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, and feelings of being overwhelmed. These mild depressive feelings are known as "baby blues" and may include the following:

• Having doubts about being a good mom
• Putting pressure on yourself to be a perfect mom
• Feeling that you are no longer the person you were before having your baby
• Feeling less attractive after having your baby
• Having no free time for yourself
• Feeling tired and moody due to poor sleep

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

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

The symptoms of postpartum depression are similar to those of depression, with duration and intensity varying from person to person. The symptoms may include:

• Depressed mood
• Loss of interest
• Agitation
• Anxiety
• Changes in sleep patterns or insomnia
• Change in appetite
• Feelings of worthlessness or guilt
• Loss of energy or fatigue
• Inability to concentrate or indecisiveness
• Recurrent thoughts of death, including thoughts about or planning suicide
• Change in weight or appetite (weight change of 5% over one month)

Patients may also experience delusions or hallucinations.

Postpartum depression needs to be addressed as it interferes with a woman's ability to care for herself and her baby, can lead to poor maternal-infant bonding, failure of breastfeeding, negative parenting practices, marital discord, and worse outcomes concerning the child's physical and psychological development.

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

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 bodies during pregnancy, but only about 10–15% suffer from postpartum depression (PPD).

The female reproductive hormones progesterone and estrogen are ten times more abundant during pregnancy. Within 48 hours following birth, the levels of these hormones dramatically lower, usually returning to normal within three days after childbirth. The rapid changes in these reproductive hormones following delivery can be a potential stressor in susceptible women, leading 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.

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.

• Age: Having a child before the age of 20 years predisposes the woman to postpartum depression.
• Genetics: Family history of depression or postpartum depression.
• Emotional factors:
  • Lack of sleep makes it difficult to deal with even small issues.
  • Worries about being able to take care of a newborn.
  • Feelings of being less attractive, identity issues, or lack of control over one’s life.
  • A poor relationship with one’s own mother.
  • Stressful life events (e.g., marital conflict, emigration, or the COVID-19 pandemic) during pregnancy or after delivery.
  • Lack of emotional support from the partner or family.
• Social factors:
  • Lack of support from family or friends.
  • Unemployment, low income, or lack of financial support.
  • Domestic violence or verbal abuse.
  • Intimate partner violence and a lifetime history of physical and/or sexual abuse.
• Psychological factors:
  • History of depression and anxiety, or depression during pregnancy.
  • A prior episode of postpartum depression.
  • Premenstrual syndrome (PMS).
  • Unplanned pregnancy.
  • Fear of childbirth.
  • Negative attitudes towards the baby.
  • Reluctance regarding 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).
• Obstetric factors:
  • Complications during pregnancy, such as premature birth, multiple pregnancies, birth defects, and pregnancy loss.
  • Previous miscarriage.
• Overall health status:
  • Poor perinatal health, e.g., 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, which can lead to feelings of tiredness, depression, or agitation.
• Lifestyle choices:
  • Smoking or excessive alcohol consumption.
  • Less sunlight exposure, which can lead to a drop in serotonin and melatonin levels, disrupting mood and sleep.
  • Working late and getting up late or spending less time outdoors, which can disrupt the circadian rhythm and may trigger depression.

Postpartum depression may not be entirely preventable. However, knowing the symptoms can help you manage the condition and seek 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.
• Maintain a balanced diet and try to get some exercise and fresh air every day.
• Avoid alcohol and caffeine.
• Get adequate sleep and general rest.
• Reduce alcohol intake or avoid it altogether.

Your doctor can prescribe medical counseling and medication during pregnancy if you experience any symptoms associated with depression. After delivery, the doctor might recommend an early postpartum checkup to look for symptoms of depression.

Additionally, psychological and psychosocial methods can help prevent postpartum depression. Interpersonal therapy and cognitive behavioral therapy, which helps 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.

If you have a history of depression or are taking an antidepressant, inform your ob-gyn or healthcare professional early in your prenatal care.

Management of PPD involves both non-pharmacological and pharmacological components. Non-pharmacological treatment is usually the first line of treatment and, if necessary, is followed by pharmacological treatment.

A. Non-Pharmacological Treatment

Psychotherapy helps individuals discuss their concerns with a psychiatrist, psychologist, or other mental health professional. This involves sessions that assist patients in understanding and addressing feelings of anxiety, modifying behavior, and improving responses to specific 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. A therapist engages the patient to work on their communication with others and resolve their issues.
• Cognitive Behavioral Therapy (CBT): This psychological therapy teaches patients various coping skills to manage difficult situations. It helps patients change their thoughts about particular situations, and the behavioral component further assists them in changing their reactions.

For mild to moderate postpartum depression, psychotherapy is an effective treatment. It 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:

• Selective Serotonin Reuptake Inhibitors (SSRIs): SSRIs are the first choice of drugs, which include Citalopram, Escitalopram, Fluoxetine, Paroxetine, Sertraline, etc.
• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): If SSRIs are not effective, then SNRIs are prescribed. These include Desvenlafaxine, Duloxetine, Venlafaxine, etc.
• Other Medications: A combination of medicines such as antidepressants, antipsychotic medications, mood stabilizers, and benzodiazepines may be required to control symptoms. Examples include Diazepam, Lorazepam, Bupropion, etc.

Note: Many women are concerned 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 crucial that all concerns 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 have not 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, it involves inducing seizures by placing electrodes on the person's head while the person is fully sedated. ECT appears to cause changes in brain chemistry that can reduce 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.

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, and smiling with the baby.
• 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. Rich sources of Omega-3s include fish, salmon, nuts, seeds, plant oils, walnuts, flaxseeds, and chia seeds. Consider covering any gaps in your diet with Omega fatty acid supplements.
• Folic acid: It also provides beneficial effects on depressive symptoms. Rich sources include beans, peanuts, sunflower seeds, whole grains, liver, and seafood.
• Maintain a healthy lifestyle: Exercise regularly, take walks with your baby, get enough rest, and avoid alcohol and smoking.
• Take out time for yourself: Indulge in self-care, visit friends, spend time alone with your partner, or engage in a hobby or entertainment that makes you happy.
• Avoid being isolated: Keep in touch with family and friends. Don’t isolate yourself. Talk to your partner or family members 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: Limit the time spent on phone calls or watching television. Instead, spend time outside in the fresh air.
• Time management: Try to sleep or rest when your baby sleeps. Sleep deprivation may lead to other problems. Aim for at least 7–8 hours of sleep each night.
• Talk to your partner: Nurture your relationship with your partner. Spend quality time together and discuss your feelings with them, as well as supportive family members and friends.
• Ask for help: Don’t try to do everything by yourself. Ask your partner, family, and friends for assistance. Open up to those close to you and let them know you need help. If someone offers to babysit, accept their offer.
• Do proper planning: Proper planning before conceiving and during pregnancy can significantly reduce stress after delivery.
• Follow up with doctors: Keep up with all your medical appointments and follow-ups regarding your health concerns.

Postpartum depression not only affects the mother but also impacts the infant and the father in the following ways:

• Mother: If postpartum depression is not treated promptly, it can persist for months or longer, potentially evolving into a chronic depressive disorder. Even after treatment, it may increase the likelihood of experiencing depressive episodes in the future.
• Father: When the mother is experiencing depression, it can be a contributing factor for the father's own depression, as this situation creates stress for the entire family. Symptoms may include irritability, restricted emotions, and depression.
• Infant: Babies born to mothers with postpartum depression are at risk for various issues, including prematurity, low birth weight, sleep disturbances, increased irritability, excessive crying, delays in language development, eating difficulties, and attention deficit/hyperactivity disorder (ADHD).

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

• Bright light therapy: This inexpensive therapy can be done at home and has a low risk of side effects. Exposure to bright light induces a chemical change in the brain that improves mood and reduces symptoms such as fatigue.
• Acupuncture: This therapy offers significant relief from symptoms associated with anxiety and depression. It regulates the nervous system and enhances blood flow, promoting calmness, inner peace, and strength.
• Yoga: Numerous studies suggest that yoga can improve mood and induce feelings of happiness, positivity, and exhilaration. Here are some yoga postures to help combat depression and anxiety.
• Massage: Both light touch and deeper massage techniques can help relax muscles, improve blood circulation, and reduce stress hormones.

Additionally, consider exploring age-old practices such as meditation, tai chi (a form of exercise), and breathing exercises, which can also help reduce stress and anxiety.

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 burdens.
• 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 yourself. Take others’ help but do not stretch yourself for any activity.
• Seek medical help: If all the tips mentioned above fail to yield results, it is better to seek help from a therapist. Medical assistance 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 accompany her to see her healthcare provider.
• Be a good listener. Let her know you're there to listen and help.
• Offer to help watch her baby while she sleeps or rests.