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Tuesday, 28 April 2020

Depression During and After Pregnancy (Things We Don’t Know about Pregnancy Series #18)

Postnatal depression is thought to occur in ~1 in 10 mothers, making it a common form of mental illness. The onset and peak of the illness may be weeks or even months after the birth of a baby, and the condition lasts for weeks, months, or longer.

Symptoms


The condition is characterised by persistent negative feelings – towards yourself, your baby, and things you previously had an interest in. Most parents find their inability to bond to their baby most upsetting, and many feel guilty, hopeless, and even suicidal. Physical symptoms include disturbed sleep, tiredness, increased or decreased appetite, and difficulty decision-making.

We don’t know what causes postnatal depression


We don’t know what causes postnatal depression, although it’s associated with hormonal changes, such as a drop in one hormone called allopregnanolone. But these alone can’t explain everything. Women go through huge and varied hormonal changes during pregnancy and early motherhood, and postnatal depression doesn’t effect everyone. In fact, for a long time, people believed that pregnancy hormones were protective against depression, and it was simply something new mothers couldn’t get – leading to many undiagnosed sufferers[1].

Worried Woman Image credit: RyanMcGuire (CC0 Public Domain via Pixabay)

Scientists now think that a range of physical, emotional, genetic, and social factors contribute[2]. Some of these risk factors include previous mental illness (including postnatal depression), physical or psychological trauma or abuse, stress, complications during childbirth, and use of drugs, cigarettes or other medications. Formula-feedings, low self-esteem, sleep deprivation and painful pre-menstrual symptoms may also cause or worsen the condition (we don’t know which), and researchers have also found that postnatal depression is more common in women with low socioeconomic status or less support from friends and family[3][4][5]. In one project, findings showed that the most important factor was how attached a mother was to her baby before it was born.

Postnatal depression in men


Father and daughter. Image credit: Wolfowitz via Wikipedia Commons.
Fathers can also get postnatal depression. It’s been long believed they don’t because of the assumption that hormone changes are crucial – but men do experience hormone changes (such as drops in testosterone) when they become fathers, and hormones are not the only factor!

In 2016, a study of the literature concluded that postnatal depression occurs in 8% of men – almost as much as women[6] – and this could be higher because the condition is chronically undiagnosed, and screening tools for detecting it (the “Edinburgh scale”) are aimed at women, and may be less reliable in men[7][8].

In men, postnatal depression can start during or after the pregnancy, and most commonly shows up in tiredness and disordered eating patterns.

Health outcomes in babies


And it doesn’t just effect the men. A Swedish study of 366,499 births found that when fathers develop depression alongside a pregnancy, this correlates with higher than usual rates of preterm birth (but we don’t know the order of causality)[9]. The Avon Longitudinal Study of Parents and Children looked at 3,176 father and child pairs, where they found not only did 1 in 20 fathers developed postnatal depression, but this correlated with a small but significant increased risk of daughters (but not sons!) developing depression at age 18[10]. Scientists are unsure why the effect is only seen in girls.

Babies born to postnatally depressed women also face increased health risks. When the woman is depressed before the baby is born, this can correlate with low birth weight, poor growth, reduced activity, infections, difficulties breastfeeding, and even spontaneous abortion[11]. Scientists are unsure whether miscarriage is linked to depression or depression medication, although one study suggests rates are higher in women not taking medication than ones who are[12].

Treatment


There is no conclusive medication used to treat postnatal depression. Tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed and seem to be effective after 2-3 weeks. These seem to be safe during pregnancy and breastfeeding, but there is some suggestion that stopping the medication can lead to drug withdrawal symptoms such as jitters and seizures in the babies. Sometimes, sodium valproate is used to treat depression before pregnancy, but this medication can cause severe neurological damage in foetuses, and isn’t prescribed for women who develop depression during pregnancy or after.

One over-the-counter herbal antidepressant is St John's wort (hypericum perforatum). However, the potency of this drug isn’t regulated, and it can interact with other medication, breastfeeding, and hormones, and isn’t recommended for postnatal depression.

Hormone therapies are being explored, and oestradiol patches might be effective. However, increased oestrogen can increase the risk of blot clots in new mothers, and the effect on breastfeeding is yet to be studied[13]. The newest drug is brexanolone, a synthetic version of the allopregnanolone hormone. Trials suggest it’s effective, but it’s injected, and, when administered, can lead to unconsciousness.

Drug alternatives includes psychological treatments such as cognitive behavioural therapy (CBT), guided self-help, interpersonal therapy, problem-solving therapy and psychodynamic psychotherapy. These talking therapies have been shown to be effective in mental health treatments, but vary between individuals.

Others have tried acupuncture, electroconvulsive therapy (ECT), or transcranial magnetic stimulation (rTMS). Evidence is inconclusive[14]. Lifestyle changes include bright light exposure, taking omega-3 fatty acid or vitamin D supplements, avoiding caffeine, and reducing stress[15] [16].

Others have pointed out that an effective screening programme – which would cost £20 million a year in the UK – would massively reduce the £8 billion a year maternal mental health bill.

Other mental health conditions


Boy by window Image credit: Unsplash (CC0 Public Domain via Pixabay)
Other mental health conditions associated with birth include the baby blues, perinatal depression, bipolar disorder, psychosis, and birth trauma.

The baby blues is the most common: a drop in hormones directly after the birth leads to tearfulness and anxiety that lasts starting around 3 days after birth and lasting for about a week.

We call it perinatal (or antenatal) depression if it starts before the baby is born, but there is a big overlap between peri- and postnatal depression, and the one may be a precursor of the other. Scientists think it affects 7% to 20% of women, but estimates vary around the world[17].

Postpartum bipolar disorder, the least well-known postpartum mental health disorder, is characterised by mood episodes of mania, hypomania or depression that interfere with everyday life and performing ordinary tasks. We don’t know the cause.

Postnatal (puerperal) psychosis is an uncommon but severe condition, which can include low mood – or manic mood – delusions, hallucinations, and out-of-character behaviour. No one’s sure what causes it, but trauma or a history of other mental illnesses are risk indicators.

Birth trauma, a type of PTSD (post-traumatic stress disorder) is mostly triggered by loss of control during childbirth, including not being heard, having medical things done without consent, or not knowing about the health of the baby. There is more about this condition in our last blog post.

There are many unknowns when it comes to pregnancy, and over the next few months, I’ll be exploring more of them with you. Look out for my next blog post, which will be about SIDS.

To read our full article on the things we don't know about pregnancy, check out our site. This article will be updated as we add posts across the coming months.




References
why don't all references have links?

[1] Mukherjee S, Trepka MJ, Pierre-Victor D, Bahelah R, Avent T (September 2016). Racial/Ethnic Disparities in Antenatal Depression in the United States: A Systematic Review. Maternal and Child Health Journal. 20 (9): 1780–97. doi:10.1007/s10995-016-1989-x.
[2] Grace SL, Evindar A, Stewart DE (November 2003). The effect of postpartum depression on child cognitive development and behavior: a review and critical analysis of the literature. Archives of Women's Mental Health. 6 (4): 263–74. doi:10.1007/s00737-003-0024-6.
[3] McCoy SJ, Beal JM, Shipman SB, Payton ME, Watson GH (April 2006). Risk factors for postpartum depression: a retrospective investigation at 4-weeks postnatal and a review of the literature. The Journal of the American Osteopathic Association. 106 (4): 193–8.
[4] Stewart DE, Vigod SN (January 2019). Postpartum Depression: Pathophysiology, Treatment, and Emerging Therapeutics. Annual Review of Medicine. 70 (1): 183–196. doi:10.1146/annurev-med-041217-011106.
[5] Howell EA, Mora P, Leventhal H (March 2006). Correlates of early postpartum depressive symptoms. Maternal and Child Health Journal. 10 (2): 149–57. doi:10.1007/s10995-005-0048-9.
[6] Cameron, Emily E., Ivan D. Sedov, and Lianne M. Tomfohr-Madsen. Prevalence of paternal depression in pregnancy and the postpartum: an updated meta-analysis. Journal of affective disorders 206 (2016): 189-203. 10.1016/j.jad.2016.07.044.
[7] JL Cox, JM Holden, R Sagovsky. Detection of Postnatal Depression: Development of the 10-item Edinburgh Postnatal Depression Scale. 150: Br J Psychiatry 782-786. 1987. Doi: 10.1192/bjp.150.6.782.
[8] KL Wisner, BL Parry, CM Piontek. Postpartum Depression. 347(3): N Engl J Med 194-199. 2002. doi: 10.1056/NEJMcp011542.
[9] Liu, Can, et al. Prenatal parental depression and preterm birth: a national cohort study. BJOG: An International Journal of Obstetrics & Gynaecology 123.12 (2016): 1973-1982. doi: 10.1111/1471-0528.13891.
[10] Gutierrez-Galve, Leticia, et al. Association of maternal and paternal depression in the postnatal period with offspring depression at age 18 years. JAMA psychiatry 76.3 (2019): 290-296.
[11] Chung EK, McCollum KF, Elo IT, Lee HJ, Culhane JF (June 2004). Maternal depressive symptoms and infant health practices among low-income women. Pediatrics. 113 (6): e523-9. doi:10.1542/peds.113.6.e523.
[12] Johansen, Rie Laurine Rosenthal; Mortensen, Laust Hvas; Andersen, Anne-Marie Nybo; Hansen, Anne Vinkel; Strandberg‐Larsen, Katrine (2015). Maternal Use of Selective Serotonin Reuptake Inhibitors and Risk of Miscarriage – Assessing Potential Biases. Paediatric and Perinatal Epidemiology. 29 (1): 72–81. doi:10.1111/ppe.12160. ISSN 1365-3016.
[13] Fitelson E, Kim S, Baker AS, Leight K (December 2010). Treatment of postpartum depression: clinical, psychological and pharmacological options. International Journal of Women's Health. 3: 1–14. doi:10.2147/IJWH.S6938.
[14] Cole J, Bright K, Gagnon L, McGirr A (August 2019). A systematic review of the safety and effectiveness of repetitive transcranial magnetic stimulation in the treatment of peripartum depression. Journal of Psychiatric Research. 115: 142–150. doi:10.1016/j.jpsychires.2019.05.015.
[15] Dennis CL, Dowswell T (July 2013). Interventions (other than pharmacological, psychosocial or psychological) for treating antenatal depression. The Cochrane Database of Systematic Reviews. 7 (7): CD006795. doi:10.1002/14651858.CD006795.pub3.
[16] Aghajafari F, Letourneau N, Mahinpey N, Cosic N, Giesbrecht G (April 2018). Vitamin D Deficiency and Antenatal and Postpartum Depression: A Systematic Review. Nutrients. 10 (4): 478. doi:10.3390/nu10040478.
[17] Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G, Swinson T (November 2005). Perinatal depression: a systematic review of prevalence and incidence. Obstetrics and Gynecology. 106 (5 Pt 1): 1071–83.

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