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| There are several risk factors associated with the development of Postpartum depression that relate to the mother, her child and other external influences. If the mother has a history of depression during her pregnancy or at other times prior to her pregnancy, she is at greater risk for postpartum depression. Other notable risk factors include the presence of bipolar disorder and postpartum depression after a previous pregnancy. Some external risk factors include family members who have had depression or other mood stability issues, difficulty breastfeeding the baby as well as health problems with the baby. Other external factors include stressful events during the last year including complications with pregnancy, illnesses or job loss. They may also include having problems in relationship with a significant other, having an unplanned or unwanted pregnancy, a lack of social support, lower socioeconomic status and even the method of childbirth (Couto, 2105). | There are several risk factors associated with the development of Postpartum depression that relate to the mother, her child and other external influences. If the mother has a history of depression during her pregnancy or at other times prior to her pregnancy, she is at greater risk for postpartum depression. Other notable risk factors include the presence of bipolar disorder and postpartum depression after a previous pregnancy. Some external risk factors include family members who have had depression or other mood stability issues, difficulty breastfeeding the baby as well as health problems with the baby. Other external factors include stressful events during the last year including complications with pregnancy, illnesses or job loss. They may also include having problems in relationship with a significant other, having an unplanned or unwanted pregnancy, a lack of social support, lower socioeconomic status and even the method of childbirth (Couto, 2105). | ||
| - | Other risk factors for Postpartum depression include the use of alcohol, the use of drugs, smoking and physical or sexual abuse. As seen in Figure #, The Government of Canada reported the results from the Canadian Maternity Experiences Survey and found that 7.5% of women overall reported experiencing depressive symptoms during the postpartum period. Of these 7.5%, 15.4% of women smoked in the last 3 months of pregnancy, 11.9% of women used alcohol at some point during pregnancy, 3.7% of women used drugs at anytime during pregnancy and 23.2% of women experienced physical/sexual abuse in the last 2 years (Public Health Agency of Canada, 2014). | + | Other risk factors for Postpartum depression include the use of alcohol, the use of drugs, smoking and physical or sexual abuse. As seen in Figure 1, The Government of Canada reported the results from the Canadian Maternity Experiences Survey and found that 7.5% of women overall reported experiencing depressive symptoms during the postpartum period. Of these 7.5%, 15.4% of women smoked in the last 3 months of pregnancy, 11.9% of women used alcohol at some point during pregnancy, 3.7% of women used drugs at anytime during pregnancy and 23.2% of women experienced physical/sexual abuse in the last 2 years (Public Health Agency of Canada, 2014). |
| <box 72% round | >{{ :pregnancy-mental-health-grossesse-sante-mentale-fig1-eng.jpg |}}</box| Figure 1: Four risk factors relating to the development of Postpartum depression (Public Health Agency of Canada, 2014) > | <box 72% round | >{{ :pregnancy-mental-health-grossesse-sante-mentale-fig1-eng.jpg |}}</box| Figure 1: Four risk factors relating to the development of Postpartum depression (Public Health Agency of Canada, 2014) > | ||
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| ==== Genetic Causes of Postpartum Depression ==== | ==== Genetic Causes of Postpartum Depression ==== | ||
| - | There is evidence to suggest that genetics may contribute to the development of Postpartum depression based on several studies. One study recruited 45 pairs of sisters who had unipolar depression. Several exclusion factors were considered to control for adoption, alcohol induced depression and others. The researchers observed defined narrow Postpartum depression as presentation of symptoms within four weeks of delivery and broad Postpartum depression as presentation of symptoms within 6 months of delivery. 31 women were determined to have narrowly defined PPD and 59 did not. Of the 31, 9 sisters developed PPD (29% overall but 42% on first pregnancy) and of the 59, 8 developed PPD (13% overall but 15% on first pregnancy). This relationship is depicted in Figure # and was determined to be significant indicating that genetics plays a role in Postpartum depression. The researchers did not find a significant difference in the broad definition of Postpartum depression (Forty et al., 2006). | + | There is evidence to suggest that genetics may contribute to the development of Postpartum depression based on several studies. One study recruited 45 pairs of sisters who had unipolar depression. Several exclusion factors were considered to control for adoption, alcohol induced depression and others. The researchers observed defined narrow Postpartum depression as presentation of symptoms within four weeks of delivery and broad Postpartum depression as presentation of symptoms within 6 months of delivery. 31 women were determined to have narrowly defined PPD and 59 did not. Of the 31, 9 sisters developed PPD (29% overall but 42% on first pregnancy) and of the 59, 8 developed PPD (13% overall but 15% on first pregnancy). This relationship is depicted in Figure 2 and was determined to be significant indicating that genetics plays a role in Postpartum depression. The researchers did not find a significant difference in the broad definition of Postpartum depression (Forty et al., 2006). |
| <box 72% round | >{{ :geneticdepressiontwins.png?750|}}</box| Figure 2: Number of twin sisters presenting with narrow and broad Postpartum depression in relation to whether or not their sister also presented with Postpartum depression (Forty et al., 2006) > | <box 72% round | >{{ :geneticdepressiontwins.png?750|}}</box| Figure 2: Number of twin sisters presenting with narrow and broad Postpartum depression in relation to whether or not their sister also presented with Postpartum depression (Forty et al., 2006) > | ||
| - | To further explore the genetic influence on Postpartum depression, researchers conducted a study involving 89 pregnant women. These women filled in two Edinburgh Postpartum Depression Scale (EPDS) questionnaires during and after pregnancy. The researchers also took blood samples and isolated DNA to analyze 5-HTT, MAO (Monoamine Oxidase) and COMT (Catechol-O-methyl transferase) polymorphisms via real time PCR. The researchers found that polymorphisms in 5-HTT, MAO and COMT interact with development of depressive symptoms. Specifically, low activity MAO increased the EPDS score, 5-HTT sl & ll polymorphism increased the EPDS score and COMT met/met polymorphism also increased the EPDS score. As seen in Figure #, women with a combination of low active MAO and COMT the met/met polymorphism showed the greatest increase in EPDS Score (Doornbos et al., 2009). There are also several other genes that have been explored to play a role in Postpartum depression apart from the ones previously mentioned which is further evidence to support the importance of genetics. | + | To further explore the genetic influence on Postpartum depression, researchers conducted a study involving 89 pregnant women. These women filled in two Edinburgh Postpartum Depression Scale (EPDS) questionnaires during and after pregnancy. The researchers also took blood samples and isolated DNA to analyze 5-HTT, MAO (Monoamine Oxidase) and COMT (Catechol-O-methyl transferase) polymorphisms via real time PCR. The researchers found that polymorphisms in 5-HTT, MAO and COMT interact with development of depressive symptoms. Specifically, low activity MAO increased the EPDS score, 5-HTT sl & ll polymorphism increased the EPDS score and COMT met/met polymorphism also increased the EPDS score. As seen in Figure 3, women with a combination of low active MAO and COMT the met/met polymorphism showed the greatest increase in EPDS Score (Doornbos et al., 2009). There are also several other genes that have been explored to play a role in Postpartum depression apart from the ones previously mentioned which is further evidence to support the importance of genetics. |
| <box 72% round | >{{ :maoa_low_active.png?500 |}}</box| Figure 3: EPDS Score with various COMT polymorphisms with low activity MAO at two time points during pregnancy and two time points postpartum. (Doornbos et al., 2009) > | <box 72% round | >{{ :maoa_low_active.png?500 |}}</box| Figure 3: EPDS Score with various COMT polymorphisms with low activity MAO at two time points during pregnancy and two time points postpartum. (Doornbos et al., 2009) > | ||
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| ==== Postpartum Depression ==== | ==== Postpartum Depression ==== | ||
| - | PPD easily ranks as one of the most common complication associated with childbirth. It is estimated to occur in one out of every eight women after delivery, that is roughly half a million women in the USA alone with this disorder. According to the Diagnostic and Statistical Manual of Mental Disorders, the onset of postpartum depression is believed to occur within four weeks of a prior episode of depression. Scientifically however, researchers rely on the onset of postpartum depression within three months of delivery for the purpose of epidemiological studies. In addition to the symptoms of baby blues women experiencing postpartum depression will display symptoms that interfere with their daily living. These include, lack of joy, sense of emotional numbness and failure, insomnia, severe mood swings. This is considered a more moderate form of depression that affects up to an estimated 10% to 13% of women after childbirth. | + | PPD easily ranks as one of the most common complication associated with childbirth. It is estimated to occur in one out of every eight women after delivery, that is roughly half a million women in the USA alone with this disorder (Sit, Rothschild and Wisner, 2006). According to the Diagnostic and Statistical Manual of Mental Disorders (DSM), the onset of postpartum depression is believed to occur within four weeks of a prior episode of depression. Scientifically however, researchers rely on the onset of postpartum depression within three months of delivery for the purpose of epidemiological studies (Sit, Rothschild and Wisner, 2006). In addition to the symptoms of baby blues women experiencing postpartum depression will display symptoms that interfere with their daily living. These include, lack of joy, sense of emotional numbness and failure, insomnia, severe mood swings. This is considered a more moderate form of depression that affects up to an estimated 10% to 13% of women after childbirth (Sit, Rothschild and Wisner, 2006). |
| ==== Postpartum Psychosis ==== | ==== Postpartum Psychosis ==== | ||
| - | A more severe and rare form of PPD is Postpartum psychosis. Postpartum psychosis is believed to be a manifestation of bipolar disorder (Sit, Rothschild and Wisner, 2006). It is estimated to occur in one to two women per 1000 births within the first two to four weeks after childbirth. Unlike postpartum baby blues and postpartum depression, postpartum psychosis is a psychiatric emergency that requires immediate professional treatment due to severe symptoms such as hallucinations, paranoia, delusions and self-harming thoughts that could potentially result in suicide or infanticide (Sit, Rothschild and Wisner, 2006)(Beck, 2006). As a result women with postpartum psychosis must never be left alone, they must be under supervision 24hours of the day as they are a risk to themselves and their babies (Beck, 2006). The leading cause of maternal death up to one year postpartum is suicide and the risk of suicide increases by 70% in women with PP. The prevalence of suicide in women with PP is 2 out of every 1000 and it has been noted that these women often result to more drastic, irreversible and extremely aggressive means such as self incineration and jumping from heights (Sit, Rothschild and Wisner, 2006). Conversely another study indicated that women without PP generally result to non-violent suicide such as overdosing. With regards to homicidal thoughts, studies have shown that 28%-35% of women hospitalised for PP reported delusions about their infant but only 9% had thoughts of infanticide (Sit, Rothschild and Wisner, 2006). Although PP is classified by the DSM-IV as a major form of depression, there is mounting evidence that suggests PP is an overt presentation of bipolar disorder after delivery. This can be seen in epidemiological studies where the prevalence of PP after childbirth is 72%-88% for mothers with bipolar disorder and 12% for mothers with schizophrenia (Sit, Rothschild and Wisner, 2006). Epidemiological studies have calculated the mean age of onset of PP to be 26.3 years, a time when most women have undergone their first or second childbirth (Sit, Rothschild and Wisner, 2006). | + | A more severe and rare form of PPD is Postpartum psychosis (PPP). Postpartum psychosis is believed to be a manifestation of bipolar disorder (Sit, Rothschild and Wisner, 2006). It is estimated to occur in one to two women per 1000 births within the first two to four weeks after childbirth. Unlike postpartum baby blues and postpartum depression, postpartum psychosis is a psychiatric emergency that requires immediate professional treatment due to severe symptoms such as hallucinations, paranoia, delusions and self-harming thoughts that could potentially result in suicide or infanticide (Sit, Rothschild and Wisner, 2006)(Beck, 2006). As a result women with postpartum psychosis must never be left alone, they must be under supervision 24hours of the day as they are a risk to themselves and their babies (Beck, 2006). The leading cause of maternal death up to one year postpartum is suicide and the risk of suicide increases by 70% in women with PPP. The prevalence of suicide in women with PPP is 2 out of every 1000 and it has been noted that these women often result to more drastic, irreversible and extremely aggressive means such as self incineration and jumping from heights (Sit, Rothschild and Wisner, 2006). Conversely another study indicated that women without PP generally result to non-violent suicide such as overdosing. With regards to homicidal thoughts, studies have shown that 28%-35% of women hospitalised for PPP reported delusions about their infant but only 9% had thoughts of infanticide (Sit, Rothschild and Wisner, 2006). Although PPP is classified by the DSM-IV as a major form of depression, there is mounting evidence that suggests PPP is an overt presentation of bipolar disorder after delivery. This can be seen in epidemiological studies where the prevalence of PPP after childbirth is 72%-88% for mothers with bipolar disorder and 12% for mothers with schizophrenia (Sit, Rothschild and Wisner, 2006). Epidemiological studies have calculated the mean age of onset of PP to be 26.3 years, a time when most women have undergone their first or second childbirth (Sit, Rothschild and Wisner, 2006). |
| ====== Prevention of Postpartum Depression ====== | ====== Prevention of Postpartum Depression ====== | ||
| - | The consequences of postpartum depression can be devastating. Suicide and infanticide discussed earlier are not the only consequences of untreated postpartum depression and the mother does not bear these consequences alone. The offspring also suffers adverse effects such as emotional regulation and stress reactivity etc. as a result of postpartum depression (Miller & LaRusso, 2011). Studies have showed the apparent effect of PPD during infancy which continue to persist through adolescence and even adulthood. Given the lack of scientific knowledge on PPD it is understandably difficult to formulate preventative measures. However certain risk factors discussed in this wiki and presented in Figure 1 have been shown to display a positive correlation with increased risk of developing PPD. Therefore it follows that improving one or more of these areas could serve as primary prevention by reducing vulnerability to PPD, secondary prevention by reducing severity, duration and symptoms of PPD, and finally tertiary prevention by improving relationships and prognosis for women and their offspring (Miller & LaRusso, 2011). One such approach to the prevention of PPD is the identification of the optimal protective factors for a healthy woman and crafting an individual plan to enable each PPD patient conform to this ideal profile (Miller & LaRusso, 2011). The optimal protective factors have been shown to include protection from the effects of abrupt hormonal flux, practising of a healthy diet, high ability to manage stress, availability of social support, breastfeeding, exercise and a host of other factors (Miller & LaRusso, 2011). Preventative strategies can then be formulated for an individual depending on which of the above factors they require or need to strengthen. Those strategies can be either psychological and psychosocial (Interpersonal Psychotherapy and Postnatal Psychological Debriefing) or biological and pharmacological (Estrogen Therapy and Calcium Supplementation). | + | The consequences of postpartum depression can be devastating. Suicide and infanticide discussed earlier are not the only consequences of untreated postpartum depression and the mother does not bear these consequences alone. The offspring also suffers adverse effects such as emotional regulation and stress reactivity etc. as a result of postpartum depression (Miller & LaRusso, 2011). Studies have showed the apparent effect of PPD during infancy which continue to persist through adolescence and even adulthood. Given the lack of scientific knowledge on PPD it is understandably difficult to formulate preventative measures. However certain risk factors discussed in this wiki and presented in Figure 4, have been shown to display a positive correlation with increased risk of developing PPD. Therefore it follows that improving one or more of these areas could serve as primary prevention by reducing vulnerability to PPD, secondary prevention by reducing severity, duration and symptoms of PPD, and finally tertiary prevention by improving relationships and prognosis for women and their offspring (Miller & LaRusso, 2011). One such approach to the prevention of PPD is the identification of the optimal protective factors for a healthy woman and crafting an individual plan to enable each PPD patient conform to this ideal profile (Miller & LaRusso, 2011). The optimal protective factors have been shown to include protection from the effects of abrupt hormonal flux, practising of a healthy diet, high ability to manage stress, availability of social support, breastfeeding, exercise and a host of other factors (Miller & LaRusso, 2011). Preventative strategies can then be formulated for an individual depending on which of the above factors they require or need to strengthen. Those strategies can be either psychological and psychosocial (Interpersonal Psychotherapy and Postnatal Psychological Debriefing) or biological and pharmacological (Estrogen Therapy and Calcium Supplementation). |
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| * **Calcium Supplementation.** | * **Calcium Supplementation.** | ||
| Evidence for dietary calcium as a potential preventative measure for PPD stems from studies conducted on its effect on premenstrual syndrome (PMS) (Dennis, 2004). A low level of total and ionised calcium were observed at the midpoint of menstrual cycle by one of these studies. This low level of total and ionised calcium was then proven to correlate with an increased level of estradiol (Dennis, 2004). The study concluded that there was a statistical significant difference in the level of total serum calcium across both the women with PMS and the control group. This data suggests that the menstrual cycle plays a key role in calcium metabolism and it indicates the possibility that the reduction of calcium metabolism in women as a result of PMS is further exacerbated by the constant flux of hormones (Dennis, 2004). To modify the above for PPD a study was conducted in the USA, specifically, Portland, Oregon, and Albuquerque, New Mexico. This randomised control trial (RCT) sought to prevent pre-eclampsia, and participants were evaluated using the EPDS scale are 6 and 12 weeks postpartum. EPDS scores greater than 14 was registered in 11% of the experimental calcium group and 18% for the placebo group from Portland at 6 weeks (Dennis, 2004). Albuquerque on the other hand observed 24% for the experimental and 21% for the placebo (P>0.05). At 12 weeks an EPDS score of >14 was reported by 5.7% of the calcium group compared with 15.3% of the placebo group (P>0.01) (Dennis, 2004). These results serves as evidence of the significant reduction of point prevalence of PPD at 12 weeks and marginally at 6 weeks by calcium supplementation. | Evidence for dietary calcium as a potential preventative measure for PPD stems from studies conducted on its effect on premenstrual syndrome (PMS) (Dennis, 2004). A low level of total and ionised calcium were observed at the midpoint of menstrual cycle by one of these studies. This low level of total and ionised calcium was then proven to correlate with an increased level of estradiol (Dennis, 2004). The study concluded that there was a statistical significant difference in the level of total serum calcium across both the women with PMS and the control group. This data suggests that the menstrual cycle plays a key role in calcium metabolism and it indicates the possibility that the reduction of calcium metabolism in women as a result of PMS is further exacerbated by the constant flux of hormones (Dennis, 2004). To modify the above for PPD a study was conducted in the USA, specifically, Portland, Oregon, and Albuquerque, New Mexico. This randomised control trial (RCT) sought to prevent pre-eclampsia, and participants were evaluated using the EPDS scale are 6 and 12 weeks postpartum. EPDS scores greater than 14 was registered in 11% of the experimental calcium group and 18% for the placebo group from Portland at 6 weeks (Dennis, 2004). Albuquerque on the other hand observed 24% for the experimental and 21% for the placebo (P>0.05). At 12 weeks an EPDS score of >14 was reported by 5.7% of the calcium group compared with 15.3% of the placebo group (P>0.01) (Dennis, 2004). These results serves as evidence of the significant reduction of point prevalence of PPD at 12 weeks and marginally at 6 weeks by calcium supplementation. | ||
| + | |||
| + | |||
| + | <box 72% round | >{{ :risk_factors.png?750 |}}</box| Figure 4: Risk factors and preventive interventions for postpartum depressionu (Miller and LaRusso, 2011) > | ||
| ==== Psychosocial and Psychological Prevention ==== | ==== Psychosocial and Psychological Prevention ==== | ||
| - | * Interpersonal Psychotherapy | + | * **Interpersonal Psychotherapy** |
| - | IPT as a short term prevention is a psychotherapy that aims to rectify present psychological issues while emphasising the interpersonal context in which depressive symptoms arise (Werner, Miller, Osborne, Kuzava & Monk, 2014). IPT was first originally developed as a treatment for Major Depressive Disorder but has since been adapted to function as a preventative measure for PPD for pregnant women. To date three of seven studies on the efficacy of IPT in the prevention of PPD have incorporated the ROSE program (Reach Out, Stay strong, Essentials for new mothers) (Werner, Miller, Osborne, Kuzava & Monk, 2014). The ROSE program developed by Zlotnick is a brief group intervention based on IPT with the aim of helping pregnant women one public assistance overcome the risk factors listed on Figure FFF. It consists of 4 weekly 1 hour group meetings during pregnancy. In a study by Zlotnick incorporating the ROSE program, 35 women who had previously reported at least one risk factor for PPD (Figure 1) were randomised into experimental and control group. All participants in this study were required to enrol in standard antenatal care but only the experimental group were participants of the ROSE program (Werner, Miller, Osborne, Kuzava & Monk, 2014). 33% of the control group compared to none of the experimental group had developed PPD as measured by the DSM-IV. Whatsmore, there was a significant reduction in the BDI scores of the ROSE program participants compared to that of the control group (p<.001) (Werner, Miller, Osborne, Kuzava & Monk, 2014). A second study by Zloknick with the same conditions as the above study and an increased sample population of 99 women between 23 to 32 weeks pregnant reported similar results. In that study 4% of women in the intervention group developed PPD as opposed to 20% of women in the control group (p=0.04) (Werner, Miller, Osborne, Kuzava & Monk, 2014). In summary all seven studies with IPT as a preventative measure consistently demonstrated a reduced risk of PPD. Finally some of the above studies utilised untrained non-clinical staff, which suggests the possibility of a wider application. | + | IPT as a short term prevention is a psychotherapy that aims to rectify present psychological issues while emphasising the interpersonal context in which depressive symptoms arise (Werner, Miller, Osborne, Kuzava & Monk, 2014). IPT was first originally developed as a treatment for Major Depressive Disorder but has since been adapted to function as a preventative measure for PPD for pregnant women. To date three of seven studies on the efficacy of IPT in the prevention of PPD have incorporated the ROSE program (Reach Out, Stay strong, Essentials for new mothers) (Werner, Miller, Osborne, Kuzava & Monk, 2014). The ROSE program developed by Zlotnick is a brief group intervention based on IPT with the aim of helping pregnant women on public assistance overcome the risk factors of PPD (Figure 4). It consists of 4 weekly 1 hour group meetings during pregnancy. In a study by Zlotnick incorporating the ROSE program, 35 women who had previously reported at least one risk factor for PPD (Figure 4) were randomised into experimental and control group. All participants in this study were required to enrol in standard antenatal care but only the experimental group were participants of the ROSE program (Werner, Miller, Osborne, Kuzava & Monk, 2014). 33% of the control group compared to none of the experimental group had developed PPD as measured by the DSM-IV. Whatsmore, there was a significant reduction in the BDI scores of the ROSE program participants compared to that of the control group (p<.001) (Werner, Miller, Osborne, Kuzava & Monk, 2014). A second study by Zloknick with the same conditions as the above study and an increased sample population of 99 women between 23 to 32 weeks pregnant reported similar results. In that study 4% of women in the intervention group developed PPD as opposed to 20% of women in the control group (p=0.04) (Werner, Miller, Osborne, Kuzava & Monk, 2014). In summary all seven studies with IPT as a preventative measure consistently demonstrated a reduced risk of PPD. Finally some of the above studies utilised untrained non-clinical staff, which suggests the possibility of a wider application. |
| - | * Postnatal Psychological Debriefing | + | * **Postnatal Psychological Debriefing** |
| Psychological debriefing consist of semi-structured psychological interview in which a person’s traumatic event is explored with the aim of reducing psychological stress, in the postnatal setting this takes the form of a discussion of a mother’s concerns about labour and motherhood (Werner, Miller, Osborne, Kuzava & Monk, 2014). Two of the five RCTs exploring the efficacy of postnatal psychological debriefing in the prevention of PPD showed positive results. One such study is that conducted by Lavender and Walkinshaw (1998), in which some 120 British women with normal at-term vaginal deliveries were studied. Subjects were randomised without prior screening for antenatal depression to either receive a single debriefing session by an untrained midwife before discharge or to continue treatment as normal. This single debriefing session involved an "interactive interview” in which the interview spent the necessary time exploring their feelings and experience of labor (Werner, Miller, Osborne, Kuzava & Monk, 2014). All participants were subsequently mailed a Hospital Anxiety and Depression Scale (HADS) questionnaire 3 weeks after discharged and these questionnaires were scored using the HADS scale ranging from 0 to 21. Results showed a significantly decreased likelihood of developing high depression and anxiety (defined as a depression or anxiety score >10 points, p<0.0001 and p<0.001 respectively) three weeks postpartum (Werner, Miller, Osborne, Kuzava & Monk, 2014). | Psychological debriefing consist of semi-structured psychological interview in which a person’s traumatic event is explored with the aim of reducing psychological stress, in the postnatal setting this takes the form of a discussion of a mother’s concerns about labour and motherhood (Werner, Miller, Osborne, Kuzava & Monk, 2014). Two of the five RCTs exploring the efficacy of postnatal psychological debriefing in the prevention of PPD showed positive results. One such study is that conducted by Lavender and Walkinshaw (1998), in which some 120 British women with normal at-term vaginal deliveries were studied. Subjects were randomised without prior screening for antenatal depression to either receive a single debriefing session by an untrained midwife before discharge or to continue treatment as normal. This single debriefing session involved an "interactive interview” in which the interview spent the necessary time exploring their feelings and experience of labor (Werner, Miller, Osborne, Kuzava & Monk, 2014). All participants were subsequently mailed a Hospital Anxiety and Depression Scale (HADS) questionnaire 3 weeks after discharged and these questionnaires were scored using the HADS scale ranging from 0 to 21. Results showed a significantly decreased likelihood of developing high depression and anxiety (defined as a depression or anxiety score >10 points, p<0.0001 and p<0.001 respectively) three weeks postpartum (Werner, Miller, Osborne, Kuzava & Monk, 2014). | ||
| ====== Treatment ====== | ====== Treatment ====== | ||
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| === Estrogen Hormone Therapy === | === Estrogen Hormone Therapy === | ||
| - | During pregnancy and postpartum, there are dramatic changes in hormone levels occurring. One notable change in maternal levels of estrogen and progesterone occurs at the time of <box 40% left>{{:figure_4.png?400|}}</box|Figure 4 : Observed patient scores on the Cornell Dysthymia Rating Scale prior to and following estrogen and progesterone replacement was administered in 8 women with a history of PPD and 8 without a history of PPD. A significant different was observed between baseline and withdrawal periods in women with a history of PPD. Modified from Bloch et al. (2000).> delivery. This significant drop in estrogen and progesterone has been proposed as a potential trigger for the onset of postpartum depression (Moses-Kolko et al., 2009). This discovery led to the hypothesis that estradiol could be used as a potential hormone therapy for women suffering from postpartum depression. Estradiol functions similarly to other psychotropic drugs, however, there is not yet sufficient evidence to determine if it a suitable treatment for postpartum depression (Bloch et al., 2000; Moses-Kolko et al., 2009). While more conventional pharmacological antidepressant treatments can be very effective for treating postpartum depression, a natural alternative may be preferred, especially by women who breastfeed their infants. | + | During pregnancy and postpartum, there are dramatic changes in hormone levels occurring. One notable change in maternal levels of estrogen and progesterone occurs at the time of <box 40% left>{{:figure_4.png?400|}}</box|Figure 5 : Observed patient scores on the Cornell Dysthymia Rating Scale prior to and following estrogen and progesterone replacement was administered in 8 women with a history of PPD and 8 without a history of PPD. A significant different was observed between baseline and withdrawal periods in women with a history of PPD. Modified from Bloch et al. (2000).> delivery. This significant drop in estrogen and progesterone has been proposed as a potential trigger for the onset of postpartum depression (Moses-Kolko et al., 2009). This discovery led to the hypothesis that estradiol could be used as a potential hormone therapy for women suffering from postpartum depression. Estradiol functions similarly to other psychotropic drugs, however, there is not yet sufficient evidence to determine if it a suitable treatment for postpartum depression (Bloch et al., 2000; Moses-Kolko et al., 2009). While more conventional pharmacological antidepressant treatments can be very effective for treating postpartum depression, a natural alternative may be preferred, especially by women who breastfeed their infants. |
| The treatment of postpartum depression with synthetic forms of naturally occurring estrogen is appealing due to the estrogen withdrawal that occurs at parturition. A study published in American Journal of Psychiatry in 2000 determined that women with a prior history of postpartum depression experienced mood symptoms following exposure to declining levels of estradiol (an estrogen steroid hormone) and progesterone, meanwhile women that did not have a history of postpartum depression did not experience these mood symptoms (Bloch et al., 2000). | The treatment of postpartum depression with synthetic forms of naturally occurring estrogen is appealing due to the estrogen withdrawal that occurs at parturition. A study published in American Journal of Psychiatry in 2000 determined that women with a prior history of postpartum depression experienced mood symptoms following exposure to declining levels of estradiol (an estrogen steroid hormone) and progesterone, meanwhile women that did not have a history of postpartum depression did not experience these mood symptoms (Bloch et al., 2000). | ||
| In the study conducted by Bloch et al. (2000), women aged 22 to 45 one year postpartum were divided <box 36% right> | In the study conducted by Bloch et al. (2000), women aged 22 to 45 one year postpartum were divided <box 36% right> | ||
| - | {{:figure_5.png?360|}}</box|Figure 5 : Mean patient scores of 8 women with a history of PPD using the Cornell Dysthymia Rating Scale after the Addback phase (active medication was being administered) and following the Withdrawal phase (placebo medication was administered). These results best exhibit the typical mood shift observed in women with a history of PPD. Modified from Bloch et al. (2000).> into two separate groups based on whether they had a history of postpartum depression in previous pregnancies. For two months, baseline measurements were taken with participants providing Cornell Dysthymia Scale ratings. The Cornell Dysthymia Scale is a 20-item questionnaire created to improve upon the commonly-used Hamilton Depression Rating Scale (HDRS) in assessing the symptoms of dysthymia, a form of chronic depression. Next, participants received 1 monthly injection for 5 months of gonadotropin-releasing hormone analog (leuprolide acetate, 3.75/month) to produce a stable hypogonadal condition. | + | {{:figure_5.png?360|}}</box|Figure 6 : Mean patient scores of 8 women with a history of PPD using the Cornell Dysthymia Rating Scale after the Addback phase (active medication was being administered) and following the Withdrawal phase (placebo medication was administered). These results best exhibit the typical mood shift observed in women with a history of PPD. Modified from Bloch et al. (2000).> into two separate groups based on whether they had a history of postpartum depression in previous pregnancies. For two months, baseline measurements were taken with participants providing Cornell Dysthymia Scale ratings. The Cornell Dysthymia Scale is a 20-item questionnaire created to improve upon the commonly-used Hamilton Depression Rating Scale (HDRS) in assessing the symptoms of dysthymia, a form of chronic depression. Next, participants received 1 monthly injection for 5 months of gonadotropin-releasing hormone analog (leuprolide acetate, 3.75/month) to produce a stable hypogonadal condition. |
| - | During the baseline phase, concurrently received either placebo or active medication (increasing amounts of estradiol and progesterone: 4mg/day of estradiol to 10mg/day of estradiol by the end of the trial; 400mg/day of progesterone to 900mg/day of progesterone by the end of the trial). During the withdrawal and follow up phases, active medications were replaced with placebo medications and the control patients continued to take placebo medications. This induced the dramatic drop in estradiol and progesterone seen in Figure 4 and Figure 5. | + | During the baseline phase, concurrently received either placebo or active medication (increasing amounts of estradiol and progesterone: 4mg/day of estradiol to 10mg/day of estradiol by the end of the trial; 400mg/day of progesterone to 900mg/day of progesterone by the end of the trial). During the withdrawal and follow up phases, active medications were replaced with placebo medications and the control patients continued to take placebo medications. This induced the dramatic drop in estradiol and progesterone seen in Figure 5 and Figure 6. |
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| ==== Worldwide ==== | ==== Worldwide ==== | ||
| - | <box 29% round right| > {{ :worldwide_prevalence.png?300|}} </box| Figure 6: Prevalence of PPD in selected low-and-middle-income countries worldwide. Modified from Gelaye B et al. (2016). > | + | <box 29% round right| > {{ :worldwide_prevalence.png?300|}} </box| Figure 7: Prevalence of PPD in selected low-and-middle-income countries worldwide. Modified from Gelaye B et al. (2016). > |
| Based on a meta-analysis conducted by Gelaye B et al. (2016), the pooled prevalence of postpartum depression (PPD) in women from low-and-middle-income (LAMIC) countries worldwide is estimated to be 19%. The meta-analysis included 53 studies published between 1998 and 2015. The data collected from these studies represented 23 LAMIC countries and a total of 38,142 participants. Of the 53 studies, 7 studies were from Brazil, 6 from Turkey, 4 from India, 4 from Thailand, 4 from China, 3 from Mexico, 3 from Nigeria, 3 from Iran and the rest (1 or 2 studies) from other LAMICs (Armenia, Ghana, Jordan, Lebanon, Malaysia, Mongolia, Morocco, Nepal, Pakistan, Peru, South Africa, Tunisia, Uganda, Vietnam and Zimbabwe). Sample sizes ranged from 41 in Thailand to 13,360 in Ghana. | Based on a meta-analysis conducted by Gelaye B et al. (2016), the pooled prevalence of postpartum depression (PPD) in women from low-and-middle-income (LAMIC) countries worldwide is estimated to be 19%. The meta-analysis included 53 studies published between 1998 and 2015. The data collected from these studies represented 23 LAMIC countries and a total of 38,142 participants. Of the 53 studies, 7 studies were from Brazil, 6 from Turkey, 4 from India, 4 from Thailand, 4 from China, 3 from Mexico, 3 from Nigeria, 3 from Iran and the rest (1 or 2 studies) from other LAMICs (Armenia, Ghana, Jordan, Lebanon, Malaysia, Mongolia, Morocco, Nepal, Pakistan, Peru, South Africa, Tunisia, Uganda, Vietnam and Zimbabwe). Sample sizes ranged from 41 in Thailand to 13,360 in Ghana. | ||
| - | Figure 6 shows a subset of the studies analyzed and the associated prevalence of PPD (%), as well as the scale used to measure PPD. While there was significant heterogeneity observed between studies, the highest prevalence of PPD was seen in India (48.5%) and the lowest prevalence of PPD was observed in Ghana (3.8%). PPD was predominantly measured using the Edinburgh Postnatal Depression Scale (EPDS). The EPDS is a 10-item, self-reported scale that includes questions such as "I have felt scared or panicky for no good reason," "I look forward with enjoyment to things," and "The thought of harming myself has occurred to me." Other scales utilized to measure PPD included the Patient Health Questionnaire-9 (PHQ-9) and the Structured Clinical Interview for DSM-IV (SCID). | + | Figure 7 shows a subset of the studies analyzed and the associated prevalence of PPD (%), as well as the scale used to measure PPD. While there was significant heterogeneity observed between studies, the highest prevalence of PPD was seen in India (48.5%) and the lowest prevalence of PPD was observed in Ghana (3.8%). PPD was predominantly measured using the Edinburgh Postnatal Depression Scale (EPDS). The EPDS is a 10-item, self-reported scale that includes questions such as "I have felt scared or panicky for no good reason," "I look forward with enjoyment to things," and "The thought of harming myself has occurred to me." Other scales utilized to measure PPD included the Patient Health Questionnaire-9 (PHQ-9) and the Structured Clinical Interview for DSM-IV (SCID). |
| ==== Canada ==== | ==== Canada ==== | ||
| - | A study conducted by Lanes A et al. (2011) estimated the overall prevalence of minor and minor/major Postpartum Depressive Symptomatology (PPDS) in Canadian women to be 17.15%, with the highest prevalence of PPDS in the Territories (29.95%) and the lowest prevalence of PPDS in Prince Edward Island (10.89%; Figure 7). PPDS was measured using the EPSD, where a score of 0-9 indicated no risk of experiencing symptoms of PPD, a score of 10-12 indicated a minor/major risk, and a score of 13 or more indicated a major risk of experiencing PPD symptoms. | + | A study conducted by Lanes A et al. (2011) estimated the overall prevalence of minor and minor/major Postpartum Depressive Symptomatology (PPDS) in Canadian women to be 17.15%, with the highest prevalence of PPDS in the Territories (29.95%) and the lowest prevalence of PPDS in Prince Edward Island (10.89%; Figure 8). PPDS was measured using the EPSD, where a score of 0-9 indicated no risk of experiencing symptoms of PPD, a score of 10-12 indicated a minor/major risk, and a score of 13 or more indicated a major risk of experiencing PPD symptoms. |
| - | <box 39% round right| > {{::canada_prevalence.png?400|}} </box| Figure 7: Prevalence of PPD in Canadian women. Modified from Lanes A et al. (2011). > | + | <box 39% round right| > {{::canada_prevalence.png?400|}} </box| Figure 8: Prevalence of PPD in Canadian women. Modified from Lanes A et al. (2011). > |
| A total of 6,421 Canadian women from 10 provinces and 3 Territories were included in the study. These women had a live birth between 2005 and 2006 as well as previously completed the Maternity Experience Survey (MES), a nationwide survey conducted by Statistics Canada between 2006 and 2007 to assess pregnancy, delivery, and postnatal experiences of mothers and their children. | A total of 6,421 Canadian women from 10 provinces and 3 Territories were included in the study. These women had a live birth between 2005 and 2006 as well as previously completed the Maternity Experience Survey (MES), a nationwide survey conducted by Statistics Canada between 2006 and 2007 to assess pregnancy, delivery, and postnatal experiences of mothers and their children. | ||
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| The prevalence of PPD in the USA was calculated by Ko LY et al. (2017) using self-reported data collected from 27 US States participating in the Pregnancy Risk Assessment Monitoring System (PRAMS). PRAMS is an ongoing, population-based surveillance system that collects state-specific data on maternal attitudes and experiences before, during, and after pregnancy (CDC, 2018). Questions are based on attitudes and feelings about a woman's most current pregnancy, maternal alcohol and tobacco consumption, physical abuse before and during pregnancy, infant health care, and mother's knowledge of pregnancy-related health issues, among other topics (CDC, 2018). | The prevalence of PPD in the USA was calculated by Ko LY et al. (2017) using self-reported data collected from 27 US States participating in the Pregnancy Risk Assessment Monitoring System (PRAMS). PRAMS is an ongoing, population-based surveillance system that collects state-specific data on maternal attitudes and experiences before, during, and after pregnancy (CDC, 2018). Questions are based on attitudes and feelings about a woman's most current pregnancy, maternal alcohol and tobacco consumption, physical abuse before and during pregnancy, infant health care, and mother's knowledge of pregnancy-related health issues, among other topics (CDC, 2018). | ||
| - | The PRAMS data indicated an overall incidence of postpartum depressive symptoms (PDS) in 11.5% of women in 2012. In 13 of the states participating in PRAMS, there was a decline in PDS from 14.8% in 2004 to 9.8% in 2012 (Figure #). PDS was found to be highest in mothers who had less than 12 years of education, were unmarried, were postpartum smokers, had greater than or equal to 3 stressful life events in a year before birth of the child, and had a child of abnormally low birthweight or that had to be admitted to the intensive care unit (ICU). | + | The PRAMS data indicated an overall incidence of postpartum depressive symptoms (PDS) in 11.5% of women in 2012. In 13 of the states participating in PRAMS, there was a decline in PDS from 14.8% in 2004 to 9.8% in 2012 (Figure 9). PDS was found to be highest in mothers who had less than 12 years of education, were unmarried, were postpartum smokers, had greater than or equal to 3 stressful life events in a year before birth of the child, and had a child of abnormally low birthweight or that had to be admitted to the intensive care unit (ICU). |
| - | <box 32% round right| > {{ ::usa_prevalence.png?330|}} </box| Figure 8: Prevalence of PPD in women from 23 and 13 US States. Modified from Ko LY et al. (2017).> | + | <box 32% round right| > {{ ::usa_prevalence.png?330|}} </box| Figure 9: Prevalence of PPD in women from 23 and 13 US States. Modified from Ko LY et al. (2017).> |
| ==== PPD in Men ==== | ==== PPD in Men ==== | ||
