Postpartum Depression

Postpartum depression (PPD), also known as postnatal depression, is a significant mood disorder experienced by women postpartum, typically occurring within a week to a month after childbirth. It is characterised by symptoms like extreme sadness, low energy, anxiety, crying episodes, and irritability, significantly impacting the well-being of the mother and the newborn.

Signs & Symptoms

Symptoms of PPD can manifest anytime within the first year postpartum, usually diagnosed when they persist beyond two weeks.

Emotional Symptoms

• Persistent sadness and anxiety
• Severe mood swings and irritability
• Feelings of hopelessness, guilt, and worthlessness
• Low self-esteem and numbness
• Exhaustion and trouble bonding with the baby

Behavioural Symptoms

• Lack of interest in usual activities and social withdrawal
• Changes in appetite and sleep patterns
• Low libido and poor self-care
• Fatigue and decreased energy
• Worry about harming self, baby, or partner

Neurobiological Insights

fMRI studies indicate altered brain activity in mothers with PPD, showing decreased activity in the left frontal lobe and increased activity in the right frontal lobe. These changes affect essential brain structures like the anterior cingulate cortex, amygdala, and hippocampus. Such neurobiological differences are more pronounced when mothers are exposed to non-infant emotional cues.

Onset and Duration

PPD typically begins between two weeks to a month after delivery. It can last several months to a year and is not uncommon in women who have experienced a miscarriage. Fathers can also experience PPD, often between 3–6 months postpartum.

Parent-Infant Relationship

PPD can disrupt maternal-infant bonding, leading to inconsistent childcare and adverse effects on child development. In severe cases, it can escalate to postpartum psychosis, impacting about 1 to 2 per 1,000 women and increasing the risk of infanticide.

Causes

The exact cause of PPD is unknown but is believed to result from a mix of physical, emotional, genetic, and social factors. Hormonal changes, especially the dramatic drop in oestrogen and progesterone post-delivery, are significant contributors. Sleep deprivation and profound lifestyle changes also play very important roles.

Risk Factors

• Prior episodes of PPD or a family history of depression
• Bipolar disorder and psychological stress
• Complications during childbirth and lack of support
• Drug use disorders and low socioeconomic status
• Cultural factors and migration away from support networks

Diagnosis

PPD is diagnosed based on symptoms, typically requiring the presence of five out of nine specific symptoms over two weeks. Differential diagnoses include postpartum blues, which is milder and resolves within two weeks, and postpartum psychosis, a psychiatric emergency requiring immediate treatment.

Childbirth-Related PTSD

Childbirth-related PTSD is closely related to PPD, marked by symptoms like flashbacks, nightmares, and avoidance of anything related to childbirth. It affects around 3-6% of mothers postpartum, with higher rates in high-risk groups.

Screening

Screening for PPD is very important, with tools like the Edinburgh Postnatal Depression Scale (EPDS) widely used. However, cultural differences in symptom expression can affect the reliability of these tools.

Prevention

Psychosocial and psychological interventions post-childbirth can reduce the risk of PPD. Support systems, counselling, and addressing relationship quality are essential preventive measures. In high-risk individuals, preventative antidepressants may be considered, although evidence is weak.

Treatments

Treatment varies based on the severity of PPD. Mild to moderate cases can benefit from psychological interventions like cognitive behavioural therapy (CBT) and interpersonal therapy (IPT). Severe cases may require a combination of therapy and medication.

Psychotherapy

Psychotherapy, including CBT and IPT, is effective in treating PPD. Internet-based CBT is beneficial for those with limited access to in-person therapy.

Medication

Selective serotonin reuptake inhibitors (SSRIs) like sertraline are commonly used, though evidence on their efficacy is mixed. Hormone therapy with estradiol patches and newer treatments like brexanolone and zuranolone have shown promise.

Other Treatments

Electroconvulsive therapy (ECT) and repetitive transcranial magnetic stimulation (rTMS) are considered for severe cases. The effectiveness of acupuncture, massage, and omega-3 fatty acids remains unclear.

Accessibility to Care

Barriers to seeking help include stigma, lack of knowledge, and health service barriers. Cultural competence in healthcare provision is essential for effective treatment, especially in diverse populations.

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Self-assessment MCQs (single best answer)

What is the typical time frame for the onset of postpartum depression (PPD) after childbirth?

Which of the following is NOT a common emotional symptom of PPD?

Which brain structures are typically affected in mothers with PPD according to fMRI studies?

What percentage of fathers experience postpartum depression?

Which of the following is NOT considered a risk factor for PPD?

Which screening tool is widely used for detecting PPD?

Which form of therapy is considered effective for mild to moderate cases of PPD?

Which of the following medications is commonly used to treat PPD?

What is a major barrier to seeking help for PPD?

Which treatment is considered for severe cases of PPD when other treatments have failed?