as a safe option for lactating mothers with fewer side effects on both the mother and the infant. 

Home-care For Postpartum Depression

In addition to pharmacological and non-pharmacological treatment, you can do some things for yourself that build on your treatment plan and help speed recovery.

• Build a secure bond with your baby- Emotional bonding is the secure attachment that forms between parents and children. It may include skin-to-skin contact with the baby, baby massage, smiling with the baby etc.
  
  
• Pay attention to your diet- Consuming a diet rich in omega-3 fatty acids during pregnancy and after delivery can lower the risk of postpartum depression. Omega-3s can easily travel through the brain cell membrane and interact with mood-related molecules inside the brain. Fish, salmon, nuts and seeds, plant oils, walnuts, flaxseeds, chia seeds etc. are rich sources of Omega-3s.
  
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• Folic acid - It also provides beneficial effects in depressive symptoms. Rich sources include beans, peanuts, sunflower seeds, whole grains, liver, seafood etc.
  
  
• Maintain a healthy lifestyle- Exercise regularly, take a walk with your baby, get enough rest and avoid alcohol and smoking. 
  
  
• Take out time for yourself- Indulge in self-care, visit friends, or spend time alone with your partner, or do something that makes you happy such as a hobby or some form of entertainment.
  
  
• Avoid being isolated- Keep in touch with family and friends. Don’t isolate yourself. Talk to your partner or any family member and share your feelings with them.
  
  
• Set realistic expectations- Expect some good days and some bad days. Do not pressure yourself to do everything on your own. 
  
  
• Reduce your screen time- Reduce spending much time on phone calls or television. Rather, go outside in the fresh air.
  
  
• Time management- Try to take sleep or rest when your baby sleeps. Otherwise, sleep deprivation may lead you to other problems. Try getting at least 7–8 hours of sleep each night.
  
  
• Talk to your partner- Try to nurture the relationship with your partner. Take out time for yourselves and spend some quality time together. Talk about your feelings with your partner, supportive family members, and friends.
  
  
• Ask for help- Don’t try to do too much or to do everything by yourself. Ask your partner, family, and friends for help. Try to open up to the people close to you and let them know you need help. If someone offers to babysit, take them up on it.
  
• Do proper planning- Proper planning before conceiving and during pregnancy goes a long way in reducing stress after delivery.
  
  
• Follow up with doctors- Keep up with all your medical appointments and follow-ups about your health concerns.

Complications Of Postpartum Depression

Postpartum depression not only affects the mother but the infant and the father as well in the following ways:

1. Mother- If postpartum depression is not treated timely, it can last for months or longer, even turning into a chronic depressive disorder. Even after the treatment of PDP, it can make you more likely to have depression episodes in future as well.

2. Father- If the mother is in depression, it can be a precipitating factor for depression in the father as this will be a stressful event for the entire family. The symptoms may include irritability, restricted emotions, and depression. 

3. Infant- Babies or infants born to women with a medical condition of postpartum depression are at risk of prematurity, low birth weight, problems with sleeping, cranky, crying more than usual, delays in language development, eating difficulties, attention deficit/hyperactivity disorder (ADHD) etc.

Alternative Therapies For Postpartum Depression

Some alternatives that can help your postpartum depression symptoms may include-

1. Bright light therapy

It is an inexpensive therapy that can be done at home and has a low risk of side effects. When you are exposed to this type of light, your brain undergoes a chemical change that improves your mood and reduces symptoms such as fatigue.

2. Acupuncture

It offers great relief from the symptoms associated with anxiety and depression. It regulates the nervous system and enhances blood flow to bring one to a place of calm, inner peace, and strength.

3. Yoga

There is plenty of evidence that suggests yoga can help improve a person’s mood and induce feelings of happiness, positivity, and exhilaration.

Here are some yoga postures to help you fight depression and anxiety.

4. Massage

A light touch massage or a deeper massage can help relax muscles, improves blood circulation and reduces stress hormones.

Learn more about some age-old practices like meditation, tai chi (a form of exercise), and breathing exercises that can help reduce stress and anxiety.

Living With Postpartum Depression

Living with postpartum depression is often very challenging as it interferes with a person's day-to-day life and affects work and social interactions. Here are a few tips that will help you cope with depression effectively:

• Speak up-  Seek social help, connect with your friends, and share your feelings or burden.
  
  
• Engage in activities that make you feel happy- Stay active by opting for activities that relax and energize you, it will help to fight depression effectively.
  
  
• Don’t be harsh on yourself- To overcome this condition, it is important for you to love your own self. Take others’ help but do not stretch yourself for any activity.
  
  
• Seek medical help- If all the tips mentioned above fail to get results it is better that you seek help from a therapist. Medical help will help you combat the situation and keep your symptoms in check.

Here are some ways you can help women with postpartum depression-

• Help her get an appropriate diagnosis and treatment. You may need to make an appointment and go with her to see her healthcare provider.
• Be a good listener. Let them know you're there to listen and help.
• Offer to help watch their baby while they sleep or rest.