Postpartum depression ( PPD ), also called postnatal depression , is a form of clinical depression which can affect women, and less frequently men, after childbirth. Studies report prevalence rates among women from 5% to 25%, but methodological differences among the studies make the actual prevalence rate unclear. Postpartum depression occurs in women after they have carried a child, usually in the first few months. Symptoms include sadness, fatigue, insomnia, appetite changes, reduced libido, crying episodes, anxiety, and irritability. The condition is surprisingly common. Current data suggests that 5 to 9 percent of women will develop postpartum depression, but less than one in five of these women will seek professional help. It is sometimes assumed that postpartum depression is caused by a lack of vitamins, but studies tend to show that more likely causes are the significant changes in a woman's hormones during pregnancy. On the other hand, hormonal treatment has not helped postpartum depression victims. Many women recover because of a support group or counseling.
Postpartum Exhaustion (PPE)
PPE is caused by sleep deprivation coupled with hormonal changes in a woman's body shortly after giving birth. It may be mild or severe. Most cases are noted in women who have babies with severe colic or other underlying causes that result in abnormal sleep schedules. PPE is not the same as postpartum depression, but can be classified as a postpartum depression even though exhaustion is usually only caused from extreme fatigue. Medical treatment is minimal. PPE can last from 1 to 20 days and responds with adequate amounts of sleep.
PPD and the "baby blues"
Baby or maternity blues are a mild and transitory moodiness suffered by up to 80% of postnatal women (and in some cases fathers). Symptoms typically last from a few hours to several days, and include tearfulness, irritability, hypochondriasis, sleeplessness, impairment of concentration, feelings of isolation and headache. The maternity blues are not the same thing as postpartum depression, nor are they a precursor to postpartum depression or postnatal psychosis.
Symptoms
Symptoms of PPD can occur anytime in the first year postpartum and include, but are not limited to, the following:
- Sadness
- Hopelessness
- Low self-esteem
- Guilt
- A feeling of being overwhelmed
- Sleep and eating disturbances
- Inability to be comforted
- Exhaustion
- Emptiness
- Anhedonia
- Social withdrawal
- Low or no energy
- Becoming easily frustrated
- Feeling inadequate in taking care of the baby
- Impaired speech and writing
- Spells of anger towards others
- Increased anxiety or panic attacks
- Decreased sex drive
One method of detecting Postnatal Depression (PND) is the use of Edinburgh Postnatal Depression Scale. If the new mother scores more than 13, she is likely to develop PND.
Risk factors
While not all causes of PPD are known, a number of factors have been identified as predictors of PPD (the effect size is given in parentheses, where larger values indicate larger effects):
- Formula feeding rather than breast feeding (2.04)
- A history of depression (1.87) (.38 to.39) Beck (2001)
- Cigarette smoking (1.58)
- Low self esteem (.45 to. 47) Beck (2001)
- Childcare stress (.45 to .46) Beck (2001)
- Prenatal depression during pregnancy (.44 to .46) Beck (2001)
- Prenatal anxiety (.41 to .45) Beck (2001)
- Life stress (.38 to .40) Beck (2001)
- Low social support (.36 to .41) Beck (2001)
- Poor marital relationship (.38 to .39) Beck (2001)
- Infant temperament problems/colic (.33 to .34) Beck (2001)
- Maternity blues (.25 to .31) Beck (2001)
- Single parent (.21 to .35) Beck (2001)
- Low socioeconomic status (.19 to .22) Beck (2001)
- Unplanned/unwanted pregnancy (.14 to .17) Beck (2001)
Of these, three factors - formula feeding, a history of depression, and cigarette smoking - have been shown to be additive effects.
These factors are known to correlate with PPD. "Correlation" in this case means that, for example, high levels of prenatal depression are associated with high levels of postnatal depression, and low levels of prenatal depression are associated with low levels of postnatal depression. But this does not mean the prenatal depression causes postnatal depression—they might both be caused by some third factor. In contrast, some factors, such as lack of social support, almost certainly cause postpartum depression. (The causal role of lack of social support in PPD is strongly suggested by several studies, including O'Hara 1985, Field et al. 1985; and Gotlib et al. 1991.)
In addition to Beck’s meta-analysis cited above, other academic studies have shown a correlation between a mother’s race, social class and/or sexual orientation and postpartum depression. In 2006 Segre et al., conducted a study "on the extent to which race/ethnicity is a risk factor" for PPD. Studying 26,877 postpartum women they found that 15.7% were depressed. Of the women suffering from PPD, 25.2% were African American, 22.9% were American Indian/Native Alaskan, 15.5% were White, 15.3% were Hispanic, and 11.5% were Asian/Pacific Islander. Even when "important social factors such as age, income, education, marital status, and baby’s health were controlled, African American women still emerged with significantly increased risk for…PPD".
Segre et al., also found a correlation between a mother’s social class and PPD. Not surprisingly, women with fewer resources indicate a higher level of postpartum depression and stress than those with more financial resources. Rates of PPD decreased as income increased as follows:
- <$10,000 — 24.3%
- $10,000-$19,000 — 20.0%
- $20,000-$29,000 — 18.8%
- $30,000-$39,000 — 15.3%
- $40,000-$49,000 — 13.7%
- $50,000 — 10.8%
Likewise, a study conducted by Howell et al. in 2006 confirms Segre’s findings that women who are nonwhite and in lower socioeconomic categories have more symptoms of PPD.
In a 2007 study conducted by Ross et al., lesbian and bisexual mothers were tested for PPD and then compared with a heterosexual sample. Ross et al. found that "lesbian and bisexual biological mothers had significantly higher Edinburgh Postnatal Depression Scale (EPDS) scores than the…sample of heterosexual women." The Ross study suggests that PPD may be more common among lesbian and bisexual mothers. From a study conducted in 2005 by Ross, the higher rates of PPD in lesbian/bisexual mothers than heterosexual mothers may be due to less "social support, particularly from their families of origin and…additional stress due to homophobic discrimination" in society.
Although profound hormonal changes after childbirth are often claimed to cause PPD, there is little evidence that variation in pregnancy hormone levels is correlated with variation in PPD levels: Studies that have examined pregnancy hormone levels and PPD have usually failed to find a relationship (see Harris 1994; O'Hara 1995). Further, fathers, who are not undergoing profound hormonal changes, suffer PPD at relatively high rates (e.g., Goodman 2004). Finally, all mothers experience these hormonal changes, yet only about 10–15% suffer PPD. This does not mean, however, that hormones do not play a role in PPD. For example, in women with a history of PPD , a hormone treatment simulating pregnancy and parturition caused these women to suffer mood symptoms. The same treatment, however, did not cause mood symptoms in women with no history of PPD. One interpretation of these results is that there is a subgroup of women who are vulnerable to hormone changes during pregnancy. Another interpretation is that simulating a pregnancy will trigger PPD in women who are vulnerable to PPD for any of the reasons indicated by Beck's meta-analysis (summarized above).
Profound lifestyle changes brought about by caring for the infant are also frequently claimed to cause PPD, but, again, there is little evidence for this hypothesis. Mothers who have had several previous children without suffering PPD can nonetheless suffer it with their latest child (Nielsen Forman et al. 2000). Plus, most women experience profound lifestyle changes with their first pregnancy, yet most do not suffer PPD.
Sometimes a pre-existing mental illness can be brought to the forefront through PPD. It is widely found in women whose families have a history of mental illnesses and disorders such as bipolar disorder, schizophrenia and autism, and above-average rates of drug addiction and alcoholism.
In 2009, researchers at the University of California, Irvine, reported that the levels of placental corticotropin-releasing hormone (CRH) during the 25th week of pregnancy may help predict a woman's chances of developing postpartum depression .
Evolutionary psychological hypothesis
Evolutionary approaches to parental care (e.g., Trivers 1972) suggest that parents (human and non-human) will not automatically invest in all offspring, and will reduce or eliminate investment in an offspring when the costs outweigh the benefits, that is, when the offspring is "unaffordable". Reduced care, abandonment, and killing of offspring have been documented in a wide range of species. In many bird species, for example, both pre- and post-hatching abandonment of broods is common (Ackerman et al. 2003; Cezilly 1993
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