case study of postnatal depression

Case-based learning: postnatal depression

Appropriate early recognition and timely treatment of postnatal depression is essential if patients are to make a full recovery.

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Postnatal depression (PND) is a common, but under-reported, condition that can affect both men and women after the birth of a child [1] . PND is an illness and not simply related to hormones or the changes a new baby brings. Unlike the ‘baby blues’, which is self-limiting, PND is longer lasting and often requires treatment.

The symptoms of PND are similar to those of depression, such as low self-esteem and persistent low mood, and can range from being relatively mild to severe. Red flag signs include persistent expressions of incompetency as a parent and suicidal thoughts. The greatest risk factor for developing PND is a history of PND or depression, although other risk factors include financial instability and poor social support. Simple screening tools, such as the Whooley questions or Generalised Anxiety Disorder scale, can help identify people at risk of, or who have, PND [2] , [3] . For more information about recognising PND please see here .

Treatment type should be selected based on the severity of the condition and patient preference. Pharmacists can provide advice to patients prescribed antidepressants for PND, including potential side effects and information about breastfeeding. This article describes management and self-care options for patients, including three worked case studies.

Asking simple open questions, such as “how are you?”, can be a good way to encourage a new parent to talk without being intrusive. Where a parent shows signs of PND, ask them if they would like to talk about their concerns or if would like any further support. Signposting them to groups available in the area (e.g. community baby groups) can be beneficial.

Avoid comparing the patient with other parents because this can exacerbate feelings of failure. Do not use language that may come across as critical, particularly where parents are worried about how they are coping, and do not suggest that these feelings will simply pass or improve by themselves.

It is important to destigmatise PND and reassure parents about seeking help. Encourage all new parents to look after their emotional wellbeing through self-care, getting support from friends or family, undertaking gentle exercise and eating well [4] .

Psychological therapy

Cognitive behavioural therapy (CBT) has been shown to be effective for patients with PND, improving symptoms in both the short- and long-term [5] , [6] , [7] .

CBT aims to challenge unhelpful thinking patterns through practical activities and helps patients understand their symptoms and illness. Patients are normally offered a course of sessions on a one-to-one basis with a healthcare professional. CBT can also be offered via a group, but individual therapy may be more effective [5] , [6] , [7] .

For patients with mild-to-moderate PND, CBT can be recommended. If there are prior episodes of more severe depression, CBT may be offered with antidepressants [8] . For patients with moderate-to-severe depression, high-intensity psychological therapy (e.g. interpersonal therapy) can initially be offered alone or alongside antidepressants.

Pharmacological therapy

There is little evidence to guide selection of medicine specifically in PND. Therefore, guidelines for managing depression should be followed, taking into account the safety of the medicine for both the mother and, where relevant, the child [9] , [10] .

When selecting an antidepressant, the patient’s previous response to these drugs, as well as previous effective antidepressants should be considered (even if the antidepressant would not be considered as first-line treatment in breastfeeding mothers) [9] .

Women with PND who choose not to breastfeed and men with PND can both be treated with any suitable antidepressant. However, it is imperative to counsel parents on taking medicines that may cause sedation because they must not co-sleep with their baby (in-line with safe co-sleeping guidance) [11] , [12] .

Breastfeeding and antidepressants

The World Health Organization recommends children are breastfed exclusively for at least the first four to six months of life; however, this can be complicated if the mother requires treatment for depression [13] , [14] . Women with  mental health problems should be encouraged to breastfeed unless they are taking clozapine or lithium, because these drugs can pass into breast milk and put the infant at risk of toxicity [9] .

There is a lack of robust evidence to guide choice of treatment. However, women who wish to breastfeed should be supported to do so and be provided with all available evidence about the risks of the antidepressant and how to limit exposure of the medicine to the baby via breast milk. For example, the level of antidepressant medicine in breast milk depends on the prescribed drug and it is possible to avoid breastfeeding at the time the medicine peaks in the mother, either by timing the medicine around the longest feed or bottle feeding the baby at that time if a feed is due. This may be difficult to achieve in very young babies, however, owing to the frequency of feeding and since many antidepressants have long half-lives or unpredictable times at which they peak. Therefore, a specialist’s advice should be sought regarding this.

Future perspective

Brexanolone is currently in development as a first-line treatment designed specifically to treat PND. It has recently been licensed in the United States, but it is not yet known whether or when it may be marketed in the UK [15] .

Evidence shows that PND that is not recognised and managed early can become difficult to treat and can lead to longer-term illness [16] . Early psychosocial support is thought to help prevent the development of PND in at-risk mothers [17] , [18] , [19] , [20] . However, limitations of the current evidence base mean that the effectiveness of specific psychological and pharmacological interventions are not yet conclusive [17] , [19] , [20] .

Where women have been taking antidepressants during pregnancy , medication should ideally be continued post-birth owing to the risk of recurrence of depression.

In addition, signposting parents to available groups where they can get professional or peer support may help reduce loneliness and increase social support, which may help prevent PND (see Useful resources).

Case studies

Case study 1: mild postnatal depression in a woman* .

A woman aged 21 years comes into the pharmacy to buy something for her three-month-old baby who has colic. When her baby starts to cry, the mother becomes very irritated. She apologises and says she is very tired as the baby has not been sleeping well. She looks teary and upset.

Questions to ask

Offer to talk in the consultation room and ask the following questions to discuss or highlight any issues the mother is facing:

• How are you managing with the baby?
• How is your baby’s constant crying affecting how you feel?
• What support do you have that allows you a break from your baby?

Advice and recommendations

The patient describes mild symptoms of postnatal depression (PND) and has no previous history of a mental health condition; therefore, self-help measures may be beneficial, such as:

• Taking advantage of available support, such as appropriate family members to take a break from the baby or to help manage household chores;
• Sharing day-to-day care of the baby with their partner;
• Eating well and taking gentle exercise (e.g. a walk);
• Attending classes or groups that may be available locally.

Even if the patient is trying self-help measures, it may still be helpful to refer them to their GP or health visitor. Alternatively, recommend ‘Improving Access to Psychological Therapies’ services in the area (people with PND may be able to self-refer without having to see a GP).

Explain that it is common for mothers to have mood disturbances after the birth of a child and that it is important that they address these feelings, rather than hope that they will pass.

Provide the patient with leaflets on PND and how parents can get help, as well as information on local services, numbers to call in an emergency, children’s centres that may offer drop-in sessions, breastfeeding support and any baby groups that parents can attend (see Useful resources).

Case study 2: risk of severe postnatal depression in a woman*

A woman aged 38 years with bad indigestion comes into the pharmacy. She has been taking antacids to ease the symptoms, but the indigestion is not resolving, and she is worried about it. Several years ago, she was treated with escitalopram for depression and anxiety, but has since stopped it. She is not taking any other medicine, has a baby aged three weeks and is struggling with breastfeeding.

The patient should be assessed for indigestion; however, it is important to notice the risk factors for postnatal depression (PND) in this patient. Persistent physical symptoms are common in anxiety and depression and should warrant further discussion. Some patients will find it easier to discuss physical problems, which can provide a way for them to open up about other difficulties they may be experiencing.

Ask the patient about:

• Their indigestion – what may be causing it or when it is worst, which may lead to a conversation about how she is feeling or coping;
• Previous episodes of depression – this is the major risk factor for developing PND, therefore, if it has not already been brought up, ask how she is feeling and whether she has any support;
• Breastfeeding – difficulty in establishing breastfeeding is a further risk factor for PND and can exacerbate feelings of failure as a mother. PND is linked to reduced rates of breastfeeding, which can have a negative impact on the mother’s mental health [21] .

Since the patient wants to continue to try to breastfeed, signpost her to places where she can get help in the local area or find more information (see Useful resources). Feelings of guilt at being unable to breastfeed are common; however, unnecessary blame and feelings of worthlessness should raise serious concerns. This red flag, coupled with her history of depression, means she should be promptly referred to her specialist perinatal mental health team. Different geographic areas require a GP referral, while some allow patients to self-refer.

Reassure the patient about how she is feeling and that there is help and support available to her. Most mental health trusts have a crisis line that operates 24 hours per day and there are charities providing similar support lines (e.g. Samaritans). However, if the patient expresses thoughts about harming herself or her baby, contact their mental health crisis team or GP for an emergency appointment. If the patient has already harmed themselves, call 999.

Potential outcome of the advice

Where there are signs of severe PND and evidence of good prior treatment with antidepressants, it is likely that the patient will be offered antidepressants and psychological therapy. Most mothers will be treated in primary care with follow-up provided by specialist mental health perinatal services.

The previous antidepressant, escitalopram, would be considered for this patient. Many resources will recommend sertraline as first-line treatment in breastfeeding (owing to its shorter half-life and low levels in breastmilk) [22] . While sertraline will be appropriate for mothers with no prior history of depression, if another antidepressant has had a good response in a previous episode of PND or depression, this will likely be used. In resistant cases, treatment with another antidepressant, lithium or antipsychotic can be considered.

The Specialist Pharmacy Service provides information to healthcare professionals on the safety of medicines in breastmilk [23] .

Case study 3: perinatal mental health problems in a man*

A man aged 30 years whose partner has recently given birth to their first child comes into the pharmacy. He looks tired and worn out as he collects a prescription for sertraline for his wife. He provides the wrong address and makes a comment about how he always seems to be getting things wrong nowadays and needs to pull himself together.

There are fewer opportunities for healthcare professionals to interact with new fathers as most antenatal care involves assessment of the mother and baby. Furthermore, men are also less likely to seek healthcare advice. Therefore, it is important to try and talk to a new father where there is an opportunity.

Ask questions, such as:

• Having a new baby can be stressful – are you both getting some time to rest?
• It can be especially difficult when mum isn’t feeling well – do you have support available to help?
• Are you getting time together with the baby? How are you finding it?

The man explains that he is struggling, feels quite low and that his wife has postnatal depression. Paternal PND has high comorbidity with maternal PND; therefore, children in such families, particularly where PND is left untreated, are at greater risk of emotional and behavioural problems later in life [24] . Although there is no single official diagnostic criteria for paternal PND [24] , the man should be referred to his GP because he is at risk.

Reassure the man that PND is common in men and seeking treatment will help. Most of the advice and support groups aimed at women also provide support to men. Furthermore, there is a specific advice group through the  PANDAS Foundation  for fathers who have PND. In some areas, there are specific baby groups for fathers, which can help to forge peer support, particularly where fathers have limited social networks with other fathers.

It is important to encourage the father to seek help and support. It can be helpful to follow up how he is feeling, particularly if he appears ambivalent about taking advice. There is no specific guidance for treating paternal PND and, therefore, usual depression treatment guidelines should be followed [25] . Treatment may involve psychological interventions or antidepressants. Where antidepressants are used, it is important to consider the effects of medicine and co-sleeping, and to advise that he should not share a bed with a baby [12] .

*All case studies are fictional.

Useful resources

• Association for Post Natal Illness
• MBRRACE-UK. Saving Lives, Improving Mothers’ Care. Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2014–2016  
• Choice and medication  
• LactMed – Drugs and Lactation Database  
• Start 4 Life. Breast feeding support  
• PANDAS helpline 0808 1961 776

How to have effective consultations on contraception in pharmacy

What benefits do long-acting reversible contraceptives offer compared with other available methods? 

Community pharmacists can use this summary of the available devices to address misconceptions & provide effective counselling.

Content supported by Bayer

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[2] Howard LM, Ryan EG, Trevillion K et al . Accuracy of the Whooley questions and the Edinburgh Postnatal Depression Scale in identifying depression and other mental disorders in early pregnancy. Br J Psychiatry 2018;212(1):50–56. doi: 10.1192/bjp.2017.9

[3] National Institute for Health and Care Excellence. Identifying and assessing common mental health disorders. 2018. Available at: https://pathways.nice.org.uk/pathways/common-mental-health-disorders-in-primary-care/identifying-and-assessing-common-mental-health-disorders#content=view-node%3Anodes-asking-questions-to-identify-anxiety-disorders  (accessed January 2020)

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[6] Clout D & Brown R. Sociodemographic, pregnancy, obstetric, and postnatal predictors of postpartum stress, anxiety and depression in new mothers. J Affect Disord 2015;188:60–67. doi: 10.1016/J.JAD.2015.08.054

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[10] National Institute for Health and Care Excellence. Postnatal care up to 8 weeks after birth. Clinical guideline [CG37]. 2015. Available at: https://www.nice.org.uk/guidance/cg37  (accessed January 2020)

[11] McMahon CA, Boivin J, Gibson FL et al . Older maternal age and major depressive episodes in the first two years after birth: findings from the Parental Age and Transition to Parenthood Australia (PATPA) study. J Affect Disord 2015;175:454–462. doi: 10.1016/J.JAD.2015.01.025

[12] The Lullaby Trust. Co-sleeping with your baby. 2013. Available at: https://www.lullabytrust.org.uk/safer-sleep-advice/co-sleeping/  (accessed January 2020)

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[19] Molyneaux E, Telesia LA, Henshaw C et al. Antidepressants for preventing postnatal depression. C ochrane Database Syst Rev 2018;(4):CD004363. doi: 10.1002/14651858.CD004363.pub3

[20] O’Connor E, Senger CA, Henninger ML et al . Interventions to prevent perinatal depression. JAMA 2019;321(6):588–601. doi: 10.1001/jama.2018.20865

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• Research article
• Open access
• Published: 14 October 2014

Women’s experiences of postnatal distress: a qualitative study

• Rose Coates 1 ,
• Susan Ayers 2 &
• Richard de Visser 1  

BMC Pregnancy and Childbirth volume  14 , Article number:  359 ( 2014 ) Cite this article

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Women can experience a range of psychological problems after birth, including anxiety, depression and adjustment disorders. However, research has predominantly focused on depression. Qualitative work on women’s experiences of postnatal mental health problems has sampled women within particular diagnostic categories so not looked at the range of potential psychological problems. The aims of this study were to explore how women experienced and made sense of the range of emotional distress states in the first postnatal year.

A qualitative study of 17 women who experienced psychological problems in the first year after having a baby. Semi-structured interviews took place in person (n =15) or on the telephone (n =2). Topics included women’s experiences of becoming distressed and their recovery. Data were analysed using Interpretative Phenomenological Analysis (IPA). Themes were developed within each interview before identifying similar themes for multiple participants across interviews, in order to retain an idiographic approach.

Psychological processes such as guilt, avoidance and adjustment difficulties were experienced across different types of distress. Women placed these in the context of defining moments of becoming a mother; giving birth and breastfeeding. Four superordinate themes were identified. Two concerned women’s unwanted negative emotions and difficulties adjusting to their new role. “Living with an unwelcome beginning” describes the way mothers’ new lives with their babies started out with unwelcome emotions, often in the context of birth and breastfeeding difficulties. All women spoke about the importance of their postnatal healthcare experiences in “Relationships in the healthcare system” . “ The shock of the new” describes women’s difficulties adjusting to the demands of motherhood and women emphasised the importance of social support in “Meeting new support needs” .

Conclusions

These findings emphasise the need for exploration of psychological processes such as distancing, guilt and self-blame across different types of emotional difficulties, as these may be viable targets for therapeutic intervention. Breastfeeding and birth trauma were key areas with which women felt they needed support with but which was not easily available.

Peer Review reports

Giving birth and having a new baby are emotive experiences, and many women are vulnerable to psychological problems during this time. Research examining psychological problems after birth has been largely quantitative and focused on major depression in the postnatal period [ 1 , 2 ]. More recently, researchers have shown that anxiety symptoms and disorders are as common as depression in the postpartum period [ 3 ]. Levels of posttraumatic stress disorder (PTSD) following childbirth are also of clinical significance [ 4 ]. In this article we use the terms ‘distress’, ‘emotional distress,’ ‘emotional difficulties’ and ‘psychological problems’ interchangeably to refer to any psychological problem which impairs daily functioning. It was considered that mothers may identify more with terms such as ‘emotional distress’ and ‘emotional difficulties’ than with ‘psychological problems’ which is used in the academic discussion of such concepts. These psychological problems have a significant impact on women and their children, with evidence that depression and anxiety can lead to altered mother-infant interaction and developmental difficulties [ 1 – 3 , 5 – 7 ].

Symptoms of distress particular to the postnatal period may be missed by research using general measures of distress and psychopathology that are not designed for use in postnatal populations [ 8 , 9 ]. The postnatal period has unique physiological and psychological aspects such as fatigue, interrupted sleeping and the adoption of new routines such as breastfeeding. These unique aspects may affect responses on self-report measures which include items that are not appropriate for the postnatal period [ 10 ]. For example, the General Health Questionnaire GHQ [ 11 ] asks if the respondent has been able to leave the house as often as usual which may result in endorsement of a ‘symptom’ that is a normal component of new motherhood, leading to false ‘cases’ and, ultimately, the pathologising of motherhood [ 12 ].

Another issue is that self-report measures are validated against diagnostic criteria which may not be relevant to postnatal women. In a sample of mothers with unsettled infants, equal numbers of mothers (11%) were diagnosed with Generalised Anxiety Disorder (GAD) as were diagnosed with an anxiety disorder not otherwise specified (ADNOS), defined as the primary symptoms not being associated with OCD, social anxiety, specific phobias or panic disorder [ 13 ]. All of these women experienced uncontrollable worry about motherhood or their infant. It is therefore perhaps unsurprising that some postnatal women report clinically significant symptoms of both depression and anxiety [ 6 , 14 , 15 ] indicating that only part of a woman’s experience of distress is explored when using symptom measures of a specific disorder. As a result of these limitations in measurement, there could be a disparity between women’s lived experiences of distress in the postnatal period, whether those symptoms are problematic to women or a normal part of motherhood, and how those experiences are reported subject to current measurement practices.

Qualitative research examining women’s experiences of psychological disorders has also commonly worked within diagnostic categories of postnatal depression [PND; 16–20]; anxiety [ 16 ]; or post-traumatic stress disorder following childbirth [ 17 , 18 ]. Despite focusing on different diagnostic categories, there is much overlap in findings. Beck [ 19 , 20 ] conceptualised PND as a loss of former self and loss of control over one’s life, in both phenomenological and grounded theory studies of women attending a postnatal depression support group. High anxiety was also a key part of these women's experiences. Subsequent qualitative studies have identified important experiential aspects of PND such as: a sense of loss of autonomy, time, appearance, femininity, sexuality and occupational identity and feelings of loneliness, depression and panic [ 21 ]; feeling overwhelmed with their new responsibility and negative self evaluation related to being unsure about being able to meet their baby’s needs [ 22 ]; and limited social support and breastfeeding difficulties [ 23 ]. Hall [ 24 ] interviewed 10 women who had experienced postnatal depression: they commonly described their unrealistic expectations of motherhood as a key aspect in the development of depression.

There is far less qualitative research examining experiences of postnatal anxiety. Wardrop and Papaduik [ 16 ] interviewed six women for whom anxiety was the primary mental health concern in the first six months postpartum. A key theme for these women related to feeling misunderstood and alienated because their symptoms did not fit with the dominant concept of postnatal depression. In common with qualitative research on postnatal depression women spoke of a relationship between high expectations, perceived lack of competence as a mother and anxiety, loneliness and feeling overwhelmed. Lack of social support was also an important factor in experiences of anxiety.

In contrast, there is a substantial body of qualitative work on PTSD following childbirth. A meta-synthesis of ten qualitative studies of women’s perceptions and experiences of traumatic birth identified themes of feeling out of control, feeling inhumanely treated, feeling trapped with the childbirth experience, a ‘rollercoaster of emotions’, disrupted relationships and finding ways of succeeding as a mother after feeling their mothering ability had been hampered by a traumatic birth [ 25 ]. These qualitative studies also show the potential debilitating effect of traumatic births on breastfeeding [ 26 ], and the mother’s relationships with the father and the baby [ 18 , 27 ].

In the research to date women were selected due to their experience of one specific type of disorder (i.e., depression, anxiety or posttraumatic stress disorder following childbirth) in line with the disorder-focus of most contemporary research. However several themes appear in qualitative reports that span anxiety, depression and postnatal post-traumatic stress disorder, particularly high expectations, feeling overwhelmed, perceived lack of competence as a mother, lack of social support and breastfeeding. This suggests that a transdiagnostic approach to postnatal distress may be useful. Such an approach could explain high comorbidity through establishing causal factors and maintaining processes across disorders, improve screening and identification of multiple types of postnatal distress, and help develop specific treatment components effective across a broad range of mental health problems [ 28 ].

Qualitative research that focuses on women’s actual experiences and conceptualisations of postnatal distress outside of diagnostic categories is therefore necessary. The key research question was to determine how women themselves conceptualise their postnatal distress and to obtain more information about what women themselves consider problematic or impairing and what help they would like with their distress. This study develops insight into the experiences of mothers who experienced postnatal distress. In contrast to previous research, the data highlight psychological processes experienced across different types of distress in the context of defining moments in becoming a mother; birth and breastfeeding.

A sample of 17 women aged 23–42 took part in the study. Inclusion criteria were that women had given birth to a baby in the past year and experienced “emotional difficulties” at some point during this year. All except one woman were white and one was Chinese. Two had completed GCSE level education; six had completed A level education; five had a degree or higher degree; four had completed professional qualifications. Further characteristics of the sample are presented in Table  1 . Although smaller sample sizes are often advocated in Interpretative Phenomenological Analysis (IPA) [ 29 ], larger samples are common (a review of 48 studies found samples ranged from 1–35 with a mean of 14 participants; [ 30 ]). We acknowledge that there is often a sacrifice of depth of analysis with larger samples [ 29 ]. However, we felt that because the current discourse of postnatal mental health largely focuses on postnatal depression, a larger sample size would be required to reflect the range of other emotional difficulties experienced in the postnatal period. The sampling strategy was opportunistic allowing the researchers to select participants on the basis of their experiential knowledge [ 31 ]. Advertisements were placed on relevant websites (e.g., local postnatal group Facebook pages), in local National Childbirth Trust (NCT) newsletters, and through instructors at relevant antenatal and postnatal classes e.g., pregnancy yoga classes and word of mouth.

All women who responded to the advertisement who met the inclusion criteria and wanted to take part were sent an information sheet, a consent form and demographics and pregnancy/birth questionnaire to complete, sign and send back should they wish to participate. All women who initially showed an interest took part; due to this sampling method there were not any women who were not included in the study. Ethical approval was obtained from the university Research Governance Committee and NCT Research Office. The information sheets, consent forms and interview questions were careful to avoid the term ‘depression’ and instead focused on ‘distress’ to be congruent with the study aims of exploring different types of emotional difficulties that women experience.

Interviews were conducted between September 2010 and February 2011 at women’s homes in the South East of England (n =15) or via telephone when women lived in other areas of England and had heard about the study through word of mouth (n =2). Present at the interview were the researcher (RC) and the mother participating in the interview, and in most cases her baby and/or other young children. Participants gave their consent for the interviews to be recorded and were made aware that they could stop the interview at any time without giving a reason. The interviews followed a semi-structured format whereby an interview schedule was used but the order in which questions were asked questions and answered could vary according to the responses of the participant. Follow-up questions were asked and the clarification of points which arose was also sought. Participants were first asked ‘Can you tell me about when you first started to feel distressed?’ Examples of further questions included:

‘What thoughts and feelings did you experience?’

‘How did you cope with your symptoms?’

‘What was your experience of seeking help (if you did so) during this period?’

‘What was your experience of being offered help?’

Participants were further encouraged to discuss any issues that they felt were relevant to their experience of distress. Interviews ranged from 22–72 minutes (Mean = 43 minutes). Various factors may help to explain variation in interview times. In the first interviews the questions were asked in a sequential manner to ensure that the entire schedule was covered, however, it became clear that a more open and flexible strategy would produce the most rich data as it would allow participants to follow their own stories and discuss further aspects that were not covered on the interview schedule but were important in their stories of distress (e.g. breastfeeding). Beyond this, although all mothers self-selected to take part in the study, some were more willing or better able to elaborate on their experiences.

The telephone interviews followed the same process, including being recorded. It is acknowledged that telephone interviews can limit the building of rapport and non-verbal communication cannot be tended to in the same way as face-to-face interviews; however they were no less rich in terms of outcome. The second telephone interview was one of the shortest interviews (25 minutes) whilst the first was 48 minutes.

Interviews were transcribed verbatim by RC and checked by RdV and SA. Participant numbers are used to ensure confidentiality. Data analysis was conducted according to the principles of interpretative phenomenological analysis (IPA; [ 29 – 32 ]): pre-identified themes were not used to guide analysis. This method was suitable for the purpose of the study as it aims to examine underlying cognitions and emotions as well as describe the participants’ experience.

The method involved using emic (insider) and etic (interpretative, outsider) positions [ 32 ]. The analysis followed a four stage process as follows. In step (1) of the analysis, transcripts were read repeatedly to identify accounts of experiences that were important to the interviewee. The emic phenomenological position employed here concerned hearing and understanding the participant’s story in their own words and keeping their experience at the centre of their account. In step (2), the etic phase, the accounts identified were re-read and pertinent sections summarized and given shorthand labels (codes) representing the researcher's interpretation. Steps (1) and (2) reflect the ‘double hermeneutic’ aspect of IPA whereby the participant interprets their own life experience and the researcher further interprets the participant’s account. Step (3) involved a shift to identifying how these codes clustered together into themes and how themes were related to each other. Interviews were coded on a case-by-case analysis and themes labelled using key words and phrases from participants where possible to retain an idiographic approach. In step (4) comparisons were made across the body of interviews to determine how prevalent themes were and how important they were to interviewees. The authors agreed on an approach to analysis prior to commencing analysis. The first author discussed emerging themes with the second and third authors to ensure that a consistent and balanced approach was applied to all four step described above. Self-reflexive application of these four steps meant that the authors gave priority to the interviewees’ accounts rather than their own personal or professional knowledge of the experiences of pregnancy, birth, and the postnatal period. The results section provides descriptions of these themes, using verbatim quotes to illustrate these interpretations.

Four major themes were identified: “Living with an unwelcome beginning” concerning mothers’ early days with their new baby; “Relationships within the healthcare system” speaks of mothers’ experiences with healthcare providers; “The shock of the new” relates the instant, permanent and challenging change to one’s life immediately after having a baby; and “Meeting new support needs” considers the types of needs mothers have to adapt to and satisfy. These themes will be discussed in turn using direct quotes to support them. Superordinate themes and the subthemes are presented in Table  2 .

Living with an unwelcome beginning

Eleven mothers described their new life with their baby as starting in a way that was not as they had hoped. This theme is characterised by a sense of feeling removed, or distant, from their day-to-day life with their baby. Some mothers acknowledged this sense of distance whilst others avoided their own negative emotions. The characterisation of distress as an overarching feeling of remoteness was explained by many women in terms of negative birth experiences that women often blamed themselves for, and which they found difficult to move on from. These negative experiences were often compounded by difficulties faced in one of the central aspects of caring for a new baby; breastfeeding. Women reflected on a subsequent feeling of having lost the important new-baby stage of their own and their baby’s life.

Distancing and avoidance of emotions

Rather than being an easily describable phenomenon, or feeling categorically unhappy or worried, there was often an underlying feeling of something not being quite right or feeling out of character and somehow detached from their own life. The sense of feeling outside of one’s own head or body was described by participant 1 , who could not pinpoint discrete emotions or feelings at first but felt an unusual sense of unease:

It is as if I was playing a part, going through the motions, so I was doing all the right things for him, playing with him, chatting to him, but not feeling like it was me or that it was very natural.

This highlights the idea that there are both ‘natural’ and ‘right’ ways of caring for a baby or of feeling about one’s baby, and for this participant, that an unsatisfactory comparison with these ways is related to feelings of disconnection. For participant 8 the feeling of detachment was more pronounced and alien:

I really just felt like I was watching myself in day-to-day life and I wasn’t actually in my own body. It’s quite strange.

Feelings of detachment were also embodied in experiences of bonding that were not as desired. In recounting her immediate feelings of not connecting with her baby, participant 1 alluded to the expectation of instant and intense love that new mothers sometimes expect to feel:

As soon as she was born I didn’t feel right, like I didn’t have a connection with her … I felt like it was someone else’s baby I was holding, it was really weird.

Furthermore, for participant 12 , feeling better was characterised by starting to feel a connection with her baby:

I hadn’t spoken to anybody for weeks, so I was starting to ring people that week and said ‘I love her [her daughter], you know I’m having a nice time, I’m going for walks’ and it was just brilliant.

For some mothers, the feelings of distance were acknowledged, with a desire for those feelings to change, whilst others actively tried to avoid dealing with their feelings of distress in the hope that they would change in the near future or that keeping busy would keep them at bay. There was a sense of hope that life as a mother as it ‘should be' would present itself if one was able to deal with the present unwanted feelings of distance. In describing her avoidance of emotions, participant 1 drew on her intense desire for a happy family life:

I didn’t want to admit that I had something wrong because I didn’t want things to go wrong … I thought it’s like a perfect kind of thing, a perfect family, like everything could be OK, maybe next week I’ll feel a bit better, but it didn’t feel any better the next week.

Birth- related distress

Whilst for some mothers the sense of an unwelcome beginning related to a general feeling of distress in their new life as a mother, for others this theme was exemplified by reference to the temporal beginning of life; an unexpected or difficult birth experience. For most, a sense of disappointment that the birth had not been as they had hoped or expected led to feelings of their new life being at fault from the outset:

[Labour and birth] was just nothing like what I’d imagined so I just felt . . . like just at a disadvantage. Like I’d been thwarted all the way through and um something was taken away from me so I felt like I couldn’t really recover, to get back to square one, how I wanted to start out with this new life. ( Participant 7 )

Mothers made sense of their unmet expectations of birth in differing ways; some mothers felt unprepared, others felt that having prepared for the birth it should have been more as they would have expected. Premature, late, quick, or complex births all led to feelings of distress.

Feelings of distress around birth experiences left mothers feeling that they could not move on without some kind of resolution of the birth. Such resolution was described through needing to know fully about the birth, or being able to explore what had happened to them during birth, or through having space and sleep to ‘process’ what had happened, which was unlikely with a new baby to care for. In recounting her need to move on, participant 17 stressed how she considered finding out the specifics of her experience to be the most important factor in this:

I don’t know what happened when he went into the Special Care. I never managed to find out, so I’m quite keen to find out exactly what happened, and I’m hoping that will just put a lid on it to be honest, and put it to bed.

Other factors they were not so able to influence could prevent women from moving on. Reminders of lost birth experiences revived early feelings of distress and other negative emotions, as participant 8 recounted:

I had some friends who had children around the same time who had normal births, and when I heard that they’d had their babies I felt quite jealous and angry inside that everything was OK . . . I kind of felt “Why should they have everything perfect and I shouldn’t?”

Guilt/Self-blame

Feelings of guilt about negative birth experiences were frequent, with mothers often feeling defeated through the birth not being the commonly-desired birthing without intervention. Participant 13 expressed ambivalence about self-blame, seemingly unwilling to rationally blame herself but feeling something akin to it:

I don’t know if I was blaming…I wasn’t blaming myself but I still felt in some way a bit useless about it. I wanted to be the mummy who just did it all naturally and it was all gorgeous and the way it should be.

For some mothers the feelings of culpability were more explicit. Discussing birth experiences, mothers spoke of a separation between their mind and their body, blaming their body for opposing their will, and indicating the complex nature of interaction between physical and psychological control during birth and labour. Reflecting on her own experience as well as that of other mothers, participant 16 described her feeling that her body let down both herself and her baby:

I’ve spoken to other new mums you know, and no matter what kind of experiences they’ve had, a lot of them mention the guilt word […] I had this guilt, and probably still do a little bit that my body let me and her down because she came so early, and you kind of have this guilt that you know, you somehow have caused your baby to suffer…

Breastfeeding experiences

All but two women who experienced birth-related distress went on to experience difficulties with breastfeeding. The perception of having no control over their birth experience led to an attempt to regain control over childbearing via breastfeeding. A determination to breastfeed was present even if women felt that it took all their time and resources to succeed at this.

Sometimes the determination to breastfeed led to women feeling that they were engaged in a fight to succeed. Participant 5 was ‘desperate’ to breastfeed but described it as the ‘hardest thing’ she’d ‘ever had to do.’ Many women expected breastfeeding to be either something ‘amazing’ ( participant 4 ) or a process that would ‘be the most natural thing in the world’ ( participant 2 ); or that ‘everyone thinks it’s really easy’ ( participant 11 ). There was a feeling that the mechanics of breastfeeding were explained at antenatal classes but problem-solving of breastfeeding issues was not raised. Participant 5 explained that mothers could be better prepared for feeding difficulties:

Everyone has feeding problems . . . sometimes you feel like you’re the only one, and I think if maybe they’re more open about the problems you can face, because no one actually tells you, “Oh your baby might not feed from you”. . . then it’s not such a shock.

Breastfeeding overshadowed all other aspects of daily life with women reporting feelings of anxiety, stress and frustration about their feeding experiences. The nature of new-born babies needing frequent feeding meant that these emotions could be experienced periodically throughout the day, as participant 4 recounted:

I had anxiety every time I fed her - she would go to sleep and I would build up this worry about what would happen when she woke up again you know, would feeding go well? How long would it take?. . . I would find myself willing her to stay asleep for as long as possible just so that I wouldn’t have to do that again.

All women reported feeling unsupported with breastfeeding by healthcare professionals and were proactive with trying to access support, trying multiple helplines and charities as well as the NHS. When accessible, advice from helplines was no replacement for practical help:

I just got the usual spiel you know, lots of skin to skin contact, and all the stuff that I knew and I remember saying to her you know “I really need practical help to tell me whether we’re doing it right” and she was like ‘well, that’s the health visitor really I’m just here to…’ and you kind of get bounced from person to person. ( Participant 4 )

Participant 11 felt that a more proactive stance from healthcare professionals was required:

A lot of women don’t realise it’s going to be difficult or don’t realise they’re not doing it properly, I think there should be a bit more hands on help, people coming round and saying “I’m actually going to check that you’re doing it right,” without waiting for people to ask.

Some women felt that pressure to breastfeed compounded their distress. Participant 9 , who developed acute pre-eclampsia and experienced a traumatic birth, felt shocked that health professionals would or could not suggest artificial feeding to her overtly:

One of the ward nurses came in and sat down on my bed when I was trying to feed him and said ‘you don’t, I shouldn’t be telling you this, but you don’t have to do this’ and it was such a relief, again to be authorised to not beat myself up about it.

Relationships in the healthcare system

Women’s relationships with midwives, GPs and health visitors and with the processes surrounding maternity and postnatal care were at the forefront of their described experiences. Many women felt they had been mistreated or ignored. They often associated this with a lack of staff being available, and with the perceived limited staff not having sufficient time to help to the extent mothers felt necessary. Positive experiences were often in the context of developing a supportive relationship with one healthcare provider.

Uncared for in the healthcare system

Most women spoke of feeling uncared for in the healthcare system at some point during their postnatal period. Most often, women felt that a dialogue with health professionals was missing; that they were not listened to; not asked how they were feeling or not treated as equals in decision-making. Participant 1 felt that health professionals often did not probe sufficiently to determine whether women were distressed:

Health visitors should be as supportive as they can and talk more to people . . . they always seem to refer you on to somebody else, like they don’t want to.

Many experiences of feeling uncared for related to a perceived lack of maternity and neonatal staff, and a perception that time-constrained staff who were available were not approachable, could only deal with major emergencies, or did not fulfil offers of help. Participant 2 related her experience of hours waiting for help with breastfeeding her new-born:

One of the midwives said to me, “Oh don’t feed your baby, we’ll come in and we’ll help with the breastfeeding”, and like five, six hours later, I’m thinking “Well I’ve got to feed my baby, where are you?”

Once home, women similarly felt that health visitors were often in a rush and did not have time to talk about mothers’ emotions, or did not have sufficient time to assess breastfeeding efficacy. Almost half of the sample perceived that the hospital where they gave birth had made direct errors contributing to their feelings of being uncared for and disrespected. These errors varied greatly, but examples included: being unable to access food or medication whilst catheterised, being sent home before breastfeeding was established or without telling mothers what happened during their labour and birth when complications arose, feeding a baby artificial milk without the mother’s knowledge, not changing blood-stained sheets, being put on inappropriate hospital wards, stitches not being checked resulting in subsequent infections, and, mainly, not being listened to or feeling that staff were unsupportive, as participant 7 recalled:

The way that I was being talked to during my labour it just made me feel like I didn’t know what I was doing and I should just put it in their hands.

Unknown in the healthcare system

Beyond feeling directly or indirectly uncared for, many women felt anonymous within the healthcare system. This was characterised by feeling that they did not have one point of contact or one healthcare professional who knew them, their baby and their situation. Women described a ‘tick box’ approach to women’s postnatal wellbeing. This did not facilitate building a relationship within which they could disclose distress. Participant 1 felt that her depression was not taken seriously at first:

I think the doctors should be more like . . .’cause he just said “Oh you need to talk to the health visitor,” he didn’t seem that interested.

Furthermore, women felt uninformed about sources of support that they could access, and felt that health professionals could do more to link women to local support networks. Consequently there was a sense that mothers could only get support if they were proactive enough to research and access it themselves:

I didn’t think that the care was there easily. I mean there’s a lot of care there if you ask for it, but it isn’t easily accessible. ( Participant 12 )

Positive experiences

Women did also describe times where they had felt supported within the healthcare system. Almost always this was in the context of having formed a close empathic relationship with one healthcare professional (GP, midwife, health visitor or lactation consultant) within which women felt they could discuss their feelings without being hurried. Participant 14 commented:

My GP was just, he was understanding, he’s got kids of his own and kids that are quite close together in age and he was telling me about his family, he was very compassionate, understanding, I didn’t feel rushed, um it was, I just got more empathy.

In almost all cases, women experienced these positive relationships through sharing of experiences on the health professional’s part, as participant 16 recalled after her baby was born prematurely:

There was one particularly great nurse who took good care of the mums . . .but she’d had a premature baby herself, she’d had a baby I think at 33 weeks, the same as [baby] and she really knew what to say to the mums and what to do for the mums, and how to be there for them and to, was really nurturing and really looked after us.

Understanding and unrushed healthcare professionals were viewed as a great help when navigating the new and immediate challenges of motherhood. The immediacy of the challenge is discussed in the next section.

The shock of the new: diving into motherhood

The term ‘transition’ to motherhood has purposefully been avoided here as women’s reports throughout the interviews were not of transition but more a sudden and challenging change to their life. From being self-sufficient and independent throughout life, many mothers felt vulnerable and dependent for the first time whilst having to learn to manage with a new baby.

Adjustment to the unknown

A conflict often existed for women, who felt on the one hand that the emotions they were experiencing were ‘normal’ parts of the role of a new mother and were to be expected, yet on the other hand they felt distressed. Participant 10 had given birth to her third child, but still found it difficult to decide if her distress was ‘normal’:

I was burning myself out by trying to do everything on my own and post-caesarean. Um so it was just really difficult but I kind of didn’t think I had a problem it was kind of like new mums do this all the time and get on with it.

For first time mothers, the lack of a point of reference made it difficult to decide whether feelings of distress were normal, particularly when mothers felt they needed to disentangle tiredness, hormonal changes or feelings of trauma from birth. Sometimes mothers needed to talk to other new or experienced mothers or to a health visitor to decide if they should take some action about their distress. If distress was not encountered as a constant feeling, it could be difficult to decide if action needed to be taken, as participant 6 described:

It takes quite a while to work out that you do have a problem um and to work out what it is. . .I’ve been . . . Points of terrifying thoughts of having postnatal depression and um then other periods of, you know, thinking I’m absolutely fine.

There was an expectation that life with a baby would be difficult at first but would get easier. Women spoke of the impact of sleep deprivation on their well-being and the sense of eagerly awaiting their baby to sleep for longer stretches so that they could feel better emotionally, as participant 16 recalled:

Now she’s starting to sleep a little bit more of a stretch of sleep at night …you have more of a normal existence rather than this thing where you’re up all night watching the hours tick by until it’s morning again but you’ve not slept and you just, yeah, you just live in a weird world for a while.

Overwhelming responsibility

Many women spoke about feeling overwhelmed once their baby was born. Being the responsible adult with total care for their baby left mothers feeling overpowered by a new person that they did not yet know and who demanded so much of them. Sometimes this led to a feeling of wanting to pass the baby over or walk away from their situation, as participant 16 described:

That’s what makes having a baby hard, is that it’s not something you can give back or to say I’ve had enough of doing this now, it’s not working out, someone else can take over, so um yeah I guess maybe there was the occasional thought of yeah it would be nice to get dressed and walk out the front door and just go out for the day and not ever, or that day think about having a baby.

Inexperience

Feeling overwhelmed and uncertain was often put in the context of a lack of experience with babies. The new-born period and its challenges were something that was previously inaccessible and that women were not prepared for, having focused on positive aspects throughout their pregnancy. Women tended to feel that being pregnant should have prepared them for being a mother, although participant 14 described how this was not the real picture:

The whole range of things that are suddenly thrust upon you that you should know, you should know when they need a feed, you should know when they’re thirsty, you should know but you don’t, they’re not born with a manual and it’s only through experience and advice that’s passed on…but yet you think ‘I should know, you know, I’ve carried them, they’re mine, I should know what to do.’

Even when women had supportive partners and families, inevitably there came a point when mothers would be at home on their own with the baby. This was a significant time-point for participant 10 , who highlighted the scary nature of a perceived disconnection between advice about, and reality of, caring for a baby:

You can read as many books as you want but when you get that baby home and you’re kind of on your own you’re like “Right. OK. What do I do now?” Then all the visitors go away and everyone goes back to work and you know then two, three weeks later it’s just you and this baby. It’s very, very scary.

Meeting new support needs

Women spoke of an increased need for emotional and practical support from partners and close family, as well as a desire to share experiences with others in similar situations.

Needing and seeking support

Often the relationship women had with their partners was the closest they had and was the only one in which they could disclose everything they were feeling. With the partner usually at work for a large part of the day, there was a build-up of need to talk through how the day with the baby had been, but which had to wait until the partner returned. Women recognised the pressure placed on their partners from working and now supporting them at home with the baby as participant 7 described:

[Husband]’s having to work really long hours to support us but also coming home and I haven’t been able to do housework . . . he’s just had to have this massive emotional resource for me, and have [baby] and sort the flat out and do all the work so that’s been really affected.

Partners often suggested, encouraged or facilitated accessing additional support. However, even with the most supportive partner, it was sometimes felt that partners simply could not understand what mothers had been through during birth and in looking after the baby all day.

Thus, many women spoke about the importance of accessing support and help outside their relationship with their partner. Whilst it was acknowledged that sometimes professional help was necessary, as a first step there was a sense that mothers had to ensure they got out and met supportive peers. Trying hard to talk to people, to find out what was wrong, and to admit that there was a problem were all considered imperative, if difficult. For example, participant 10 spoke of a need to persevere with going to postnatal groups to find one that would suit the mother and be source of support:

I think with all new mums, if there’s support there take it. You know it’s very hard to be sort of, you’re ‘I’m a new mum, I’m going to do it all on my own’ but there will come points where being on your own is very, very isolating, very lonely, um, get out there, go to one or two groups you know, you’re not going to know if they’re for you unless you go.

Nonetheless, it was recognised that seeking support was difficult. Women often did not feel like talking when they were feeling particularly distressed. Similarly, admitting to a problem felt like a compromise of their independence and ability to cope. However, when feelings of distress lessened, it was easy to convince oneself that there was not a problem, sometimes resulting in family or close friends demanding that women sought help. Even if women did want to access help, sometimes they felt that their problems were not serious enough to warrant ‘bothering’ health professionals, as participant 11 recalled when trying to find help with breastfeeding:

The midwives all said ‘Call if you have any problems’ and they did leave a number, but you feel like you’re bothering them, you know, really busy hospital department with people having babies, you don’t really feel like you can phone up and say well I’m having a few problems with breastfeeding.

Action to help move on

When talking about improvements in how they were feeling, most often women brought up how helpful they had found talking on a one-to-one basis. Participant 1 felt that if talking did not directly affect the symptoms of distress, social support was appreciated:

Once people realise that I do have, might possibly have, postnatal depression then I’ve started to feel better because they were talking to me, because they were concerned. I didn’t feel better but I had more people to talk to about it.

Some mothers felt more comfortable discussing distress on a one-to-one basis before being comfortable in groups, but many women found that discussing experiences with others in a similar situation was invaluable, ‘to feel like you’re not the only one who’s completely mad having a baby’ ( participant 5 ). Groups did not need to be highly-structured or run by health professionals but just needed to include other new mothers, as participant 2 described:

You also feel like you’re the only one that’s ever had all these problems, then you sit in a group with ten people all having the same problems as you breastfeeding and you think ‘oh’ that it’s not me, you know, it’s not me, it’s not because I’m a bad mum, it’s because that’s life. So that was definitely a help.

However, some mothers felt that they had not found the appropriate place to discuss their feelings. Participant 6 felt that it would be ‘helpful to be put in touch with other mums in a more similar position’ and Participant 4 related how she wanted, but felt unable, to discuss her birth experience at a local postnatal group:

The parenting class I went to in [village], everyone had relatively good births, so you kind of feel like the black sheep walking in saying mine was really horrible and I hated it and etcetera etcetera because you feel like a bit of a black cloud to everybody else.

Many mothers felt that beyond talking, the experience of ‘purely getting out of the house’ ( participant 14 ) and changing surroundings was important for alleviating distress. Participant 6 described how vital it was for her to leave the house once a day:

The best thing I did was have a plan for getting out the house every day. That was literally my survival plan so, and it really did work . . .at least you’re out and you don’t feel quite as wracked.

Parity, birth trauma and previous mental health

It is acknowledged that factors such as parity, mother’s age, previous mental health condition, lower education and traumatic birth are significant predictors of postnatal distress. It was not our intention however to try and explain the reasons for women’s postnatal distress in terms of socio-demographic or maternal factors. Rather, we attempt to illustrate how mothers themselves come to interpret, understand and make sense of their lived experience of distress. Having said that, some interesting patterns emerged within the sample, each of which is described below.

As noted above, six mothers in the sample (35%) had given birth to a second or subsequent baby (articipants 1, 5, 10, 11, 14, 15). Half of the multiparous mothers reported birth-event related distress (10, 11, 15) compared with 8 of 11 (73%) primiparous women. Although multiparous mothers appeared to be less likely than primiparous to report breastfeeding issues (3 of 6 multiparous compared with 9 of 11 primiparous), it is notable that half of the mothers with more than one baby still reported breastfeeding issues. Multiparous mothers appeared less likely to report feelings of detachment or distancing (2 of 6 multiparous compared with 9 of 11 primiparous). Whereas 7 of the 11 primiparous mothers reported feeling stuck or unable to move on, none of the multiparous mothers did. All except one mother with more than one baby (and all primiparas) were represented by the theme ‘The shock of the new’. All multiparous mothers reported positive experiences of the healthcare system (as opposed to 6/11 primiparas), but all women (regardless of parity) reported feeling uncared for or anonymous at some point. More multiparous (4 of 6) than primiparous women (5 of 11) were represented in the theme ‘Inexperience,’ which suggests that it is important to consider not only experience with a first child, but also with multiple children. All multiparous women who had a partner spoke of increased need of support from them, compared with 4 of the 11 primiparous women. However, only one multiparous woman described new support needs (compared with 8 of 11 primiparous women). Thus, it appears that in our sample, multiparous and primiparous women comparably endorsed themes, even where it may be expected that one group (primiparas) would endorse a theme such as ‘Inexperience’ more.

Traumatic vs not traumatic birth

Eleven mothers (65%) experienced distress related to the labour and birthing experience (articipants 2, 4, 7, 8, 9, 10, 11, 13, 15, 16, 17). Nine of these eleven mothers (82%) spoke of feeling guilty and of blaming themselves, whereas such feelings were reported by only one of the six women who did not experience a traumatic birth. Women who experienced a traumatic birth appeared to have more negative post-natal experiences, they were more likely to speak of feeling distant and detached from their life with their baby (8 of 11 compared with 3 of 6), and more likely to experience difficulties with breastfeeding (9 of 11 compared with 3 of 6). Women who experienced a traumatic birth were more likely to speak of feeling uncared for by the healthcare system (10 of 11 compared with 4 of 6), but a majority in each group spoke of positive experiences of the healthcare system (7 of 11 and 5 of 6). Similar proportions of women who did (6 of 11) and did not experience traumatic births (2 of 6) reported feeling overwhelmed by the responsibility of motherhood, and both groups reported similar support needs.

Previous mental health issue

In our sample, seven mothers (41%) disclosed a previous mental health issue (articipants 1, 3, 7, 8, 10, 12, 14). On almost all themes, similar proportions of women with and without a previous mental health issue endorse each theme. For example, five of the seven (71%) women with a previous mental health issue (compared with 6 of 10 other women) described feelings of distance and detachment from their new life with their baby, and four of the 7 women with a previous issue (compared with 5 of 10 other women) described an increased need of support from their partner. However, it is notable that only one of the seven (14%) women with a previous mental health issue spoke of the overwhelming responsibility of motherhood, whereas 7 of 10 (70%) women without a previous issue reported this.

This study explored experiences of postnatal distress phenomenologically by giving priority to the accounts of women interviewed, outside of diagnosed disorders. The results showed the importance to mothers of multiple factors in their experience of becoming distressed and their journey to feeling better. This discussion focuses on three insightful ways in which women explained their distress. First, through temporal points in the process of becoming a mother; distress around birth experiences and establishing and maintaining breastfeeding. Second, through the psychological processes that characterised and maintained distress states, such as feeling overwhelmed, guilt, avoidance and distancing. Third, the importance to mothers of postnatal support: their old, new and changing relationships, for example with healthcare professionals, partners, and other mothers.

The process of becoming a mother

This study demonstrates the importance of the birth experience to mothers’ subsequent mental health. Birth factors mentioned were largely consistent with previous research which has shown, for example, that low perceived control is associated with low satisfaction with birth, postnatal depression and perceiving the birth as traumatic [ 33 – 35 ]. Furthermore, women in this study corroborated the importance of health-practitioner support in maternal satisfaction with birth, and possibly depression [ 36 , 37 ]. Quality and continuity of care were also perceived by all participants to be key in their experience of distress around the birth and the early days of caring for their new babies. This is consistent with previous research [ 18 , 38 , 39 ]. This study suggests that research into postnatal distress would benefit from including a measure of how well-supported mothers feel by healthcare professionals, with the aim of understanding the relationship between support during childbirth and multiple types of postnatal distress, beyond PTSD, and in informing development of postnatal care.

Breastfeeding rates in the UK are around the lowest of developed countries (81% breastfeed at least once, but only 42% breastfeed for at least 6 months; [ 40 ]). The women in this study wanted to breastfeed but often felt that they had to battle to establish and maintain breastfeeding alone due to the lack of time and lack of practical assistance afforded to helping them in this area by healthcare professionals. Women’s views of having limited support for breastfeeding is consistent with previous research showing that breastfeeding women’s needs for information, practical and emotional support are often unmet due to a lack of health practitioner time and no established relationship with women in need of support [ 41 , 42 ]. Women did not experience a lack of services to assist with breastfeeding but were frustrated at the lack of clarity over which service would provide the help needed. This fits with the national picture that women in the UK felt less supported with breastfeeding in 2010 than they did in 2005, possibly due to a reduction in the number of health visitors [ 40 ]. Of particular importance to women in this study was the all-encompassing nature of feeding problems. With new-born feeding being faced every few hours, the emotions and challenges are compounded, perhaps explaining the definite causal stressor status women attributed to it. It is likely that interventions aimed at resolving breastfeeding difficulties, which could be delivered through primary care, could also resolve emotional difficulties in the mother, as has been the case with other infant-care issues [ 43 ].

Psychological processes

Feelings of being overwhelmed, inexperienced and unsure about their ability to be competent mothers are consistent with previous qualitative research of postnatal depression, anxiety, and posttraumatic stress disorder. A sense of feeling overwhelmed after a traumatic birth merged into feeling a lack of competence at mothering for some women in this study, feelings of guilt, and a struggle to find ways of taking back the mothering role. In this study, breastfeeding was discussed as a way of re-asserting the mother role, a finding observed in other studies [ 25 ]. This suggests that breastfeeding could act as a moderator between traumatic birth experience and subsequent distress states. Outside of the traumatic birth literature, a perceived lack of competence in the mothering role contributed to feelings of anxiety, feeling overwhelmed, loneliness [ 16 ] and depressive symptoms [ 23 ]. Therefore, further research may show that building self-confidence in domains of motherhood could be a valid target for interventions to reduce postnatal distress across disorders.

Mothers’ experiences of avoidance and distancing are also worth further investigation. In a review of coping strategies and maternal well-being, researchers concluded that avoiding focusing on the problematic situation (distancing) is associated with higher odds of developing postnatal depressive symptoms [ 44 ]. Avoidance also comprises one of the symptom clusters of PTSD. Mothers in the present study reported avoidance of emotions, thoughts, breastfeeding and of seeking help. Outside the perinatal literature, there is evidence that overt avoidance behaviour is a transdiagnostic process for which behavioural activation (replacing patterns of avoidance with adaptive patterns) has been an effective treatment [ 28 ].

Social support

Researchers have consistently shown that poor communication with healthcare staff and perceived unhelpful staff attitudes are detrimental to new mothers [ 39 , 45 – 47 ]. The women in this study largely corroborated the negative effect on their wellbeing of feeling ignored, uncared for, or poorly communicated with during birth, the postnatal hospital stay, postnatal home-care and concerning breastfeeding. Conversely, women in this study described a positive effect of the presence of healthcare staff who were parents themselves, who were experienced in the challenges of motherhood and who were able to provide high levels of empathy. This supports previous research showing that feeling ‘mothered’, cared for and listened to helps new mothers to feel confident and well-recovered from birth [ 42 , 48 ]. Regarding in-patient care, Brown et al. [ 45 ] found that the sensitivity and understanding in interactions with caregivers had the greatest effect on women’s ratings of care. The findings of this study confirm that listening and communicating skills of postnatal staff are an important area for development [ 39 ]. The well-voiced view that postnatal services were understaffed and the staff working were perceived as too busy was also apparent for women in this study [ 41 ]. A key issue in perceptions of care is how individual healthcare providers interact with and listen to women [ 39 , 42 ]. In line with research showing that multiple psychological approaches to intervention can be beneficial to a mother’s mental health (e.g., for PTSD [ 49 ]; for postnatal depression, [ 50 ]) it may be that training in listening and counselling skills combined with time to practise these skills with new mothers may be enough to reduce levels of distress.

Social support from a partner is well-documented as being a protective factor against depressive symptoms [ 44 ]. Women in this study spoke of increased demands on their partner but felt that these were largely met and that support was lacking in other areas, primarily from health professionals. Furthermore, the voiced need of mothers to connect with and speak to others in a similar situation was universal. Peer support has led to fewer depressive symptoms in high-risk mothers and this type of support may be useful across different types of distress [ 51 ].

Clear differences between multiparous and primiparous women were not seen in experiences of distress in this sample. This largely reflects the picture from quantitative studies which shows that the relationship between parity and postnatal distress is unclear. In a sample of 5252 Danish mothers of whom 5.5% were depressed at 4 months postpartum, previous psychiatric illness and high parity were important risk factors for developing postnatal depression [ 52 ], whereas in 944 Swiss mothers experiencing distress in the early postpartum days, primiparity was a risk factor for maternal distress [ 53 ].

Concerning birth trauma, it is estimated that up to 30% of women experience subclinical debilitating symptoms of posttraumatic stress disorder after birth [ 54 , 55 ]. Our study was not diagnostic in nature, many mothers reported feeling debilitated by their birth experience. There is also evidence that anxiety and symptoms of posttraumatic stress following childbirth are strong predictors of postnatal depression [ 8 , 56 ].

Previous psychiatric illness is a risk factor for postnatal distress that has been confirmed in multiple large cohort studies [ 8 , 52 ] and seven mothers in our sample disclosed a previous mental health issue. However, these women experience of distress did not qualitatively differ in our sample. Further longitudinal qualitative research to examine the experiences of women who are not distressed antenatally and follow them into the postpartum period would help to address this question.

Limitations

We do not claim that these findings apply to all mothers who have experienced postnatal distress. The sample was self-selected and it is probable that participants were motivated to talk about their experiences and take action. The women who took part were mostly white, well-educated, employed before having their baby, and in long-term relationships. Further exploration with women of different ethnicities, relationship status, and ages would be beneficial to expand on and compare with the findings in our study. It could be considered that using a broad definition of distress (‘any emotional difficulties’) could lead to inclusion of women with normal levels of adjustment difficulties that would dissipate over time. However, all the women in this study experienced distress that they felt they needed extra support with, regardless of diagnosis.

This study has addressed two important issues that need to be explored in order to improve understanding of postnatal distress. The first is how women experience and make sense of their distress. Women clearly explained their emotional difficulties as relating to both key temporal points in the process of becoming a mother (particularly childbirth and breastfeeding) and in terms of psychological processes across different types of distress (particularly feelings of detachment, avoidance, guilt and social comparison). The second issue concerns the aspects of distress mothers felt they needed help with and how they experienced that help. Breastfeeding again emerged as a key area with which women felt they needed support with but which was not easily available. Mothers also felt that they needed support with resolving feelings around traumatic births. A desire to validate and normalise feelings through talking both in groups and on a one-to-one basis with healthcare providers such as midwives or health visitors was universal.

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We thank all the women who gave up their time to be interviewed and Donna Moore for assistance with developing the interview schedule and editing.

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Cognitive-Behavioural therapy and interpersonal psychotherapy for the treatment of post-natal depression: a narrative review

• George Stamou 1 , 2 ,
• Azucena García-Palacios 3 &
• Cristina Botella 3  

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Post-natal Depression (PND) is a depressive disorder that causes significant distress or impairment on different levels in the individual’s life and their families. There is already evidence of the efficacy of psychological treatments for PND. We conducted a narrative review and researched the literature for identifying systematic reviews and studies for the best psychological treatments of PND, and examined what parameters made those treatments successful.

We searched 4 electronic databases. We included reviews and randomised controlled clinical trials for our research. We excluded other types of studies such as case studies and cohort studies.

We followed a specific search strategy with specific terms and a selection process. We identified risk of bias in reviews and studies, and identified their limitations. We synthesized the data based on particular information, including: name of the authors, location, research type, target, population, delivery, outcome measures, participants, control groups, types of intervention, components of treatments, providers, experimental conditions amongst others.

We found 6 reviews and 15 studies which met our inclusion criteria focusing on Cognitive Behavioural Therapy (CBT) for PND.

Among the main findings we found that CBT can be delivered on an individual basis or within a group. It can be effective in the short-term, or up to six months post-intervention. CBT can be delivered by professionals or experts, but can also be practiced by non-experts.

We found 7 components of CBT, including psychoeducation, cognitive restructuring, and goal setting.

We also researched whether virtual reality (VR) has ever been used for the treatment of PND, and found that it has not.

From our review, we have concluded that CBT is an effective treatment for PND. We have explored the utility of VR as a possible therapeutic modality for PND and have decided to run a pilot feasibility study as a next step, which will act as the foundational guide for a clinical trial at a later stage.

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Post-natal depression: Definition, clinical features, risk factors, and effects

Post-partum period has been associated with mood disturbances since Hippocrates’ times [ 1 ]. It is reported that PND started being officially used in psychiatric manuals in 1994 [ 2 ]. It was “officially objectified” in the 1950s [ 3 ]. PND was given some “diagnostic criteria” at that time as practitioners began to notice that some women, after giving birth, would experience a psychological pattern with depressive characteristics.

In the earlier days, science was trying to understand PND in the context of causes. These varied from the socio-economic background of the individual to unplanned pregnancy [ 4 ]. In more recent years, clinicians have gained a better understanding of PND. They give emphasis to the combination of risk factors rather than single causes [ 5 ]. Risk factors can vary from low socio-economic background, family history of depression or personal history of mental health issues, low social support, smoking habits, sexuality issues, and immigration issues [ 6 ].

The Diagnostic and Statistical Manual of Mental Disorders - fourth edition (DSM-IV) [ 7 ] initially linked PND with major depression with post-partum onset within 4 weeks of birth. However, a study for the treatment of PND [ 8 ] highlights the variations amongst studies which define the onset of PND, from the first month up to the end of the first year following the infant’s birth.

The Diagnostic and Statistical Manual of Mental Disorders, DSM-5 [ 9 ] places PND in the category of unspecified depressive disorders where the main symptoms can cause significant distress or impairment on various levels in the individual’s life. PND includes different sub-categories called specifiers, amongst which are the peri-partum onset. This refers to the onset of depression during pregnancy or postpartum for the time following the birth of the child. According to the same manual, a large number of postpartum major depressive episodes begin during pregnancy, thus they are also called peri-partum episodes. These episodes range from mild to severe, with or without psychotic features. The individual may also experience hallucinations or delusions.

A study by Hewitt et al. [ 10 ] describes depression as a very serious mental health problem with important consequences on a societal level. In this study they estimate that depression will become the second-highest health problem by 2020. According to the same authors, PND is considered to be a very important category of depression with often serious consequences. It can affect both the mother and the infant, as well as the immediate and/or the extended family. PND can have long-lasting effects on the development of the infant on a cognitive and emotional level, including attachment issues amongst others [ 11 ].

PND can cause significant distress or impairment on various levels in the individual’s life, e.g. lack of motivation, affected mood, sleep and appetite issues, lack of concentration, rumination, unintentional or intentional suicidal ideation, or psychotic phenomena such as hallucinations or delusions.

PND affects 13% of women [ 12 ], and between 4 and 25% in men in the first 2 months after the baby is born [ 13 ]. Other research suggests that the proportion of mothers who suffer from PND is one in seven [ 14 ]. According to the same article, the mentality of organisations and health providers is changing, especially in the United States where there is a shift towards more systematic screening of mothers-to-be or young mothers who might experience symptoms of depression.

Psychological treatments of PND

Regarding treatment for PND, Rudlin lists its main therapeutic approaches [ 15 ]. They vary from medication, home visits, education, phone contact, one-to-one counselling, group therapy, and self-help resources such as books. CBT, together with interpersonal psychotherapy (IPT) are considered two efficacious non-pharmacological treatments for PND [ 16 ].

A meta-analysis [ 17 ] examined how effective psychological treatments are for PND in primary care. It was found that psychological interventions such as CBT and IPT, along with counselling, psychodynamic therapy and support groups can be very effective in reducing the symptoms of depression up to 6 months post-intervention.

CBT’s main focus is identifying distorted negative thinking patterns. It emphasises the link between thoughts, feelings and behaviour. Dalby [ 18 ] highlights Albert Ellis’s theory of irrational thinking patterns and how they could trigger emotional disturbance to the individual.

A common characteristic of people who suffer from depression is their tendency to experience automatic thoughts, usually of negative content. Beck [ 19 ] highlights that the negative automatic thoughts usually carry negative meaning in relation to the notion of the past or the future, about the individual themselves, and/or the world around the person.

CBT helps the individual to understand that identifying their own distorted negative thinking patterns allows them an opportunity to change them. By changing their thinking, the individual can change how they view and feel about themselves, and ultimately, change their behaviour [ 20 ]. CBT integrates many approaches in clinical practice such as problem solving, modelling, and cognitive restructuring, amongst others [ 21 ].

IPT focuses on four areas in the person’s life: grief about someone’s own sense of self or changes within their relationships, changes in roles, unresolved disagreements in interpersonal relationships, and a lack of life events. It focuses on strengthening the relationships of the individual, on increasing social support, and improves communication [ 22 ].

Conversely, Barlow [ 23 ] refers to the negative effects, or no effects of psychological interventions for various disorders, including trauma and addictions. Dimidjian and Hollon [ 24 ] talk about the adverse effect of psychotherapy, but this is yet to be researched adequately. There is no real agreement in the scientific community about ways to investigate and identify harmful psychological interventions. A review [ 25 ] published by the World Health Organisation (WHO) for psychological interventions on depression discusses the under-investigated but very real possibility of a negative effect of psychological therapies on depression. Some of those effects include the symptomatology of the individual becoming exacerbated or the individual experiencing a “relapse”.

Lambert [ 26 ] makes the point that psychological treatments for depression and other disorders have shown to be effective overall. Positive outcomes depend on the patients’ characteristics, but also the therapists’ “actions” or “inactions”. Lambert also highlights the reality of negative clinical outcomes for patients who experience depression. Lambert does, however, identify ways to minimise clinical negative impact and maximise positive outcomes which can be achieved through “measuring, monitoring, and tracking client treatment response with standardised scales”.

A meta-analysis by Cuijpers et al. [ 27 ], which we did not include in our initial search, investigates the effect of psychological treatments for PND. It was found that CBT, IPT, counselling and social support have an overall positive effect on PND, but they were less effective than what they have been on other psychological disorders. There was no real difference in therapeutic outcome between different psychological therapies. The same study also concluded that medication and electroconvulsive therapy can have higher effect size for PND than psychological treatments but that needs to be further investigated. In addition, it was found that the initial positive therapeutic effect of psychological treatments on PND could not be confirmed 6months or longer post-intervention. However, the authors of this meta-analysis highlight that some of these findings need to be interpreted with caution due to the small number of studies included, and that the quality of the studies was not the highest.

Virtual reality: Definition and its advantages

A question worthy of investigating in relation to the treatments of PND is whether they can be improved for better clinical outcomes using other treatments, such as virtual reality (VR).

VR is defined as “a way for humans to visualise, manipulate, and interact with computers, and it can be viewed as an advanced form of human-computer interface that allows the user to interact immersed in more intuitive and naturalistic fashion” [ 28 ].

VR promotes a sense of presence for the user in an environment which is computer based. According to Turner and Casey [ 29 ], VR can enhance the therapeutic effectiveness of psychological interventions. It expands beyond the strict boundaries of technology. VR is seen as a form of communication. It comprises elements such as an experience, visualisation and interaction [ 30 ].

Some of VR’s advantages in research and practice is that it can act as a powerful and effective tool which can complement traditional therapies such as CBT [ 31 ]. It is a form of therapy which enhances sense of control and raises self-efficacy. It uses technological means to help the individual. It is 3-dimensional and interactive. The VR user has the ability to “explore and engage” within the virtual environment.

VR can be delivered in a safe and controlled way [ 28 ]. It can be affordable, easy to access, and the therapist themselves can have control of how, what and when it is to be applied, which creates a sense of safety for the user [ 32 ]. One of VR’s main features and characteristics is that it can empower the individual, a very basic and essential ingredient in order for therapy to occur. The combination of CBT with VR can have a tremendous positive impact [ 29 ].

VR or virtual reality exposure therapy (VRET) has been used to explore a large number of topics, from stress, anxiety, phobias, acute pain, body image disturbances, eating disorders, training of children in spatial and navigation learning skills, functional skills [ 28 ], post-traumatic stress disorder (PTSD) [ 33 , 34 , 35 ], fear of heights and also fear of flying [ 36 , 37 ].

Improvement of traditional treatments for PND

There appears to be a gap in the literature relating to the combination of VR with traditional therapies for the treatment of PND. A brief literature review so far identified only one study on the efficacy of VR on depression. A pilot study conducted by Falconer et al. investigated the concept of compassion and self-criticism in a virtual environment [ 38 ]. They examined whether compassion could be taught to subjects in a virtual environment. The study revealed that its participants, all adults with depression, were able to practice compassion both as a life-sized avatar and as a child avatar interacting with one another through the process of embodiment. Although this particular study was limited, being a small group ( n  = 15), and having no control group, its results were promising. Results indicated that most of the study’s participants had become more compassionate and less self-critical one-month post-intervention.

Our research group is exploring the utility of using VR in the treatment of PND, the final aim being to improve the treatment that mothers with PND receive. This could potentially be beneficial for the health and well-being of mothers, their families, and society in general. The investigation of the combination of CBT and VR could possibly provide a better treatment for PND from a clinical point of view, which could save on resources including time and money spent at an organisational level.

In order to explore the possibility of combining psychological therapies with VR for the treatment of PND, we decided to review past and current published literature on traditional therapies for PND. We wanted to find out what therapies work best, and under what circumstances. Our investigation researched other reviews, within the same clinical subject area. However, our review differs from other reviews, whether systematic or narrative reviews, in three methodological aspects. It focuses purely on the treatment of PND, rather than prevention, or prevention and treatment of PND. A second difference is that this review investigates mainly CBT as treatment for PND. A third advantage of this review is around population characteristics. We focused our research mainly on the post-partum clinical population and not on other types such as the ante-natal population. However, there was one exception where the clinical population was in the last trimester of their pregnancy in the beginning of the study, but it became post-partum at a later stage. We believe this three research characteristics help this research project make a clear contribution to the literature.

We formulated the design of this review based on the working hypothesis that CBT is a successful treatment for various psychological disorders, amongst them PND. It is a therapeutic approach which is scientific based. It can follow a clinical protocol, where its clinical methods can be replicated. Its clinical efficacy can be tested and measured. We hypothesised that CBT is the most widely used and efficacious treatment for depression and PND.

We searched for specific parameters which we believe contribute to the efficacy of CBT. We wanted to pay particular attention to the types of participants, especially the ones who had been diagnosed with PND through a structured clinical interview. Another parameter was around the types of interventions or treatment components of CBT for PND. We searched for specific aspects of the CBT approach, in particular, cognitive restructuring, goal setting, and problem-solving.

In order to start this line of research and to design our PND intervention protocol, supported with VR, our first aim is to review the scientific literature relating to the most effective CBT treatments for PND. Then to identify the parameters that make those treatments effective. It will also investigate whether VR has previously been used as a treatment for PND.

More specifically, this review will answer the following three research questions:

What CBT psychological treatments are effective for PND?

What are the parameters that make those treatments have a successful clinical outcome?

Has VR previously been used for the treatment of PND?

Studies for this review were selected according to specific criteria. The studies which we included for this review were reviews and randomised controlled trials. Case studies, cohort studies, or cluster trials were excluded. The reason for including randomised controlled trials and excluding other types of studies, such as case studies, was that randomised controlled trials are considered to be the “gold standard of clinical trials” [ 39 ].

We included studies which investigated the treatment of PND. We excluded studies that investigated the prevention of PND or treatment of post-natal anxiety. We included studies where treatments were delivered in home based or in public settings such as clinics or hospitals.

There were no restrictions around the intervention providers in the included studies. They varied from professionals who are experts on CBT or are experts in other therapeutic approaches, General Practitioners, trained nurses, and non-professionals, such as women who had been diagnosed with PND themselves or who had experienced depressive episodes.

The targeted population of this review were 16 years or older. It was a requirement that they had either been diagnosed as suffering from PND and/or reported that they had been experiencing depressive symptomatology through self-report measures. Any studies with a population who were under the age of 16, or with a population that had been diagnosed or were suffering from other mental health or chronic health issues concurrently, in other words if they were mixed samples, were excluded. The mental health issues which were excluded were: personality disorders, developmental disorders, severe depression, anxiety, cognitive impairment, bipolar disorder, and psychotic disorders. The chronic physical health issues were diabetes, neurological disorders, stroke, physically handicapped, gastrointestinal problems, asthma, obesity, Alzheimer’s disease, Parkinson’s disease, and heart problems. Factors such as the socioeconomic background of the participants, educational level and/or marital status did not influence the selection of the targeted population.

For the purpose of this review, we included the following psychological interventions for the treatment of PND: CBT, cognitive therapy, psychoeducation, advice given, cognitive restructuring, behaviour management, goal setting, goal achieving, problem-solving therapy, mindfulness, stress management, relaxation, and breathing exercises.

A randomised controlled trial by Milgrom et al. [ 40 ] which we have also included in our Results Section, and which investigates the efficacy of CBT for PND through the internet, provides a comprehensive CBT model. It is called MumMoodBooster and it consists of six sessions. Each session focuses on different aspects of CBT and PND. The first session focuses on psychoeducation where information about PND and treatments are provided. The second session is about mood management and it talks about stress and anxiety, relaxation, and goals. The third session uses behaviour management where it explores issues such as life balance, goals, time management, and practicing change. The fourth session is about managing negative thoughts, while the fifth session focuses on increasing positive thoughts. The last session is about future planning where it explores the concepts of strategies, new routines, and commitment to change.

In addition the same program provides resources and has information on stress management, finding support, time management, and problem solving. It explores the concept of personal relationships with the focus on the person’s needs and also their partner’s. The program encourages the mother to meet the baby’s needs by “reading the cues” in the baby’s behaviour and to enhance the interaction between them through play. The basic need for sleep and strategies for improving it are also highlighted.

We excluded any studies from other schools of thought in psychology, such as the psychodynamic or humanistic approach, unless they were combined with other psychological approaches such as CBT, or in comparison to it for treating PND. The two main reasons for this choice were that CBT is “one of the best treatments which provides empirical evidence” [ 41 ], while psychodynamic or other psychotherapeutic therapies such as non-directive counselling are “unstructured and non-manualised” [ 42 ].

We included studies with control conditions that met the following criteria: typical primary care, waiting list, GP visits, clinic visits, home visits, anti-depressant medication, postnatal care, enhanced routine care with regular weekly or monthly visits by trained health workers, community treatment, referral to specialty services, and a single session focusing on debrief.

We conducted comparisons between various therapeutic approaches based on the following criteria:

The ratio of success of each treatment;

The duration of success of each treatment in terms of follow-ups. We included studies and follow-ups which varied in duration from one-week post-intervention to up to 5 years post-intervention;

The components of each treatment, e.g. what made each treatment successful.

We included studies in this review that used measures based on self-report questionnaires, such as the Edinburgh Postnatal Depression Scale [ 43 ], a valid and reliable scale that identifies the possibility of risk for the individual to develop perinatal depression [ 44 ], Hamilton Depression Rating Scale, Beck Depression Inventory, Global Assessment of Functioning Scale, Consumer Satisfaction Rating, Revised Clinical Interview Schedule, Therapist Rating Scale, Kruskal Wallis Test, Postpartum Adjustment Questionnaire, Social Adjustment Scale-Self-Report, and the Montgomery-Asberg Depression Rating Scale. We also included other studies which used formal diagnosis of PND based on clinical interviews of manuals such as the Structured Clinical Interview for DSM-III-R and DSM-IV.

We included studies which used measures such as depressive symptomatology, mood, coping strategies, social support, marital relationships, anxiety, social adjustment, relationship quality with partner, mother-infant relationship, suicidal ideation, suicide attempts, level of functioning, quality of life, health status, and sense of well-being.

There were no timing restrictions in terms of when studies were conducted. Studies included all types of settings. We reviewed studies published in the English language. Studies from research sources such as grey literature were not included.

We conducted a narrative review of the literature in four databases: Cochrane, PubMed, Scopus, and PsycINFO. The search took place on the 22nd and 23rd of December 2016. Reference lists of studies that were chosen initially from the four bibliographic databases were also reviewed and acted as secondary sources of information. Those reference lists were scanned, reviewed, and reported in detail accordingly. We also conducted another search in the same four bibliographical databases on the 23rd of December 2017. We wanted to find out whether there had been any published reviews or clinical trials for the treatment of PND from a psychological perspective in the year 2017.

We used 9 terms for our search: “postpartum depression” OR “treatment” OR “cognitive-behavioural therapy” OR “clinical trials” OR “randomised controlled trials” OR “reviews” OR “systematic reviews” OR “follow up”, AND “postpartum depression” OR “treatment” OR “virtual reality” OR “clinical trials” OR “reviews”. Our search took place in two parts. The first part focused on finding reviews and/or clinical studies on effective psychological evidence-based treatments for PND [ 45 ]. The second part focused on finding studies or reviews on VR as a treatment for PND.

We paid particular attention to clinical trials and randomised controlled trials, reviews and systematic reviews, CBT - VR treatment for PND. The search process and the inclusion and exclusion of reviews were cross checked by all authors independently. Any disagreements were resolved through consensus and with the support of an additional reviewer when necessary.

The selection process followed the following three steps:

Screened titles of studies to identify which could possibly fit the inclusion criteria;

Screened abstracts of the already chosen studies to further identify which better matched the inclusion criteria;

Screened the whole text in order to make sure that the studies chosen fit the inclusion criteria of our review.

If the authors identified any areas that needed clarification, they contacted the authors of those studies for ensuring those studies either fit the inclusion criteria or fit the exclusion criteria accurately. We kept a journal in which we recorded the reasons each study was included or excluded during the review process.

For the purpose of avoiding any risk of overlapping reports of the same study and to ensure avoiding bias and/or errors during the extraction data process, the extraction process was initially carried out by one reviewer. Data which focused on specific information, such as demographics, method, interventions, and outcomes were verified by the other reviewer(s) at a later stage. Any identified conflicts, misinterpretations, vague or grey areas were clarified by discussions between the reviewers and/or by contacting the authors of the studies selected, where necessary.

The results from our literature review search were recorded in an Excel spreadsheet with all relevant categories, such as studies, research design, intervention, and population, amongst others. The results were uploaded clearly and concisely based on the inclusion criteria and the keywords used for the search previously described.

We reduced bias and errors as all authors reviewed the studies separately and then later discussed any discrepancies identified.

They also identified the level of bias in terms of reporting. The authors divided the quality of each study into the following categories: yes, low, unclear, not strong, fair, and good. The decision for each of these categories for each study was based on the identification of reporting bias within the studies themselves. We considered issues in relation to selection bias, reporting bias, randomisation process, blinding of the participants, sample size, heterogeneity of methods used, generalisability of results, and limitations of each study.

We initially found 26 reviews in total. We also found 10 additional reviews through reference list searches, bringing the total of reviews up to 36. We examined all 36 reviews’ titles, names of authors, and year of publications and removed 14 reviews as duplicates. We examined the titles and abstracts of the remaining 22 reviews and we excluded 16 reviews as they did not meet the inclusion criteria of our review. We examined the remaining 6 reviews for eligibility and we included them in our review.

We examined the 6 reviews that met our inclusion criteria and we found that they included 106 studies. We examined the names of the authors, and the year of publication, and we removed 12 of those studies as duplicates. We examined the title and abstract of the remaining 94 studies and we removed 79 as they did not meet our inclusion criteria. The final number of included studies was 15 (see Fig.  1 attached). Figure  1 is a flow chart which summarises the process of selection for the studies based on PRISMA template [ 46 ] which had been found up to December 2016. The authors of this review resolved any disagreement through discussion with further consultation from an additional reviewer, where necessary.

Flow chart of study selection process

On our final list were 6 systematic reviews, one of which was a meta-analysis [ 47 ]. All six reviews included treatment studies with two reviews to include both prevention and treatment [ 47 , 48 ]. We found no reviews or clinical trials published in the year 2017 that met our inclusion criteria.

All six reviews initially reviewed 1015 studies, of which 950 were excluded with the total of final studies included 106. The population of the six reviews was 24,231 in total. However review [ 48 ] did not provide the number of participants in the intervention group for two studies [ 49 , 50 ], while in a second review [ 51 ], the number of participants in the intervention group was only reported in one out of the 10 included studies of that review.

There was a mix of pregnant and post-partum women, mothers, newly delivered mothers, and mothers and infants. Some participants had been screened for depression through a clinical interview, while others had reported depressive symptomatology through self-report measures.

The delivery of the interventions was a mixture of community based, including clinics and hospitals [ 47 ], home based [ 48 , 51 , 52 ], and a combination of individual and group therapy [ 47 , 53 ]. One review [ 54 ] did not provide any information relating to the delivery intervention.

It was assumed that the number of interventions equalled the number of sessions, a total of 538.5. Some of the reviews provided information about the number of clinical hours used for the intervention [ 48 , 53 , 54 ], while one review did not provide any information relating to the number of clinical hours [ 51 ]. Some reviews reported missing information about the exact number of interventions in the studies they had reviewed [ 47 , 51 , 54 ].

The outcome measures were varied and included the Hamilton Depression Rating Scale, Beck Depression Inventory, with the most commonly used one being the Edinburgh Postnatal Depression Scale. There was an intention-to-treat analysis in four reviews [ 51 , 52 , 53 , 54 ].

There were a multitude of interventions reported in the six reviews, ranging from CBT, IPT, to psychodynamic, non-directive counselling, infant massage and others. The most frequently used intervention being CBT, followed by the IPT model.

The providers of the interventions were a mixture of professionals from various backgrounds, including psychologists, GPs, nurses and non-professionals such as lay women. There was no available information about the providers in two reviews [ 53 , 54 ]. There is some missing data in terms of the duration of treatment and the number of sessions. We estimated the number of sessions to be approximately 610.5. There was a follow up assessment or intervention in 5 of the reviews, with only one exception [ 48 ].

In order to conduct a deeper analysis of the scientific literature, we applied our inclusion and exclusion criteria and extracted fifteen studies from the six reviews that met the inclusion criteria (see Table  1 ), 13 of them were randomised controlled trials, two studies were cluster randomised controlled trials [ 55 , 56 ], and one was a randomised controlled trial with factorial design [ 50 ]. In the following sections we will describe the characteristics of the studies.

Quality of studies

The quality of the studies varied from not strong to very good, with most to be considered fair.

This was based on the randomisation process, sample size, heterogeneity of methods, use of instruments, treatment protocol, generalisability and statistical significance of results, follow ups, and limitations of each study. Most studies reported bias except five studies for which it was unclear [ 16 , 49 , 55 , 57 , 58 ].

Treatment focus

Fourteen studies focused solely on the treatment of PND, one on the treatment of ante-natal depression and PND [ 56 ], and one on prevention and treatment of PND [ 50 ].

Almost all studies, except one [ 16 ], focused mostly on depressive symptomatology of the mother as a primary outcome measure.

Population studied

In the 15 studies the population, which in total were 2758, were either diagnosed with depression or had identified themselves as depressed. More specifically in six of the 15 studies the population were post-partum women who had been diagnosed through a clinical interview based on the DSM-IV [ 16 , 49 , 57 , 59 , 60 , 61 ]. In one of them, the population were 16 years and older [ 56 ]. In the remaining 9 studies the participants would mostly identify with depressive symptomatology, mostly through interview based questionnaires such as HAM-D, or self-report questionnaires such as EPDS. In 2 out of the 9 studies the populations were “newly delivered mothers” [ 62 , 63 ], and in one study, they were newly delivered mothers with low income [ 64 ].

Control groups

The control groups were made up of participants who would usually receive typical primary care, or they were on a waiting list. However, two out of the fifteen studies in the review did not have a control group [ 49 , 65 ]. For example, the study by Appleby et al. [ 49 ] included four study groups which all received some kind of intervention. The study by Milgrom et al. [ 65 ] included three groups which all had some type of intervention.

In addition, it was not clear what the control conditions were for two other studies [ 58 , 62 ]. For example, in the study by Honey et al. [ 62 ] the control conditions were routine primary care administered by health visitors, and in the study by Bennet et al. [ 58 ] the control conditions were standard primary care with a health visitor. However it was not clear whether, in either studies, the routine primary care involved GP visits, medication, both, or none.

In the remaining 11 studies, the control conditions were as follows: waiting list [ 16 ], health visitors contacting participants, and defining their postnatal care with the use of questionnaires and referring them to their general practitioners [ 55 ], enhanced routine care with regular weekly visits in the last month before birth, 1 month post birth and monthly visits for the next 9 months by routinely trained health workers who received regular supervision but they were not specialised in CBT [ 56 ], routine care in the form of clinic visits [ 50 ], home visits which focused on “child health and development, nurturing mother-child relationship, maternal health and self-sufficiency”, along with receiving treatment in the community [ 59 ], routine primary care which “would be typically provided by the primary health care team such as the general practitioner and health visitors with no additional input from the research team” [ 60 ], antidepressant medication received by control group subjects in a hospital outpatient program [ 61 ], “standard care with 6 weekly clinic visits lasting 20 to 60 minutes” [ 57 ], health nurses who would manage case by case the participants and refer them to other services where appropriate [ 63 ], antidepressant medication, brief psychotherapeutic interventions, GP consult, or referral to specialty services [ 64 ], and a single session with a midwife or obstetrician focusing on debrief [ 66 ].

Delivery of the interventions

In terms of the delivery of the interventions, 12 were individual-based and home visits, 2 were group-based [ 58 , 64 ], and 1 study was carried out on an individual basis and was also group based [ 63 ]. Most interventions were delivered in the homes of the participants. One study was delivered at home and in a public hospital. One study provides no data relating to delivery of the intervention.

Location of the studies

Five studies took place in the United Kingdom, three studies in Australia, two studies in the United States, one study in France, one study in Canada, one in Pakistan, one study in Chile, and one study in Sweden.

Number of sessions and content of the interventions

The interventions in all of the studies varied in terms of the number of clinical hours and number of sessions. The majority of studies provided the number of sessions and number of clinical hours. However, 4 of the 15 studies [ 49 , 56 , 57 , 60 ] provided only the number of sessions and not the number of clinical hours. The total number of clinical hours was approximately 168.5, with 1648 people having been provided with at least one of those interventions. The average number of clinical hours for each participant was 9.78. The average treatment period was 12.1 weeks.

The interventions were CBT based and most studies were a comparison between CBT and usual primary care. However one study compared 4 groups which all received some kind of treatment. The experimental conditions were medication with 1 CBT session, medication with 6 CBT sessions, placebo with 1 CBT session, and placebo with 6 CBT sessions [ 49 ]. Another study also did not have a control group but rather three intervention groups [ 65 ]. 2 CBT interventions included elements of psychoeducation, cognitive restructuring, and relaxation exercises [ 58 , 63 ], one study compared CBT delivered at home vs CBT delivered in a clinic [ 50 ], one study compared the three main interventions, i.e. CBT, non-directive counselling, and psychodynamic, and in comparison with usual care [ 60 ], one study used CBT and the psychodynamic approach [ 5 ], one intervention compared CBT delivered either by psychologists, nurses, and GPs [ 65 ], another study compared CBT in combination with medication vs. primary care [ 61 ], and lastly one study compared interpersonal psychotherapy vs. a waiting list [ 16 ]. In Table  2 we included a summary of the components included in the intervention protocols and the number of studies that used each of the components.

Intervention providers

The intervention providers varied from nurses, psychologists, GPs, health visitors, and midwives. Almost all, except two studies [ 16 , 50 ], included follow-ups varying from 1 week post-partum to 5 years following the birth of the child. The average period of follow-ups was 6.14 months.

Clinical trials using VR for the treatment of PND

We found no clinical trials that used VR for the treatment of PND. However, we found three studies in total [ 40 , 67 , 68 ] which used some form of technology. Two of them [ 67 , 68 ] used video recordings, mostly for supervision purposes. The third study [ 40 ] was internet based for the delivery of CBT.

All fifteen studies included in our review used CBT as the main treatment for PND. However, there were 9 studies which compared CBT to other treatments such as non-directive counselling, psychodynamic and primary care, and 3 studies where CBT was combined with non-directive counselling, psychodynamic and primary care.

It appears that CBT can be viewed as a large clinical territory with many different techniques for the treatment of the same mental health issue. For example, in one study, CBT emphasised psychoeducation [ 64 ] while in other studies CBT focused on challenging negative thoughts and dysfunctional beliefs [ 55 , 57 ]. In another study CBT was part of a wider community based program [ 64 ]. In the study by Rojas, the “purity” of the CBT approach was questionable [ 64 ].

We measured 7 components of CBT that were used for the treatment of PND, which were psychoeducation, cognitive restructuring, problem-solving, behaviour management, goal setting and goal achieving, stress management, and relaxation (Table 2 ).

The two most frequent used CBT interventions were found to be psychoeducation and challenging negative thoughts and beliefs with 9 studies in total having employed both at different times.

The second most frequent CBT intervention that was used was problem solving, while the third most frequently used CBT interventions were goal setting, behaviour management, and stress management.

What are the parameters that make those treatments having a successful clinical outcome?

This review shows the general outcome is that CBT as a therapeutic intervention is effective for the treatment of PND. It has an advantage over primary care for reducing depressive symptomatology in the post-partum period. However, the severity of PND varied in the included studies in our review, with most of the participants to be in the mild to moderate range. Thus it is unknown whether the same positive clinical results of CBT would be obtained for the more severe range of depression.

Another issue that was identified in relation to the effectiveness of CBT was the significance of the results. In five out of fifteen studies [ 60 , 62 , 63 , 65 , 66 ] it was found that their results on CBT’s effectiveness were positive overall but not statistically significant.

It is important to mention that although our review focused on CBT there were studies that compared CBT with other psychotherapeutic approaches that also showed effectiveness. It was found that non-directive counselling and psychodynamic approaches also had a positive effect on the reduction of symptoms of PND. To be more precise in the study conducted by Cooper et al. [ 60 ] which examined CBT, non-directive counselling and psychodynamic therapy, and compared them with typical primary care, it was found that all three interventions were effective. CBT was more effective on cognitive focus, behavioural tasks, and organisation. Nonetheless, the psychodynamic approach was more effective on relationships. It was also superior to the other two interventions in terms of depressive symptomatology according to structured interviews, especially up until the fifth month post-intervention. However, past that point, the initial therapeutic effect of all three interventions had started diminishing. From 9 months onwards up until 5 years post-intervention, the initial therapeutic effect was virtually non-existent.

Other studies have found similar results, whether the outcome is measured by self-reported measures or by a mental health professional conducting a clinical interview. CBT can be an effective treatment for PND in the short-term but its clinical effect long-term is questionable [ 65 ]. The same study measured the combination of CBT with counselling delivered either by a psychologist or a nurse. They found that the two approaches and a third one which was GP management, mainly through medication, had a good overall effect in the treatment of PND. We can conclude that CBT is an effective approach that can be delivered by various mental health professionals of different backgrounds, or even delivered by non-experts, such as lay people, or health visitors [ 56 , 58 ].

It can also be concluded that CBT can be delivered in a flexible manner, whether through a home visit, or in a public place such as a hospital or clinic [ 65 , 66 ]. There does, however, appear to be a preference toward home visits as it is believed to be more convenient and accessible to post-partum women with depression.

In addition to the treatment type and location CBT can be delivered in a brief manner which can have good therapeutic outcomes. According to Wiklund et al. [ 66 ] there is some evidence that brief CBT can benefit PND in the mild to moderate range. However it is worth noting that the population of that study were women who had not been diagnosed with depression but who only experienced signs of depression.

From the studies of this review we can conclude that CBT can also be delivered on an individual level or in a group [ 58 , 63 ]. It seems that the individual delivery of the intervention is preferential and maybe the potential of the group intervention of CBT has not been adequately investigated. We can safely assume though that group intervention might have some advantages over individual treatment such as utilising less resources. At the same time it might be a disadvantage in terms of participants who might be more reluctant to participate initially in a group setting, where its participants share the same psychological experiences. This possibly underlines stigma on a societal level but this needs to be further investigated.

The studies of this review also show that CBT’s positive therapeutic outcome on PND is not impacted by the socioeconomic status of the population. Post-partum women with depression can benefit equally whether they are from a lower-middle income country or high income country. This review includes studies from different countries and continents and are categorised differently according to the GDP per capita, e.g. Australia vs. Chile [ 64 , 65 ].

Another conclusion of this review is around the outcome measures. Most studies in this review measured individual depressive symptomatology in the post-partum period. However, one study [ 16 ] focused on the mother’s depression and measured it as a primary outcome. The authors included additional information, e.g. mother-infant relationship. It is worth mentioning here that the relationship between mother-infant was not in relation to the newborn baby, but rather on the already existing children in the family.

An issue that was raised was in relation to the target disorder and the self-reported measures which were used by the participants of some of the studies. The self-reported measures indicate depressive methodology but they do not necessarily ensure a formal diagnosis of depression. There was a lack of clinical diagnostic protocols in some of the studies.

A difficulty that one of the studies highlights was in relation to CBT. CBT was considered to be time consuming and highly demanding in terms of resource intervention [ 55 ]. Treating PND with populations of low socioeconomic characteristics, or in countries of low to middle income would prove to be a challenging task. Providing treatment to depressed mothers overall has been proven to be a challenging task on its own, especially in relation to the delivery of intervention. It becomes clear that home visits are a preferable way of delivery over GP practice or a public hospital for varying reasons. A young mother, or a mother with a high-demanding household might find it difficult to transport herself outside her home for a number of reasons, including a lack of transportation, money or time.

Another issue that was highlighted in our research was around the stigma of mental health issues. One study highlights the difficulties a clinical population, or mental health professionals might encounter in rural areas or low-income countries [ 56 ]. One way that the authors were able to deal with this issue was to support the idea that the CBT intervention was part of a larger community health program. Another way was that they promoted the idea of the infant’s health and well-being as a priority.

Some studies had a high attrition rate up to 30% but not all of them. It was reported that some participants did not complete the treatment. There was also a variation in terms of their length, and number of phases in the follow up process. All studies except two [ 16 , 50 ] had follow ups with variations in frequency the follow ups were conducted for the majority of the studies and the span of the time period over which this happened, e.g. 2 months versus 5 years.

Almost all studies included different criteria in relation to population, e.g. primiparous vs. pregnant women vs. post-partum women, with different socioeconomic backgrounds and from different countries. We also did not have enough or adequate demographic information for all the included studies, which would allow us further analysis and conclusion reaching in our review process.

Has VR been used in the treatment of PND?

From our investigation, we found no clinical trials that had used VR as a form of treatment for PND. However, we found three studies which used technological means in clinical practice. One study investigated the efficacy of Toddler-Parent Psychotherapy (TPP), for the improvement of parents’ and infants’ mental health [ 67 ]. The technological means that were employed during this study were videotapes which had recorded the interaction between the mother and the infant. However, the videotapes were used for supervision purposes to ensure the “fidelity of the intervention” itself.

Another study investigated whether CBT could be delivered through the internet [ 40 ]. They used a specific program called MumMoodBooster. However, this did not include any VR elements.

A third study used video recordings to assess the interaction between mothers and infants [ 68 ]. The intervention used in the study was infant massage in a support group.

We have identified the lack of clinical trials using VR for the treatment of PND as a gap in the literature. For this reason we are planning to conduct two clinical studies following this review. The first one will be a pilot study which will measure the feasibility of using VR for the treatment of PND. This will act as a prerequisite which will guide us to conduct a clinical trial where we will investigate what effect, if any, VR has on traditional therapies for PND.

Limitations

As a narrative review, this study has some limitations. It is missing some of the qualities and advantages of the methodologies that a systematic review and/or a meta-analysis can provide. This review does not give strong emphasis on the methodological flaws of the initial studies included in it. It also does not provide any statistical analysis of the data of the included studies which could highlight issues around variations in individual studies, heterogeneity, or effect size. In addition this review does not assess risk of bias in a systematic way. It does not use any specific tool to assess bias in regards to allocation concealment, blinding of participants, incomplete outcome data, and selective reporting. This review reports on the quality of studies and the reporting of bias within the studies but rather in a brief and not in-depth way.

Another limitation was around the strict inclusion/exclusion criteria we used, and as a result, the total number of studies included was limited. We excluded studies of different type, such as pilot studies, observational studies, and case studies. We also excluded grey literature such as unpublished data, which otherwise might have offered a different or richer perspective.

We excluded studies which had a different target disorder. In most cases, we included studies only for the treatment of PND. We did not touch upon the prevention of PND, prevention or treatment of ante-natal depression, management of ante-natal or post-natal anxiety or distress.

We decided not to include any studies which did not measure as a primary outcome, the depressive symptomatology of the participants. For example we excluded studies which had different outcome measures such as mother-infant relationship. Although, it is known that the mother’s emotional state can affect the infant in different aspects of their lives at a later stage, such as their cognitive or emotional development. However, for the purpose of this review, we decided to exclude any studies that did not have the depressive symptomatology of the participants as the main or primary outcome measure, which is limiting in itself.

Conclusions

Taking into consideration the limitations of a narrative review, we believe our study contributes to the literature on various levels.

We were able to identify reviews in the literature which had examined various treatments for PND. These varied from psychosocial and psychological interventions, to health promotion, massage, and exercise. However, we wanted to focus on CBT treatments for PND. For this reason, we searched for clinical trials which had used CBT as their main treatment. We were able to extract data on what CBT treatments have been used. We identified 7 main CBT components frequently used for the treatment of PND.

Researching mainly CBT treatments for the treatment of PND is one of the main contributions of this review to the current literature as we offer a rich CBT perspective for the treatment of PND. In other words we subtracted only the studies from the reviews that met our inclusion criteria in relation to types of interventions. For example, review [ 53 ] included 18 studies but only 8 of them met our inclusion criteria as that review investigated not only treatment but also screening of depression ante-natal and post-natal population. We borrowed only 6 out of 10 studies in another review [ 51 ] as it investigated a broader range of treatments for PND. Review [ 49 ] provided us with 4 suitable to our criteria studies out of 6 studies in total due to its focus on treatment but also prevention of PND, while review [ 54 ] with 3 out of 7 studies due to different study designs. Lastly, two reviews [ 47 , 52 ] provided us with only one study each, with the first review having included 10 studies, and the second one with 8 included studies. The reasons were due to different types of interventions and different outcome measurements respectively. In addition, only two studies [ 48 , 56 ] had been used by three different reviews at the same time [ 48 , 51 , 53 ].

Another important contribution of this review was the identification of CBT’s parameters and what makes it an efficacious clinical approach for PND. We identified parameters such as the delivery of CBT, the providers, and what measures were used, amongst others. An interesting finding was that intervention providers come from wide and varied backgrounds, both professionals and lay women.

The multitude of CBT parameters also depicts a richness of therapeutic approaches within the CBT spectrum, which highlights flexibility. CBT can be delivered by various providers, and in different ways. It is a highly effective clinical approach, but it has its clinical limitations. For example, CBT’s efficacy is time limited in the sense that it is effective for up to 6 months. Its impact plateaus after that time.

We also found a gap in the literature indicating there have been no studies using VR for the treatment of PND. This leads us to the question of whether VR could be used as a possible treatment intervention method of PND. The next step will be to test this intervention. We aim to run a pilot study and measure its feasibility as a preparation for conducting a clinical trial at a later stage.

Abbreviations

12 Item General Health Questionnaire

Ainsworth Strange Situation Procedure

Beck Depression Inventory

Bayley Scales of Infant Development

Behavioural Screening Questionnaire

Cognitive-behavioural therapy

Centre for Epidemiologic Studies Depression Scale

Dyadic Mutuality Code

Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition

Diagnostic and Statistical Manual of Mental Disorders – III – R

Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition

Edinburgh Postnatal Depression Scale

Epidemiological Studies Depression Scale

Global Assessment of Functioning Scale

General Health Questionnaire

Goldberg’s Standardised Psychiatric Interview

Hamilton Depression Rating Scale

Human Immunodeficiency Virus

Hamilton Rating Scale for Depression

Interpersonal Psychotherapy

Kessler 10-Item Scale

Mother’s Assessment of the Behaviour of the Infant

Montgomery-Asberg Depression Rating Scale

Major Depressive disorder

Mental Development Index of the Bayley Scales of Infant Development

McCarthy Scales of Children’s Abilities

Neonatal Behavioural Assessment Scale

Outside Treatment Tracking Form

Postpartum Adjustment Questionnaire

Pre-school Behaviour Checklist

Parent-Child Early Relational Assessment

Perinatal Common Mental Disorders

Controlled Psychoeducational Group

Patient Heath Questionnaire

Post-Natal Depression

Post-Partum Depression

Parenting Stress Index

Randomised Controlled Trials

Social Adjustment Scale

Social Adjustment Scale-Self-Report

Structured Clinical Interview for DSM-IV

Self-Reporting Questionnaire

Wechsler Preschool and Primary Scales of Intelligence

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Acknowledgments

We would like to thank Professor Holger Regenbrecht from the University of Otago, New Zealand for his support, and guidance on VR matters.

This review has been funded by WellSouth, the Primary Health network in Otago and Southland, New Zealand. The funder did not have any participation or contribution in the collection of the data, its analysis, and conclusion(s) of this review.

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George Stamou

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All three authors have made substantial contributions to the manuscript, in terms of the identification and development of protocols, design of the study, choice of inclusion and exclusion criteria, selection of studies, critical revision, and identification of potential biases relating to the study. GS was responsible for the collection of the data, its analysis, the interpretation of the results, and the drafting of the manuscript. AG-P carried the co-supervision, critical evaluation and guidance of the research process, and contributed to the final draft of the manuscript. CB carried the co-supervision, guidance throughout the research process, critical evaluation, and ensured the overall scientific and research quality of this review.

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GS works as a Mental Health Practitioner at WellSouth, New Zealand. AG-CB is a Professor of Abnormal Psychology at the Psychology Department at the Universitat Jaume I, Spain. CB is a Full Professor of Clinical Psychology at the Psychology Department at the Universitat Jaume I, Spain.

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Stamou, G., García-Palacios, A. & Botella, C. Cognitive-Behavioural therapy and interpersonal psychotherapy for the treatment of post-natal depression: a narrative review. BMC Psychol 6 , 28 (2018). https://doi.org/10.1186/s40359-018-0240-5

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Postpartum depression: Causes, symptoms, risk factors, and treatment options

• Women and Girls

What is postpartum depression and anxiety?

It’s common for women to experience the “baby blues”—feeling stressed, sad, anxious, lonely, tired or weepy—following their baby’s birth. But some women, up to 1 in 7, experience a much more serious mood disorder—postpartum depression (PPD). (Postpartum psychosis, a condition that may involve psychotic symptoms like delusions or hallucinations, is a different disorder and is very rare.) Unlike the baby blues, PPD doesn’t go away on its own. It can appear days or even months after delivering a baby; it can last for many weeks or months if left untreated. PPD can make it hard for you to get through the day, and it can affect your ability to take care of your baby, or yourself. PPD can affect any woman—those with easy pregnancies or problem pregnancies, first-time mothers and mothers with one or more children, women who are married and women who are not, and regardless of income, age, race or ethnicity, culture, or education.

What are the symptoms of PPD?

The warning signs are different for everyone but may include:

A loss of pleasure or interest in things you used to enjoy, including sex

Eating much more, or much less, than you usually do

Anxiety—all or most of the time—or panic attacks

Racing, scary thoughts

Feeling guilty or worthless; blaming yourself

Excessive irritability, anger, or agitation; mood swings

Sadness, crying uncontrollably for very long periods of time

Fear of not being a good mother

Fear of being left alone with the baby

Inability to sleep, sleeping too much, difficulty falling or staying asleep

Disinterest in the baby, family, and friends

Difficulty concentrating, remembering details, or making decisions

Thoughts of hurting yourself or the baby (see below for numbers to call to get immediate help).

If these warning signs or symptoms last longer than 2 weeks, you may need to get help. Whether your symptoms are mild or severe, recovery is possible with proper treatment.

What are the risk factors for PPD?

A change in hormone levels after childbirth

Previous experience of depression or anxiety

Family history of depression or mental illness

Stress involved in caring for a newborn and managing new life changes

Having a challenging baby who cries more than usual, is hard to comfort, or whose sleep and hunger needs are irregular and hard to predict

Having a baby with special needs (premature birth, medical complications, illness)

First-time motherhood, very young motherhood, or older motherhood

Other emotional stressors, such as the death of a loved one or family problems

Financial or employment problems

Isolation and lack of social support

What can I do?

Don’t face PPD alone. To find a psychologist or other licensed mental health provider near you, ask your OB/GYN, pediatrician, midwife, internist, or other primary health care provider for a referral. APA can also help you find a local psychologist: Call 1-800-964-2000, or visit the  APA Psychologist Locator .

Talk openly about your feelings with your partner, other mothers, friends, and relatives.

Join a support group for mothers—ask your health care provider for suggestions if you can’t find one.

Find a relative or close friend who can help you take care of the baby.

Get as much sleep or rest as you can even if you have to ask for more help with the baby—if you can’t rest even when you want to, tell your primary health care provider.

As soon as your doctor or other primary health care provider says it’s okay, take walks, or participate in another form of exercise.

Try not to worry about unimportant tasks. Be realistic about what you can do while taking care of a new baby.

Cut down on less important responsibilities.

Remember that postpartum depression is not your fault—it is a real, but treatable, psychological disorder. If you are having thoughts of hurting yourself or your baby, take action now: Put the baby in a safe place, like a crib. Call a friend or family member for help if you need to. Then, call a suicide hotline (free and staffed all day, every day):

IMAlive 1-800-SUICIDE (1-800-784-2433)

988 Suicide and Crisis Lifeline Dial 988 (Formerly known as The National Suicide Prevention Lifeline 1-800-273-TALK)

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Download this Brochure (PDF, 476KB)

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中文 (PDF, 513KB)

All translations of the English Postpartum Depression brochure were partially funded by a grant from the American Psychological Foundation.

Crisis hotlines and resources

Postpartum Health Alliance   

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American Foundation for Suicide Prevention

Health Resources and Services Administration

National Women’s Health Center

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Postpartum depression: a case-control study

Affiliations.

• 1 Programa de Pós-Graduação em Ciências Farmacêuticas, Laboratório de Cultura de Células, Universidade Vila Velha, Vila Velha, Brazil.
• 2 Curso Medicina da Universidade Vila Velha, Vila Velha, Brasil.
• PMID: 31581862
• DOI: 10.1080/14767058.2019.1671335

Background: Postpartum depression (PPD) is a mild to severe mood disorder, starting at 6 weeks after birth and with an incidence of approximately 25% in Brazilian puerperae. Its occurrence induce significant aggravations to maternal and child health, however, its risk factors, although known, are little explored for the appropriate diagnosis.

Purpose: To correlate PPD with anxiety, smoking, alcoholism, parity, type of birth, gestational and maternal age, identifying the possible risk factors that increase the probability of a puerpera developing a depressive episode.

Materials and methods: A case-control study performed at the Alzir Bernardino Alves Infant and Maternity Hospital in the city of Vila Velha, Espirito Santo, Brazil. The sample consisted of 227 puerperae. The cutoff point for depression was defined as >10 points according to the Edinburgh Postnatal Depression Scale (EPDS), and cutoff points for anxiety were defined as <33 points for low anxiety, between 33 and 49 for moderate anxiety and >49 for high anxiety according to the State - Trait Anxiety Inventory (STAI-T).

Results: 29.1% of the 227 interviewed puerperae presented PPD and were considered "cases", with the remaining being considered as "control". There was a positive correlation between PPD and anxiety. No significant correlation was observed for the other risk factors. Women with moderate anxiety presented 17.38 times more probability to develop depressive episodes, and puerperae with high anxiety presented 273 times more chance of developing PPD.

Conclusions: Our results evidenced a high percentage of puerperae with PPD related to maternal anxiety, demonstrating the importance and the necessity of increasing care for women's mental health in the gestational and puerperal periods.

Keywords: Anxiety; Edinburgh Postnatal Depression Scale; case-control study; mental health; postpartum depression.

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• Contextual-relationship and stress-related factors of postpartum depression symptoms in nulliparas: a prospective study from Ljubljana, Slovenia. Rus Prelog P, Vidmar Šimic M, Premru Sršen T, Rus Makovec M. Rus Prelog P, et al. Reprod Health. 2019 Sep 18;16(1):145. doi: 10.1186/s12978-019-0810-x. Reprod Health. 2019. PMID: 31533847 Free PMC article.
• Sociodemographic and clinical features of postpartum depression among Turkish women: a prospective study. Turkcapar AF, Kadıoğlu N, Aslan E, Tunc S, Zayıfoğlu M, Mollamahmutoğlu L. Turkcapar AF, et al. BMC Pregnancy Childbirth. 2015 May 3;15:108. doi: 10.1186/s12884-015-0532-1. BMC Pregnancy Childbirth. 2015. PMID: 25935726 Free PMC article.
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Postpartum Depression: Etiology, Treatment, and Consequences for Maternal Care

Daiana anne-marie dimcea.

1 Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; [email protected] (D.A.-M.D.); [email protected] (M.C.D.); [email protected] (C.M.); [email protected] (A.P.)

Răzvan-Cosmin Petca

2 Department of Urology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania

3 Department of Urology, “Prof. Dr. Th. Burghele” Clinical Hospital, 050659 Bucharest, Romania

Mihai Cristian Dumitrașcu

4 Department of Obstetrics and Gynecology, University Emergency Hospital, 050098 Bucharest, Romania

Florica Șandru

5 Department of Dermatology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; [email protected]

6 Department of Dermatology, Elias University Emergency Hospital, 011461 Bucharest, Romania

Claudia Mehedințu

7 Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, 011171 Bucharest, Romania

8 Department of Obstetrics and Gynecology, Elias University Emergency Hospital, 011461 Bucharest, Romania

Associated Data

Not applicable.

Postpartum depression (PPD) is a disabling condition that has recently shown an increase in prevalence, becoming an essential public health problem. This study is a qualitative review summarizing the most frequent risk factors associated with PPD, evaluating molecular aspects of PPD and current approaches to detect and prevent PPD. The most prevalent risk factors were detected in the areas of economic and social factors, obstetrical history, lifestyle, and history of mental illness. Research on the genetic basis for PPD has taken place in recent years to identify the genes responsible for establishing targeted therapeutic methods and understanding its pathogenesis. The most frequently studied candidate gene was the serotonin transporter gene (SERT) associated with PPD. Among biological studies, antidepressants and psychological interventions provided the most evidence of successful intervention. The obstetrician can serve an essential role in screening for and treating PPD. Postpartum women with risk factors should be screened using the Edinburgh Postnatal Depression Scale (EPDS), but, at the moment, there are no prevention programs in Europe. In conclusion, data from this review increase concerns among this vulnerable population and can be used to design a screening tool for high-risk pregnant women and create a prevention program.

1. General Features

Depression is one of the most disabling conditions for women of childbearing age. For women worldwide aged 15–44, after HIV/AIDS, it is the second leading cause of total disability [ 1 , 2 ].

Postpartum depression (PPD) (also known as peripartum depression or major depressive disorder with peripartum onset) is defined according to DSM-5 diagnostic criteria as a depressive episode that begins during pregnancy or the first four weeks after birth; however, women remain at risk of developing depression several months after childbirth [ 3 ]. In the case of some women, a recurrence of depression occurs after birth, while other patients experience the first symptoms in the postpartum period [ 4 ].

Prior studies have shown that the worldwide prevalence of PPD until 2017 would range from 9.5% in high-income countries to 20.8% in middle-income regions and around 25.8% in low-income nations [ 5 , 6 ].

A systematic review of 291 studies from 56 countries conducted in order to report PPD prevalence found a global pooled prevalence of PPD of 17.7% (95% CI: 16.6–18.8%), highlighting the significance of addressing this condition as a critical public health concern [ 7 ]. These estimates are similar to the 19% prevalence for PPD derived from studies of relatively low- and middle-income countries [ 8 ]. In India, postnatal depression is a frequent occurrence, and, according to recent statistics, the incidence is between 19.8% and 23.3% [ 9 ]. In developing countries, such as Romania, the prevalence of PPD cases is the highest [20.14 (range: 16.39–24.50)] compared to upper-middle and high-income countries [ 10 ]. According to the largest meta-analysis of PPD to date, the global prevalence of postnatal depression is 17.22% (95% CI: 16.00–18.51) [ 11 ]. Moreover, the results of the studies that analyzed the prevalence of postnatal depression during the COVID-19 pandemic indicate a two-fold higher incidence of postnatal depression cases compared to the non-pandemic period [ 12 ].

Untreated PPD has a negative impact on both mother and infant. Studies have indicated the risk to children of untreated depressed mothers (compared to mothers without PPD), including problems such as poor cognitive functioning, behavioral inhibition, emotional maladjustment, violent behavior, externalizing disorders, and psychiatric disorders with onset in adolescence [ 13 ].

Despite the increase in PPD incidence in recent years, there are multiple barriers to the provision of optimal clinical care for women with this condition. The majority of women decline to seek professional assistance due to the social stigma associated with mental illness. Finally, doctors may fail to catch the onset of depressive symptoms or consider them insignificant, which leads to underdiagnosis or undertreatment of the mental condition [ 4 ].

The aim of this review was to cover a broad range of issues in PPD, such as risk factors, with particular attention to ones that may be useful to identify at-risk pregnant and postpartum women; psychiatric diagnosis and biological diagnosis; clinical manifestations of PPD; genetic background associated with PPD; psychotherapy and pharmacotherapy trials, with an emphasis on therapy modifications that are specific to PPD; the use of antidepressant medication for breastfeeding mothers; the role of obstetrical–gynecologist specialists in the detection women at risk for PPD; and the public health context, with a particular emphasis on screening and management in primary care.

2. Epidemiological Factors

There is evidence that biological factors, such as hormonal factors, genetics, and immune function, among other types of causes, play an essential role in triggering PPD [ 14 ].

• (a). The following demographic risk factors can be grouped according to the strength of association with PPD: depression and anxiety in pregnancy, history of depression, excessive stress caused by life events, poor marital relations, lack of social support, and low self-esteem are strongly associated with PPD [ 15 ]. On the opposite side, low socioeconomic status, single marital status, and unwanted pregnancy are considered to have a weaker association with PPD [ 16 ].
• (b). Regarding obstetrics risk factors, Mayberry et al. reported a higher predisposition of depressive symptomatology in multiparous patients compared to nulliparous [ 17 ]. In a study conducted by Mathisen in 2013 that studied 86 mothers in the first six weeks postpartum, it was shown that women with two or more children are associated with a higher risk of the onset of depressive symptoms because of psychological distress [ 18 ]. Furthermore, the following are also considered obstetrical risk factors: a high-risk pregnancy requiring cesarean section, perinatal complications, and incapacity to breastfeed [ 18 ].
• (c). PPD may also be associated with different sensitivity to hormonal fluctuations [ 19 ]. A study conducted by Trifu S. et al. showed that the dramatic drop in the progesterone hormone after birth may have a role in PPD. A possible explanation is represented by the association between its reduction and decreased irritability. Furthermore, estradiol hormone levels decrease in order to stimulate lactation. The decreased estradiol level deprives the body of a natural defense to fight against depression while having an essential role in serotoninergic transmission by enhancing serotonin synthesis [ 20 ]. In addition to sensitivity to estrogen and progesterone fluctuations, biological theories have demonstrated that other changes, such as those of gonadal hormones but also neuroactive steroid levels after birth, altered cytokines and hypothalamic–pituitary–adrenal (HPA) axis hormones fluctuations, acid-altered fats, and oxytocin and arginine vasopressin levels are involved in the production of PPD onset in predisposed women [ 21 , 22 ]. The involvement of the serotoninergic system was suggested by other studies that evaluated altered platelet serotonin transporter binding and decreased postsynaptic serotonin 1-A receptor binding in the anterior cingulate cortex and mesial temporal cortex [ 23 , 24 ]. Protein-enriched foods reduce tryptophan and serotonin levels in the brain, while carbohydrates have an antagonistic effect. In nutritional deficiencies, low doses of tryptophan (a serotonin precursor) increase the rate of development of postpartum depressive symptoms [ 25 ]. Oxytocin also plays an important role in emotion regulation and higher doses of oxytocin in the second trimester of pregnancy were predictors of postnatal depression in the first two weeks after birth [ 26 ].
• (d). Social support refers to emotional support, intelligence support, and empathic relationships. Reducing social support is the most important environmental factor in the onset of PPD and anxiety. Husband abuse and other forms of domestic violence during pregnancy are seen as contributing factors to the increase in the incidence of PPD [ 27 ]. Another social factor is employee status. Mostly, women with professional careers are thought to be associated with a reduced risk of PPD [ 28 ]. Based on the finding from Lewis et al.’s study that evaluated the relationship between employment status and depression symptomatology among women at risk for PPD, it was demonstrated that postpartum women who are employed were less likely to report higher depression symptomatology than unemployed women. The study found that the protective effect of employment on PPD also occurs in women who are at an increased risk of depression [ 29 ].
• (e). Multiple lifestyle factors have been associated with the risk of depression in general, including substance abuse, smoking, nutrition, sleep, physical activity, or vitamin D deficiency [ 30 ]. Findings from the GUSTO cohort published in 2020 that evaluated the cumulative risk of lifestyle behaviors on depressive symptoms during pregnancy and after delivery have shown that women with at least four risk factors had at least a sixfold higher prevalence of having depression compared to those with zero or one risk factor. Sleep appeared to be the most substantial contributor to depressive symptoms, according to statistical analysis, as women may experience difficulty sleeping due to normal changes of pregnancy in their bodies. On the opposite level, vitamin D concentrations and MET minutes of physical activity contributed the least to the variance of an analytical sample [ 31 ].

Biological factors and social factors create intertwined rings that make women susceptible to PPD by affecting each other. Furthermore, many environmental factors, such as socioeconomic factors, cause crisis conditions and PPD by influencing mental health during pregnancy [ 32 ].

3. Gene Expression Profiles: Molecular Aspects of PPD

Research on the genetic basis for PPD has taken place in recent years to identify the genes responsible for establishing targeted therapeutic methods and understanding its pathogenesis [ 33 ]. Recent studies have focused on this issue and support the existence of an underlying genetic vulnerability to PPD, but it is still quite inconclusive whether this vulnerability is different from or correlated with the genetic susceptibility of other psychiatric conditions [ 34 , 35 ]. A recent study conducted in Sweden on 3.427 twin patients and over 500.000 sisters concluded that the heritability in PPD is 54% for the first category and 44% for the second category [ 36 ].

Most of the molecular genetic studies on PPD have focused on candidate genes. These studies have selected and tested a small number of candidate genes or genetic variants for association with a phenotype. These candidates were chosen based on the assumption that the gene products influence the phenotype through a hypothesized biological mechanism [ 37 , 38 ]. A number of candidate gene studies have been conducted in PPD, but it is considered that most of the candidate gene studies are thought to play a role in major depressive disorder (MDD) rather than PPD [ 33 ].

The most frequently studied candidate gene was the serotonin transporter gene ( SERT ), which presents two primary polymorphisms, of which the 5-HTTLPR polymorphism is the most frequently associated with PPD. There is evidence for the role played by the SERT gene in PPD; however, studies show variable outcomes [ 25 , 39 ]. Studies evaluating 5-HTTLPR have demonstrated a positive pattern when PPD is measured in the immediate postpartum period (up to 8 weeks) and a negative pattern when measured at a larger interval [ 33 ]. A recent study conducted on 276 postpartum women in Brazil that evaluated the role of serotonin transporter gene polymorphism ( 5-HTTLPR ) and stressful life events regarding the risk of PPD symptoms found similar results as a study conducted by Sanjuan et al. that showed that depressive symptoms were associated with high-expression 5-HTT genotypes only in the early postpartum period. The authors suggested that the rapid uptake of serotonin in L allele carriers, combined with the reduced availability of brain tryptophan during the postpartum period, could increase depressive symptoms during this time [ 25 , 39 ].

The catechol-O-methyltransferase ( COMT ) gene codes for enzymes that break down catecholamine neurotransmitters, including epinephrine, norepinephrine, and dopamine. It has been studied before for its association with stress, depression, and anxiety. Still, unfortunately, results obtained in different studies were inconsistent [ 33 ]. In a study conducted on 116 women of Brazilian–Caucasian descent, it was found that Val158Met COMT polymorphism was associated with postpartum depressive symptoms. According to the same authors, this polymorphism has been found to be associated with both major and bipolar depression; but, also, many negative results were published, rendering any conclusion hazardous [ 40 ].

Oxytocin plays an essential role in regulating emotions, social interactions, and stress. A recent study has shown a significant interaction between the rs53576 genotype and the presence of prenatal depression on PPD ( p = 0.0081), and further details showed that women who do not display depression in pregnancy but who harbor the rs53576_CG genotype are three times more likely to develop PPD in comparison to women with lower methylation levels. This was the first investigation of the oxytocin receptor ( OXTR) as a potential clinical genetic biomarker associated with PPD and further research is required. The biologically at-risk women in this study did not display elevated symptoms of depression in pregnancy but went on to display an increased risk of PPD after birth [ 41 ].

Estrogen receptor ( ESR ) genes are considered candidate genes for PPD, and, from its subtypes of estrogen receptors, only ESR 1 has been studied in relation to PPD. In a pilot study published in 2013 by Pinsonneault J.K. et al., association analysis of PPD and polymorphisms in ESR1 showed that two variants in the ESR1 gene, the TA repeat ( p = 0.07) and rs2077647 ( p = 0.03), were significantly associated with EPDS scores in 156 postpartum women. One of the limitations of the study was a notably small sample size, which led to low power and needs to be replicated in larger samples [ 42 ]. Furthermore, ESR2 has not been studied in PPD, and knowing its role in estrogen signaling may also be productive [ 33 ].

The monoamine oxidase A ( MAOA) gene codes for enzymes that break down amine neurotransmitters, including serotonin, dopamine, and norepinephrine. During the last 15 years of work, promising studies have shown a positive association between MAOA gene polymorphism and PPD. Two of these studies were positive at six weeks postpartum and negative at 3 and 6 months postpartum [ 43 , 44 ]. In the first study, the main finding was the association between PPD symptoms six weeks after delivery and the COMT-Val 158 Met polymorphism alone and in interaction with functional monoaminergic polymorphisms and environmental stressors. The COMT-Met 158 allele has been associated with major and bipolar depression, adverse response to antidepressant treatment, anxiety disorders, and brain activation elicited by aversive stimuli [ 43 ].

The AKR1C2 (aldo-keto reductase family 1) gene encodes AKR1C2 (aldo-keto reductase family 1, members C2) and influences the relative levels between progesterone and allopregnanolone in humans by regulating the synthetic pathway from progesterone to allopregnanolone, which may be intrinsic to the hormonal fluctuations in patients with PPD. Women with the AA genotype of SNP rs1937863 at AKR1C2 gene are associated with lower allopregnanolone levels and lower depression scores, suggesting that AKR1C2 variants may alter susceptibility to depressive symptoms by affecting central progesterone synthesis, which is not a major factor in the development of PPD [ 45 ]. However, the AKR1C2 gene can be used as a candidate gene to study the level of progesterone and allopregnanolone, AKR1C2 gene polymorphism, and PPD.

In recent years, there have been multiple genes extensively studied to demonstrate an association with PPD, such as the brain-derived neurotrophic factor ( BDNF ) or hemicentin-1 gene ( HMNC1 ), which have shown a modest association [ 46 , 47 ]. On the basis of these data, the BDNF Met allele is associated with an increase in anxiety-like behavior in females that emerges during the period of sexual maturity. It has been suggested that women carrying the BDNF Met allele may be more sensitive to the potential impact of reproductive hormones on anxiety and depressive disorders [ 46 ]. The gene HMCN1 may contain polymorphisms that confer susceptibility to postpartum mood symptoms, being particularly expressed in the hippocampus, a brain region involved in depression. Twenty-seven single nucleotide polymorphisms ( SNPs ) in HMCN1 were significant ( p < 0.05), suggesting an association with PPD, but future studies replicating these findings are mandatory [ 47 ].

The genetic risk for PPD may have a component that overlaps with the genetic risk for major depressive disorder (MDD) and/or bipolar disorder and, in addition, a component that is specific to PPD itself. Candidate gene association studies and heritability studies indicate a more substantial genetic basis when PPD occurs in the early days after birth. Further exploration of PPD-associated genes is justified and requires more extensive studies in the coming years. Ultimately, the identification of the genetic underpinnings of this disorder may bring into light the biological basis for mood disorders more generally ( Table 1 ) [ 33 ].

Genetic expression profiles associated with onset of PPF [ 25 , 33 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 ].

SERT —serotonin transporter gene; COMT —catechol-O-methyltransferase gene; OXTR —oxytocin receptor gene; ESR1 —estrogen receptor 1 gene; MAOA —monoamine oxidase A gene; AKR1C2 —aldo-keto reductase family 1 gene; BDNF —brain-derived neurotrophic factor; HMNC1 —hemicentin-1 gene; 5-HTTLPR —serotonin-transporter-linked promoter region; Val 158 Met —catechol-O-methyltransferase gene functional polymorphism; rs53576_CG —oxytocin receptor gene polymorphism; TA repeat; rs2077647 —estrogen receptor 1 gene polymorphisms; SNP rs1937863 —aldo-keto reductase family 1 gene polymorphism; BDNF Met —brain-derived neurotrophic factor polymorphism.

4. Clinical Presentation of PPD Onset: Diagnostic Criteria and Screening for Women at Risk of PPD

According to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5; 2013), PPD occurs when a person meets the criteria for a major depressive episode during the first four weeks postpartum; however, women are at risk of developing depression several months after birth [ 3 , 4 ]. Some patients show a recurrence of depression after delivery, while others develop the first symptoms in the postnatal period [ 3 ]. Risk factors for PPD include depression during pregnancy, anxiety during pregnancy, stressful life events during pregnancy or the early puerperium, low levels of social support, and a personal or family history of depression [ 4 ].

The diagnosis of major depressive syndrome requires the patient to meet at least five of the characteristic symptoms occurring on several days over a period of at least two weeks and producing significant interference or distress in daily life [ 4 , 48 ]. A general status altered by the use of substances (such as drugs, alcohol, or medication) or that is the result of a medical condition is not considered a criterion for the diagnosis of a major depressive episode.

The signs and symptoms of PPD are identical to those of non-puerperal depression, with the exception that the former is associated with a history of childbirth [ 49 ].

PPD is differentiated from two other entities of emotional impairment in the postnatal period mentioned in DSM-IV. The postpartum blues (often called “baby blues”) represents a transient and mild behavioral change that begins in the first week postpartum and lasts from a few hours to a few days. Characteristic symptoms include uncontrollable crying, psycho-emotional lability, anxiety, and insomnia. Between 50% and 80% of postnatal patients experience the blues, but the consequences are minimal. In comparison, patients suffering from postnatal psychosis experience symptoms such as confused thinking, disillusionment, hallucinations, and disorganized thinking. The prevalence of postpartum psychosis is between 1 in 500 cases and 1 in 1.000 patients. The duration of postpartum psychosis varies and requires rapid diagnosis and hospitalization. According to DSM-5, all mood and psychotic symptoms occurring during pregnancy or within the first four weeks following delivery are referred to as peripartum mood or psychotic episodes [ 3 , 48 ].

A meta-analysis conducted by Gavin et al., who diagnosed patients with PPD employing the structured interview, reported that the combined prevalence of major depressive episodes varies between 6.5% and 12.9% in the first 6 months postpartum, with a peak incidence between 2 and 6 months after delivery [ 50 ]. Another cohort study conducted in Denmark reported that the first three months after birth present an increased risk of the onset of psychiatric conditions in primiparous patients [ 51 ].

These findings emphasize the need for obstetricians to assess patients for psychiatric history correctly and, with the help of psychiatrists, optimize the treatment of mothers in the peripartum period [ 4 ].

Women who are at risk of postnatal depression should be identified as early as possible in pregnancy so that assessment and treatment can be initiated promptly [ 52 ].

Over recent years, there has been an increase in focus on the importance of the early detection and treatment of depression during pregnancy. Screening can be performed four to six weeks in the postpartum period. Several methods of detecting depression symptoms among women have been tested [ 52 ].

During the history taking of the patient by the obstetrician, special attention should be paid to the personal or family history of depression, postpartum psychosis, or bipolar disorder. Once depressive symptoms have been identified, a comprehensive evaluation of risks that influence the clinician’s treatment recommendations should be performed. Furthermore, patients should be assessed for social support, substance use, or partner abuse. The evaluation of patients should include a complete mental status examination and a physical examination to determine if the symptoms suggest a medical cause. In this context, laboratory investigations (including dosages of hemoglobin and thyroid hormones) are necessary [ 53 ].

Patients with risk factors should be screened with the Edinburgh Postnatal Depression Scale (EPDS) [ 52 ]. This validated instrument consists of 10 items and has a completion time of approximately 5 min. It also includes a question about suicidal ideation proposed by Cox et al. in 1987 [ 52 ]. Each question is scored on a scale of zero to three. Established cut-off values (a score greater than 10 is suggestive of a mild depressive episode and a score of 13 or more is suggestive of a moderate or severe depressive episode) allow clinicians to identify women at increased risk of PPD requiring additional clinical evaluation [ 54 ]. The best time to screen for PPD with this tool is in the first month after giving birth. A study conducted in Hungary between 2010 and 2011 that applied this tool to assess patients who gave birth in the last 6 to 8 weeks showed that the application of this scale demonstrated good reliability and internal consistency after applying statistical analysis [ 55 ].

The Postpartum Depression Screening Scale (PDSS) is also used as a screening tool for the detection of PPD, evolving from qualitative interviews to exploring the postpartum maternal experience. The first part comprises seven items; patients with a PDSS score ≥ 14 receive an extended questionnaire with another 28 items. A score ≥ 60 suggests a risk of a minor or major depressive episode; a score ≥ 80 is predictive of a major depressive episode. The PDSS scale has been used effectively in telephone assessment but presents an increased risk of false positive results that restrict its usefulness [ 52 , 56 ].

The Patient Health Questionnaire (PHQ-9) is a 9-item scale with two components used in the analysis of symptoms and functional imbalance in the diagnosis of depressive syndrome. It is also used to make a severity score to assess the effectiveness of treatment. The total score can range from 1 to 27 and can be classified from mild to severe forms of depression. The high sensitivity (88%) and specificity (88%) of the method ensure validity for the identification of risk factors [ 56 ].

The Edinburgh Postnatal Depression Scale (EPDS) and Postpartum Depression Screening Scale (PDSS) are used specifically for the diagnosis of postnatal depression, while the Patient Health Questionnaire (PHQ-9) is recommended for the diagnosis of depression in psychiatric medical institutions [ 54 ].

In a study conducted by Chadka-Hooks et al. in which the original Edinburgh Postnatal Depression Scale (EPDS) was used to assess screening practices in the healthcare system (including obstetricians, pediatricians, and family physicians) to assess familiarity with PPD screening methods, it was shown that healthcare providers are not familiar with screening methods [ 57 ].

Acceptability for the assessment of PPD is an important indicator of the likelihood that patients will respond to questionnaires to inform about their risk of depression [ 56 ]. In a study led by Matthey S. et al., the researchers showed that patients who readily agreed to complete the Edinburgh Postnatal Depression Scale (EPDS) had a lower risk of PPD. Thus, in the case of 87% of the studied group, no discomfort was felt in completing the questionnaire; these patients had EPDS scores < 13, compared to 64% of women at high risk and with EPDS scores ≥ 13 (chi-square = 31.9, df = 2, p < 0.0001) [ 58 ]. Therefore, the perception of discomfort with PPD screening is closely related to the risk of developing depression [ 56 ].

Although screening for the detection of perinatal depression is becoming more and more accepted both in the United States of America and in Europe, there are controversies regarding the possibility of overidentifying patients at risk or over-pathologizing behavioral symptoms in the postpartum period or the inability of the system to provide the necessary treatment and follow-up. These issues are currently unresolved. However, in recent years, much work has been conducted to develop new therapies or adapt existing ones used in PPD. Thus, current studies have demonstrated the importance of screening methods for the early detection of PPD [ 59 , 60 ].

5. Alternative Predictors Used in PPD Diagnosis

The diagnosis of PPD can be performed in multiple ways. The DSM-5 is used to guide an interview design, and self-report tools, such as questionnaires, have been extensively employed in the clinical evaluation of PPD. However, using only such arbitrary scales could result in subjective bias. In order to improve diagnostic accuracy, the most efficient method in clinical practice is to apply some objective markers in addition to these subjective assessments [ 61 ]. Consequently, the endocrine system profile is considered, together with a self-rating scale, clinic interviews, and hormones of the hypothalamic–pituitary–adrenal (HPA) axis [ 62 ]. In PPD, there are three important HPA axis hormones that have been investigated because of the psychological changes mothers experience: the corticotrophin-releasing hormone (CRH), the adrenocorticotropic hormone (ACTH), and cortisol [ 63 , 64 ].

During pregnancy, childbirth, and lactation, the HPA axis and level of hormones modify severely, especially in the last weeks of pregnancy when cortisol levels rise most steeply, reaching levels three times higher than in non-pregnant women [ 65 ]. Rather than the HPA axis, the placenta is principally responsible for the higher basal cortisol concentrations during pregnancy. The placenta progressively takes over the function of the endocrine gland throughout pregnancy. In addition to producing progesterone and estrogen, the placenta also produces pCRH, which shares structural and bioactive similarities with hypothalamic CRH [ 66 ]. Cortisol levels rise during parturition, more noticeably after vaginal delivery. The difficulty of labor may contribute to an increase in cortisol levels. After delivery, plasma CRH concentrations return to preconception levels within 15 h. [ 67 ]. Women with significant depression had reduced cortisol stress responses. A study conducted by O’Connor et al. demonstrated that a diagnosis of depression in mothers was significantly associated with cortisol levels. The results from this study indicate that the strongest effect was that women with a diagnosis of depression had a lower initial waking level (depression × wakeup) [ 68 ].

Progesterone level and PPD have a strong connection. It has been demonstrated that the level of allopregnanolone increased steadily during gestation and then sharply decreased following birth [ 69 ]. A study conducted by Osborne L.M. et al. showed an association between a low level of allopregnanolone during the second trimester and higher depressive symptoms at six weeks postpartum, although it did not reach statistical significance in the adjusted model [ 70 ]. Also, lower levels of oxytocin are linked to an increased risk of PPD development in both gestational and postpartum periods. Jobst A. et al. demonstrated in one study that oxytocin plasma levels decreased from late pregnancy to the time of delivery in the depressed group, whereas oxytocin plasma levels increased continuously from pregnancy to the postpartum period in the non-depressed group. This difference in the course of oxytocin levels was significant and predicted postpartum depressive symptoms [ 71 ].

There is evidence that the thyroid hormone, which has been associated with severe neurological impairments, may enhance the risk of PPD due to its aberrant expression in the early postpartum period [ 72 ]. There is a positive association between a high thyroid stimulating hormone (TSH) (defined as >4 mIU/L) with free thyroxine (fT4) within the normal pre-pregnancy range at delivery and the development of self-reported depressive symptoms six months postpartum [ 73 ]. The presence of thyroid peroxidase antibodies (TPO-ab) during early gestation is predictive of both autoimmune thyroid disorders and depression. A positive TPO-ab status was associated with an increased risk for first-onset depression at four months postpartum (adjusted OR: 3.8; 95% CI: 1.3–11.6), but not at other postpartum time points [ 74 ].

It has been demonstrated that in the third trimester of pregnancy, proinflammatory cytokine levels are significantly greater, and these women are also at risk of developing PPD. The presence of a proinflammatory state throughout late pregnancy and the early postpartum period is essential to increase the risk of PPD [ 75 ]. Elevated levels of the potent proinflammatory cytokine interleukin 1β (IL-1 β) very early in the postpartum period increase a woman’s risk of developing symptoms of depression [ 76 ]. Furthermore, the serum levels of IL-6 after delivery were significantly higher in women with PPD. The optimal cut-off value as an indicator for screening was estimated to be 24 pg/mL, which yielded a sensitivity of 83.1% and a specificity of 79.4% [ 77 ].

Identifying biochemical and dietary indicators for PPD diagnostics has recently gained more attention. A significant finding of one of the recent studies is that lowered zinc levels during pregnancy are associated with prenatal and PPD symptoms [ 78 ]. PDD was also related to lower 25-hydroxylated vitamin D (25OHD) levels (≤80 nmol/L) in one study [ 79 ].

The transition to motherhood, whether for the first time or subsequently, involves a series of anatomical and physiological changes during pregnancy and the postpartum period that occur to optimize fetal development, childbirth, and maternal behavior [ 80 ]. At a functional level, recent work suggests that resting-state neural activity may change from pre-pregnancy to early postpartum, with increased functional connectivity in the default mode network localized to the bilateral cuneus [ 81 ]. One reliable and valid measurement of resting-state brain activity is electroencephalogram (EEG) coherence, which provides information regarding the coordinated functioning or synchronization between brain regions [ 82 ]. A study conducted by Sandoval I.K. et al. that evaluated EEG coherence before and after giving birth demonstrated that depression scores in the postpartum period correlated with the EEG coherence values between left frontopolar and parietal areas in the alpha1 band ( r = 0.36, p < 0.04). Depression symptoms were positively correlated with the EEG interhemispheric Fp1-P3 coherence measured during the postpartum period. Nevertheless, the lower Fp1-P3 coherence from pregnancy to postpartum remained when depression symptoms were controlled for in the analyses. However, the study should be considered in light of its limitations and directions for future research to assess a specific correlation between a typical EEG pattern for PPD [ 83 ].

The endeavor to diagnose PPD using predictors from both biological and EEG evaluations has increased. However, biochemicals may also serve as appropriate signs that can be employed to detect and anticipate PPD.

6. Treatment Options for PPD

Treatment options for PPD vary depending on the severity of symptoms, functional status, and ability to care for the newborn. Mild symptoms can be managed in primary care, while cases with psychotic symptoms, those initially unresponsive to treatment, or severe forms require emergency admission to psychiatric facilities. Thus, therapeutic strategies can be divided into two categories: non-pharmacological therapies in mild forms (psychological treatment) of PPD or pharmacological ones that can be associated with the first category (drug therapies) [ 84 ].

6.1. Psychotherapeutic and Psychosocial Interventions

Clinical studies have demonstrated the slight effectiveness of psychotherapy in the treatment of PPD. Valverde N. et al. conducted a systematic review regarding the psychotherapy effect for PPD in January 2023 that included seven trials with a total of 521 women who met the inclusion criteria. For the assessment of depressive symptoms, the EPDS was the most frequently used self-report symptom measurement system, applied in five of seven trials. Two studies used an author-generated questionnaire to obtain ratings on the treatment’s effectiveness. The ad hoc questionnaire assessed interpersonal connection and relationships, general well-being, outlook on life and parenting confidence, mood, and level of anxiety. Brief dynamic psychotherapy in individual format was the most frequently used type of intervention, applied in five out of seven trials, with the number of sessions ranging from four to twelve. The studies’ methodological quality was assessed considering the presence/absence of variables of the JADAD scale. The methodological analysis highlights the lack of high-quality designs concerning psychodynamic psychotherapy and PPD. Only two studies were randomized adequately out of seven; of the five with a control group, only one received treatment. The psychodynamic approach still plays a minor role in the treatment of PPD and is probably an efficient intervention. Therefore, research should be continued to assess the effectiveness of psychodynamic interventions in PPD compared to other effective treatments [ 85 ].

In another randomized trial, the goal was to compare healthcare providers trained to apply interventional psychology methods and identify patients with mild postnatal depression symptoms versus healthcare providers who did not receive this training. Thus, patients with EPDS scores ≥ 12 at six weeks postpartum were followed for 18 months. At six months postpartum, a significant number of PPD patients in the control group had higher EPDS scores compared to the two groups that received psychological interventions [ 86 ].

Qualitative research suggests that some of the barriers to treating patients with PPD include difficulties in scheduling therapy sessions and fear and stigma of dealing with a psychiatric diagnosis. Yet, studies show that they tend to choose psychological interventions instead of pharmacological treatment, especially if they are breastfeeding [ 54 ].

6.2. Pharmacological Antidepressive Treatments

Antidepressant therapy is recommended when symptoms do not remit with psychological therapies, when the symptomatology begins severely and requires prompt treatment, or when it is preferred by the patient [ 84 ]. Once PPD is diagnosed, prompt treatment is essential. In the absence of prompt treatment, patients are at risk of long-term disease that can lead to functional disability, worsening symptoms, resistance to treatment, and suicide [ 56 ].

The first-line antidepressants used in the treatment of PPD are selective serotonin reuptake inhibitors (SSRIs) due to their easy administration and low toxicity [ 54 ]. In a meta-analysis conducted by Zhang Q. et al. that compared the efficacy and acceptability of different pharmacotherapies for PPD, they included 11 studies with 944 participants that met the inclusion criteria. They concluded that among the most effective antidepressants was an SSRI: paroxetine (64.3%) [ 87 ]. A meta-analysis evaluating the response and remission rates of patients in the selective serotonin reuptake inhibitor (SSRI) group versus the control group demonstrated higher response and remission rates in the antidepressant group (response rate: 52.2% vs. 36.5% and remission rate: 46% vs. 25.7%) [ 88 ]. Another systematic review of randomized clinical trials demonstrates the superior efficacy of treatment with selective serotonin reuptake inhibitors compared to a placebo and (or other performed treatments) for PPD. All studies demonstrated higher response and remission rates among those treated with SSRIs and more significant mean changes on depression scales, although findings were not always statistically significant [ 89 ].

Regarding mothers with PPD who are breastfeeding, although most antidepressants pass into breast milk, most infants exposed to antidepressants while breastfeeding do not develop adverse effects. A meta-analysis of 57 studies regarding antidepressants used during breastfeeding showed reduced plasma concentrations in infants exposed to paroxetine, sertraline, or nortriptyline. However, infants exposed to fluoxetine were at a greater risk of adverse events [ 90 ]. Among the most common adverse reactions in infants of fluoxetine-treated mothers, studies have described increased crying, decreased sleep hours, gastrointestinal sensitivity, and irritability [ 90 , 91 ]. The maximum concentration of sertraline and fluoxetine in breast milk is reached approximately 8 h after administration. In infants of mothers on antidepressants, serum levels were below the level of quantification for each type of drug [ 90 ]. Paroxetine and sertraline are the safest selective serotonin reuptake inhibitors during breastfeeding [ 92 ].

Serotonin–norepinephrine reuptake inhibitors are used as a second-line therapy if selective serotonin reuptake inhibitors (SSRIs) are ineffective or if the patient has a history of a positive response to this type of therapeutic agent. Data regarding their use in the treatment of PPD are limited, but their efficacy has nevertheless been demonstrated in nursing mothers due to minimal passage into breast milk [ 84 ].

For patients with severe symptoms of PPD who are breastfeeding and prioritize relatively rapid improvement, the recommended antidepressant is brexanolone. Brexanolone is a neuroactive steroid synthesized by the progesterone metabolite allopregnanolone [ 93 ]. The effect of brexanolone on depressive symptoms, anxiety, and insomnia in women with PPD was analyzed in the HUMMINGBIRD clinical program, and it was demonstrated that patients receiving BRX90 (n = 102) versus a placebo (n = 107) achieved a more rapid resolution of symptoms (response rate was 81.4% vs. 67.3%) [ 94 ]. However, for patients who are breastfeeding, it is considered that they should temporarily cease nursing during treatment with brexanolone and wait until four days after the end of infusion [ 95 ]. Based on low-quality evidence, brexanolone quickly disappears from breast milk [ 96 ].

The US Food and Drug Administration (FDA) has approved zuranolone as the first oral agent indicated for PPD [ 97 ]. Zuranolone is a neuroactive steroid that functions as a GABA-A receptor-positive allosteric modulator, with a mechanism of action compatible with brexanolone, which is intravenously administered. In a phase 3 double-blind, randomized, placebo-controlled clinical trial conducted between January 2017 and December 2018, participants with diagnosed PPD were tested for the efficacity of zuranolone. Starting at day 3, remission occurred in more patients who received zuranolone than a placebo (19% vs. 5%), and remission remained greater with active medication throughout treatment [ 98 ].

In severe forms of depression, additional drug treatments are indicated. Benzodiazepines may be used temporarily for severe forms of anxiety, insomnia, or both until antidepressant medication becomes effective. Antipsychotic therapy may become necessary for forms of depression with psychotic symptoms. In severe conditions, in cases that do not respond to treatment with antidepressant agents, or in states of psychosis with suicidal ideation, hospitalization of the patient may be necessary [ 84 ].

6.3. Alternative Therapies for PPD

Since hormonal fluctuations are considered to be a trigger for the onset of PPD in some women, hormonal interventions have been studied in the treatment of PPD. In a study published by Dowlati et al. in 2020 regarding hormone interventions to prevent PPD, it was shown that, presently, the development of hormonal products for the prevention of PPD is at an early stage, with most trials showing preliminary, not definitive, results. Given the number of trend-level findings and the multifactorial etiology of PPD, it may be more prudent to investigate combined interventions rather than monotherapies [ 99 ].

In a similar manner, other complementary therapies used in the approach to antidepressant treatment in the postpartum period are mentioned, such as electroconvulsive therapy used in severe forms unresponsive to antidepressant medication or states with psychotic symptoms. A single more recent study conducted by Forray et al. demonstrates a 100% response rate, but data are nevertheless limited [ 100 ].

7. Role of Obstetrical–Gynecologist Specialists in Detecting and Preventing PPD

Women are at higher risk of developing a major depressive episode than men, and this risk is particularly accentuated by reproductive periods: adolescence, pregnancy, the postpartum period, or menopause. Female adolescents are at a two-to-threefold higher risk of major depressive disorder than males and a nearly fourfold higher risk of severe major depressive disorder. Obstetrician–gynecologists are usually the providers of medical services that women consult during these periods of vulnerability, usually with symptoms or conditions other than depression or anxiety [ 101 ].

Several depression screening methods have been validated over time, such as the Edinburgh Postnatal Depression Scale (EPDS) and the Patient Health Questionnaire (PHQ-9) [ 102 ]. The American College of Obstetricians and Gynecologists (ACOG) recommends screening by one of these scales at least once during the perinatal period [ 103 ].

Obstetricians play a unique role in identifying patients who require psychiatric evaluation in the postpartum period and could incorporate these screening methods into their practices. An ACOG’s effort should be focused on supporting by creating a more transparent environment regarding PPD screening [ 104 ]. One study conducted in the United States of America showed that the incidence of PPD symptoms was over 23% when applying screening in an obstetrical facility, higher than the overall incidence between 10% and 15% in the general population [ 105 ].

However, at the European level, there are no concrete recommendations for the integration of the assessment of a mother’s emotional status by the obstetrician and this is the main reason that women with PPD remain underdiagnosed or undertreated. Although a study conducted in Spain in 2014–2015 evaluated screening for prenatal depression during the first trimester in an obstetrics setting in a hospital in Madrid using PHQ-9, the rate of depressive symptoms was low (87.9% scored in the none-to-mild range). One study conducted in the United States of America showed that the incidence of PPD symptoms was over 23% when applying screening in an obstetrical facility, higher than the overall incidence between 10% and 15% in the general population [ 105 ]. Based on a needs assessment, researchers determined that women could be screened for PPD in the waiting room, which enabled women more privacy. The timing of the first ultrasound also allowed enough time in the prenatal period for women to participate in the 8-week group preventive intervention if they met high-risk criteria. Of the 445 women screened, 87.9% were scored in the none-to-mild risk range (PHQ-9: <9), while 9.4% were considered at high risk and recruited for the prevention study (PHQ-9: 10–14). The study had several limitations, such as the absence of incorporating screening in the third trimester. Still, the study suggests that it is feasible to integrate prenatal depression screening into obstetrics settings. There is certainly a need for more work to prevent the negative consequences associated with perinatal depression for women and their families internationally [ 106 ].

8. Conclusions

PPD is an increasingly common health problem among women who have recently given birth. Because of the potentially severe consequences that can affect both the patient and the family, it is crucial that healthcare providers, especially obstetricians with whom the woman comes into contact most frequently during the perinatal period, facilitate the early identification and treatment of PPD.

In addition, postnatal depression negatively affects the mother’s relationship with the infant and its development, but also the relationship with the partner and other family members. The association between molecular genetics and PPD is a highly current issue that has developed in recent years. However, there is still a small amount of research in this area, and it deserves further study due to its importance in terms of public health.

Obstetricians should include brief screening methods for PPD in the evaluation of pregnant women during their visits. Thus, if PPD is diagnosed, patients should be informed about all therapeutic techniques.

Therapeutic considerations include symptom severity, breastfeeding, and therapeutic preferences. Combined therapeutic approaches, including psychotherapy and pharmacological treatment, are recommended for treating moderate and severe forms of PPD. Complementary and alternative therapeutic methods are promising but require studies to demonstrate their effectiveness.

Until prenatal screening for PPD becomes standard practice, the healthcare system will fail to detect mothers at risk of developing depression and provide early assessment and effective treatment.

Acknowledgments

This survey is part of the PhD degree study of the article’s first author.

Funding Statement

This research received no external funding. The processing charge for this article was partially supported by the PhD School, Carol Davila University and Pharmacy, Bucharest, Romania.

Author Contributions

Conceptualization, D.A.-M.D. and A.P.; methodology, R.-C.P.; resources, M.C.D., F.Ș., and C.M.; data curation, D.A.-M.D. and R.-C.P.; writing—original draft preparation, D.A.-M.D., M.C.D., F.Ș., and C.M.; writing—review and editing, A.P. and R.-C.P.; visualization, D.A.-M.D.; supervision, A.P. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Informed consent statement, data availability statement, conflicts of interest.

The authors declare no conflicts of interest.

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• Published: 21 August 2024

Air pollution and children’s mental health in rural areas: compositional spatio-temporal model

• Anna Mota-Bertran 1 , 2 ,
• Germà Coenders 1 , 2 ,
• Pere Plaja 3 ,
• Marc Saez 1 , 2 &
• Maria Antònia Barceló 1 , 2  

Scientific Reports volume  14 , Article number:  19363 ( 2024 ) Cite this article

Metrics details

• Environmental sciences
• Risk factors

Air pollution stands as an environmental risk to child mental health, with proven relationships hitherto observed only in urban areas. Understanding the impact of pollution in rural settings is equally crucial. The novelty of this article lies in the study of the relationship between air pollution and behavioural and developmental disorders, attention deficit hyperactivity disorder (ADHD), anxiety, and eating disorders in children below 15 living in a rural area. The methodology combines spatio-temporal models, Bayesian inference and Compositional Data (CoDa), that make it possible to study areas with few pollution monitoring stations. Exposure to nitrogen dioxide (NO 2 ), ozone (O 3 ), and sulphur dioxide (SO 2 ) is related to behavioural and development disorders, anxiety is related to particulate matter (PM 10 ), O 3 and SO 2 , and overall pollution is associated to ADHD and eating disorders. To sum up, like their urban counterparts, rural children are also subject to mental health risks related to air pollution, and the combination of spatio-temporal models, Bayesian inference and CoDa make it possible to relate mental health problems to pollutant concentrations in rural settings with few monitoring stations. Certain limitations persist related to misclassification of exposure to air pollutants and to the covariables available in the data sources used.

Introduction

Child mental health and air pollution.

According to the 2019 Child and Adolescent Mental Health report published by the Statistics National Institute of the United Kingdom, mental disorders between the ages of 5 and 15 have increased from 9.7 to 11.2% in the last decade 1 . The World Health Organization (WHO) states that more than 20% of adolescents worldwide (10 to 19 years old) suffer from mental disorders, and that 50% of these begin before the age of 14. In most cases, however, they are neither detected nor treated. According to the WHO, depression is one of the leading causes of illness and disability among adolescents and suicide is the third leading cause of death between the ages of 15 and 19 2 . Failure to address adolescent mental disorders has consequences that extend into adulthood, affecting both physical and mental health and limiting opportunities for a satisfying adult life 3 .

Extant research on mental health of children related to pollution is based on subjects living mainly or only in urban areas. To the best of our knowledge, there are no studies focusing on rural areas. It is thus important to conduct a study in a rural area to discern whether pollution and child mental health have a similar relationship as in urban areas. It is well known that pollution behaves differently in rural areas 4 , and it is an open question whether rural children exhibit similar or different relationships from their urban counterparts.

Regarding the association between exposure to air pollution and the occurrence of mental health problems in urban children, we carried out a bibliographic search in the PubMed database at the end of July 2023, using the key words “mental health”, “child” and “air pollution”. Specifically, we found three reviews: Volk et al . 5 ; Karrari et al. 6 and Zhao et al . 7 . The last two are systematic reviews and follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 8 reporting guidelines, whereas Volk et al . 5 , is a review within the guidelines of the Environmental Influences on Child Health Outcomes (ECHO) Program.

Karrari et al . , in their systematic review of articles published between 1990 and 2011, showed that lead exposure can have adverse effects on health throughout life such as hearing loss, anaemia, renal failure, and weakened immune system. In the case of children, it is more detrimental to mental development. At low doses, this element is related to motor and cognitive dysfunctions 6 .

Zhao et al . conducted a review of the literature between 1960 and 2017, to identify the associations between air pollution and mental health and behavioural disorders. Specifically, they studied ozone exposure and the immune and nervous systems. The results from their research did not relate ozone to autism spectrum disorders, impaired cognitive function, dementia, depression or suicide, the immune and nervous systems, mental health, or behavioural disorders 7 .

Volk et al . provide a review of the literature from 2006 to 2020 on prenatal exposure to pollution and neurodevelopment including autism spectrum disorder, attention deficit hyperactivity disorder (ADHD), general measures of cognition and intelligence, state of mood and image. They concluded that there is a relationship between prenatal exposure and neurodevelopment 5 .

In exploring the literature not included in the reviews, we looked for problems other than neurodevelopment, as well as exposure to air pollutants other than lead and ozone. Five groups of mental health problems were identified: behavioural and development disorders 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 ; ADHD 12 , 16 , 19 , 20 , 21 , 22 , 23 , 24 ; anxiety 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 ; eating disorders 33 , 34 , 35 , 36 , and other mental health problems 37 , 38 , 39 , 40 , 41 .

Long scientific evidence highlights the relationship between environmental pollution and cognitive development, understood as the processes through which human beings acquire skills that allow them to interpret reality and interact with it. Maternal exposure to air pollution is related to child neurological development during the first 24 months of life through the onset of a neurological delay 10 . There is an association between traffic pollution and the neurodevelopment of children aged 7 to 12 years, with a lower cognitive development as well as behavioural impairments 11 , 12 , 17 , 25 . There are sex-dependent differences in children aged 4 to 6 years, with increased vulnerability in male children 14 . Air pollution is also connected to memory, attention, and verbal cognition 15 . Some studies on traffic pollution show a relationship with a cognitive deficit in children, despite the lack of significance 9 while others do not identify any relationship between short-term exposure to traffic-induced pollution and neuropsychological problems 13 , 17 .

Air pollution is related to ADHD and behavioural disruptions and development problems in children aged 7 to 11 years 12 , 19 . Environmental pollutants such as O 3 , NO 2 , PM 1 , PM 2.5 and PM 10 are associated with children’s and adolescents’ mental health and the development of ADHD 20 , 21 , 22 , 23 , 24 .

When exposure to air pollution is prolonged over time, the risk of anxiety in children and adolescents increases 25 , 26 , 27 , 29 , 30 . Ma et al. highlight that the hospital admissions for anxiety increase with short-term exposure to NO 2 and sulphur dioxide (SO 2 ) 32 . Hao et al . find a positive association between PM 2.5 and anxiety 31 , however, other studies relating PM 2.5 and anxiety are unconclusive 28 .

To the best of our knowledge, evidence on pollution and eating disorders focuses on obesity and overweight, but not other mental health problems. Limaye and Salvi suggest that air pollution is a risk factor for the development of obesity 33 . In particular, prenatal exposure to PM 2.5 and NO 2 is related to an increased risk of being overweight or obese 34 , 35 . Shi et al . find that the increased risk not only develops in a prenatal stage, but also later in life 36 .

Exposure to certain fine particles such as PM 2.5 is associated with other psychiatric problems in children and adolescents like bipolar disorder, impulse control disorder, or suicidality 37 , 38 , 40 although other studies do not obtain significant results 39 , 41 .

The studies above focus on mental health of children living mainly or only in urban areas. We have identified no studies focusing on rural areas devoted to children.

However, some studies in rural areas do analyse the relationship between air pollution and mental health of the general population. Exposure to wildfire smoke in rural communities, particularly among vulnerable groups like working-age adults, non-Hispanic whites, and those without a university education, increases the risk of suicide 42 . In China, concerns about physical and mental health are growing, with air pollution, income inequality, food contamination, and limited green spaces relating to health 43 . Air pollution is also connected to the mental health of China's aging population, with urban elderly individuals having better psychological well-being compared to their rural counterparts 44 . These studies emphasize the need to address air pollution and health in various populations, with a focus on rural communities and vulnerable groups.

Methodological issues

The reviewed studies have certain limitations at the spatial and temporal level. Pollutant monitoring stations are mostly located in urban areas, thus offering limited spatial coverage 5 . This makes it very difficult to estimate the relationship between pollutants and health in rural settings.

The aim of the article is to provide first-time scientific evidence on the association between air pollution and mental health of children and adolescents under 15 in a rural setting, including behavioural and developmental disorders, ADHD, anxiety, and eating disorders beyond obesity and overweight (anorexia nervosa, bulimia nervosa, binge eating disorder, and avoidant and restrictive disorder). The methodological value of this research lies in combining spatio-temporal models, Bayesian inference, and the Compositional Data (CoDa) analysis method, thus providing a new perspective on the relationship between the concentrations of air pollutants and mental health problems. This innovative methodology allows for a better understanding of the relationship between air pollution and mental disorders in children and adolescents in rural areas where pollution monitoring stations are few and far between.

By utilizing spatio-temporal models, both the geographical location and the temporal variability of air pollutants are taken into account, providing better information about exposure. Bayesian inference makes a rigorous assessment of the associations between air pollution and mental disorders, considering the inherent uncertainty in the data and the sparse monitoring network.

The use of the CoDa analysis method is particularly relevant in this study, as it addresses the compositional nature of air pollutants. By considering the relative proportions of different components in the pollutant composition, CoDa analysis relates air pollution and mental health taking into account possible trade-offs between pollutants and not only overall pollution levels. This improves on studies focusing only on absolute pollution levels or focusing only on a single pollutant.

Population characteristics

All the variables, except age, number of chronic diseases and pollutant concentrations, were expressed in proportions. Of the population studied in the Alt Empordà region in Catalonia, Spain (24,674 children under 15 years old), 8.82% had behavioural and developmental disorders, 1.74% anxiety, 0.76% ADHD, 0.37% eating disorders, 47.9% were girls and 52.1% boys, 1.1% had glucose intolerance, 7.4% were obese, 1.6% smoked, and 0.2% consumed alcohol. In relation to the pharmaceutical co-payment, which is an indicator of individual socioeconomic level, 10.3% made an economic contribution of up to 10%, 68.8% contributed economically with 40% and the remaining 20.9% with 50% or more. Regarding the average income in the census tract, 79.0% were in the first quartile of lowest income census tracts (reference category), 8.8% in Q 2 , 5.8% in Q 3, and 6.4% in Q 4 . The average age was 11 years, and, on average, the subjects suffered from 0.15 chronic diseases. The average concentrations of each pollutant were 22.52 μg/m 3 of PM 10 , 34.69 μg/m 3 of NO 2 , 44.10 μg/m 3 of O 3 , 0.29 mg/m 3 of CO, and 2.20 μg/m 3 of SO 2 (Table 1 ).

Air pollutant concentrations

The results for the relationship between air pollutants and the behavioural and development disorders, anxiety, ADHD, and eating disorders can be seen in Table 2 . The \(\upbeta\) coeficients, show the compositional behaviour indicating trade-offs between pollutants: \({\upbeta }_{1}\) refers to PM 10 , \({\upbeta }_{2}\) to NO 2 , \({\upbeta }_{3}\) to O 3 , \({\upbeta }_{4 }\) to CO, and \({\upbeta }_{5}\) to SO 2 . \(\upgamma\) indicates the geometric mean of all pollutants standing for overall pollution, hereinafter the total. The total pollution level (γ 95% credibility interval (CI) -Bayesian equivalent of a 95% confidence interval—from 17.9264 to 20.2053) related to the incidence of behavioural and development disorders. In relative terms, when NO 2 (β 2 CI from 20.1750 to 25.9906) and O 3 (β 3 CI from 18.0670 to 23.8689) increased, and PM 10 (β 1 CI from − 28.5884 to − 20.8427) and CO (β 4 CI from − 23.6106 to − 16.3512) decreased, the incidence also increased. When adding up the β and γ coefficients, behavioural and development disorders appeared to be related to NO 2 , O 3 and SO 2 .

In the case of anxiety, total pollution (γ CI from 8.2395 to 11.2685) was also related to incidence. When O 3 (β 3 CI from 7.8187 to 15.4243) and SO 2 (β 5 CI from 1.4973 to 9.4917) increased and CO (β 4 CI from − 21.3632 to − 9.4764) decreased, the incidence also increased. When adding up the β and γ coefficients, anxiety appeared to be related to PM 10 , O 3 and SO 2 . Total pollution (γ) was also related to the incidence of ADHD (CI from 3.2102 to 4.7697) and eating disorders (CI from 3.2065 to 5.1064).

Covariables

Gender, age, number of chronic diseases, glucose intolerance, obesity, alcohol consumption, tobacco consumption and individual socioeconomic level had a significant relationship with the risk of having behavioural and development disorders. Being a girl (CI from 0.5867 to 0.8874) and having a medium (CI from 0.4690 to 0.8499) or high (CI from 0.2229 to 0.4895) individual socioeconomic level acted as protective factors. Age (CI from 1.6661 to 2.2696), number of chronic diseases (CI from 1.4647 to 2.1420), glucose intolerance (CI from 1.5983 to 5.0600), obesity (CI from 1.4125 to 2.5303), and alcohol (CI from 1.6891 to 17.8359) and tobacco (CI from 3.8947 to 10.1989) consumption indicated increased risks of behavioural and development disorders given that their odds-ratio was greater than 1 (Table 3 ).

The covariables which were significant with respect to anxiety were gender, age, glucose intolerance, obesity, alcohol and tobacco consumption, individual socioeconomic level, and average income in the census tract. Protective factors were being a girl (CI from 0.0928 to 0.3004), having a high individual socioeconomic level (CI from 6.6988 × 10 −4 to 5.4451 × 10 –3 ), and living in a census tract where the average level of income was medium to high (Q 2 (CI from 6.1181 × 10 –3 to 1.1462 × 10 –1 ) and Q 3 (CI from 2.9175 × 10 –3 to 5.3412 × 10 −2 )). Age (CI from 4.8610 to 14.0504), glucose intolerance (CI from 1.7828 to 391.4102), obesity (CI from 1.0087 to 6.2730), alcohol consumption (CI from 1.2828 to 9.3783 × 10 3 ), smoking (CI from 3.6832 to 113.2430) and living in a census tract where the average level of income was very high (Q 4 (CI from 2.0168 × 10 4 to 1.5426 × 10 7 )), were related to an increased risk of anxiety (Table 4 ).

Regarding ADHD (Table 5 ), gender, age, individual socioeconomic level, and average income in the census tract were significant. Age (CI from 2.9929 to 9.7336) and living in a census tract where the average level of income was very high (Q 4 (CI from 2.8765 to 77.3954)) were related to an increased risk. Protective factors were being a girl (CI from 5.7924 × 10 −3 to 5.3888 × 10 −2 ), having a high individual socioeconomic level (CI from 0.0134 to 0.1935), and living in a census tract where the average level of income was high (Q 3 (CI from 0.0215 to 0.3252)).

The significant variables for eating disorders were being a girl (CI from 5.7278 to 45.1946), age (CI from 3.6859 to 12.6260), obesity (CI from 1.2639 to 9.2735), and tobacco consumption (CI from 4.2096 to 350.7618). All of them acted as risk factors (Table 6 ).

Our results for the first time reveal a significant association between air pollution and child mental health in a rural setting. Exposure to PM 10 , NO 2 , O 3 , and SO 2 is linked to increased risks of behavioural and developmental disorders, anxiety, ADHD, and eating disorders. Different pollutants exhibit distinct relationships. NO 2 , O 3 , and SO 2 are linked to behavioural and developmental disorders, while PM 10 , O 3 , and SO 2 correlate with anxiety. Overall pollution levels also contribute to higher rates of the disorders under study.

Demographic factors are also linked to disorder risks. Protective factors include being female and having higher socioeconomic status, while risks rise with age, chronic diseases, glucose intolerance, obesity, and alcohol and tobacco consumption.

We compared the findings of our study to other research addressing the associations between air pollution and child mental health in urban populations, as the relationship has not yet been established in rural settings. This comparison revealed relevant similarities but also differences. We found the review by Volk et al . 5 particularly useful, as well as some individual studies in topics not covered by these authors.

Regarding behavioural and development disorders, the level of total air pollution (γ) is related to a higher incidence, a fact that also occurs when NO 2 (β 2 ) and O 3 (β 3 ) increase and PM 10 (β 1 ) and CO (β 4 ) decrease. By adding the β and γ coefficients, behavioural and developmental disorders seem to be related to NO 2 , O 3 and SO 2 ; as shown by the results of the research carried out by Sunyer et al . in children aged from 7 to 11 in the city of Barcelona, with a reduction in cognitive development when traffic-related pollutants increased 11 . Pérez-Crespo et al . 18 reached the same conclusion in their study of 9- to 12-year-olds in Rotterdam.

Regarding anxiety, our results show that incidence is also related to the total (γ) and, when adding the β and γ coefficients, to PM 10 , O 3, and SO 2 . This coincides with the research by Yolton et al . 27 in the city of Cincinnati, with a significant association between pollutants present in road traffic and anxiety in 12-year-olds. Another significant relationship between PM 10 , NO 2 and anxiety is reported by Jorcano et al . 26 in boys and girls aged 7 to 11 who had been exposed in pre- and post-natal phases.

Total air pollution (γ) is also connected to the incidence of ADHD in this investigation. Volk et al . , carried out a systematic review determining that exposure to air pollutants both pre- and post-natal is associated with an increased risk of ADHD. Some of the reviewed studies analysed similar pollutants to ours, such as PM 2.5 , NO 2 , O 3 , and PM 10 5 . Similar results were also observed by Forns et al . 12 in boys and girls aged 7 to 11 living in Barcelona. These children presented an increase in ADHD cases at higher levels of exposure. Maitre et al . 16 through data from the "Human Early Life Exposome" (HELIX) project, based on 6 longitudinal birth cohorts in Europe between the ages of 6 and 11, also found a positive relationship. Likewise, Markevych et al . 20 identified the increased risk of ADHD in relation to PM 10 and NO 2 in children under 10. Shim et al . 23 in their study with children aged 7 to 12, found a relationship between particulate matter exposure and the prevalence of ADHD. Zhou et al . 24 found a significant association between long-term ozone exposure and ADHD in children aged 3 to 12 years residing in seven cities of Liaoning, China.

With regard to eating disorders, our study relates total air pollution with anorexia nervosa, bulimia nervosa, binge eating disorder, and avoidant and restrictive disorder, all of which are absent from the literature relating pollution and eating disorders.

The relation between pollutant concentrations and behavioural and developmental disorders, ADHD, anxiety, and eating disorders has been assessed through the combination of spatio-temporal models, Bayesian inference, and CoDa. This method combination is new in air pollution and health research, but Bayesian inference has been applied by Saez et al . 21 to identify the association between environmental factors and ADHD, and gains relevance in a rural setting.

The combination of CoDa with a total pollution level is also new in studies related to air pollution and health and makes it possible to disentangle overall pollution from the relative importance of each pollutant with respect to one another. These relationships have hitherto been presented together, thus making it impossible to assess trade-offs between sets of pollutants.

There are several limitations in our study. First and foremost was the misclassification of exposure to air pollutants. In fact, this is an ecological (or average) exposure in the area in which the subject lives and does not necessarily coincide with the exposure of each subject. In addition, the subjects are not immobile, and so are exposed to air pollution not only in the place where they live, but also at the school they attend, the place where they do extracurricular activities (for example, languages or sports), etc. Fortunately, on the one hand, for the spatial prediction of exposure we considered the census tract where each subject lives 45 . While this did not eliminate the problem entirely, it did greatly minimize it. On the other hand, the subjects we analysed, boys and girls, do not move very far from their homes, so exposure would not vary very much. Furthermore, it is a non-differential misclassification. That is, all subjects have the same probability of being misclassified.

Second, the covariables used were limited to what was available in the data base. In particular, the proxy variable for individual socioeconomic level based on the grades of pharmaceutical co-payment had to be grouped into only three categories because very few cases were present in some of the original nine. Thus, this variable may have been measured in error. A less coarse measure of socioeconomic level would be desirable in future research.

Finally, there could be residual confounding bias. However, we have tried to control for bias including both a large number of observed confounders as covariables, and random effects that captured unobserved confounders.

We used a sub-cohort of a population-based cohort composed of 124,112 individuals from the Alt Empordà, a rural region in Catalonia, Spain, from 2009 to 2019. Specifically, this retrospective population-based cohort study was conducted including data from all residents in the region. Data were obtained from the Public Data Analysis for Health Research and Innovation Program (PADRIS) database, which includes admission data from primary care centres, hospitals (inpatient and outpatient care), extended care facilities, and mental health centres, as well as sociodemographic (sex and age) and socioeconomic (pharmaceutical co-payment) variables.

Alt Empordà, located in the province of Girona, Catalonia stands out as a predominantly rural area. With a population density of 104 inhabitants per square kilometre, Alt Empordà starkly contrasts with Catalonia, which boasts a density of 248 inhabitants per square kilometre. This underscores the significance of the primary sector in this region, whose value-added contribution amounts to 4%, as opposed to Catalonia's 1.2%. These figures highlight the reliance of Alt Empordà on agriculture, winery, fishery, and livestock farming. According to data from the Institute of Statistics of Catalonia in 2022, Alt Empordà had 144,926 inhabitants, of which 15.2% were 14 years old or younger, compared with 7,899,056 inhabitants in Catalonia, and 14.2% respectively 45 . We selected children and adolescents who were under the age of 15 at some point between 2009 and 2019. The number of subjects was 24,674 children and adolescents, of whom 2,382 had at least one of the following mental disorders: behavioural and development disorders, ADHD, anxiety, and eating disorders.

Outcome variables

The mental disorders listed below were considered as dependent variables. The codes of each accord to the International Classification of Diseases, 10th Revision (ICD-10):

Behavioural and development disorders (F94)

Anxiety (F41.9)

Eating disorders (F50)

Environmental explanatory variables

As explanatory environmental variables we included the pollutants PM 10 (µg/m 3 ), NO 2 (µg/m 3 ), O 3 (µg/m 3 ), carbon monoxide (CO) (mg/m 3 ), and SO 2 (µg/m 3 ). We obtained their hourly levels for 2009–2019 from the 143 automatic monitoring stations from the Catalan Network for Pollution Control and Prevention (XVPCA) (open data) 46 . Instead of the short-term effects of these pollutants on children's health, we were interested in the effects of long-term exposure. For this reason, we used the monthly averages, from January 2009 to December 2019 (further details can be found in Saez and Barceló 47 and in Bertran et al . 48 ).

While it is essential to obtain the pollution data in each census tract of the studied population, there may not always be a monitoring station, and this is even more so in a rural setting. We used a Bayesian hierarchical spatiotemporal model 47 to predict exposure to air pollutants in locations or time periods without pollution monitoring sites. The estimation of the (second-order stationary) Gaussian field suffers from the so-called 'big n problem', that is, there are large computational costs of the linear algebra operations required for model fitting and prediction. The costs are larger for large datasets in space and time, as in our case, in which a frequentist approach proved unfeasible.

Even using a Bayesian approach, these computational problems subsist when the MCMC algorithm is used, since dense matrices must be computed for each iteration. Among the solutions that have been proposed to Bayesian inferences under the 'big n problem', we select the Integrated Nested Laplace Approximation (INLA) by Rue et al . 49 , 50 , in the specification suggested by Saez and Barceló 47 and used by Mota-Bertran et al . 4 , 48 . The INLA approximation provides a fast and yet quite exact approach to fitting complex latent Gaussian models which comprise many statistical models in a Bayesian context 49 , 50 .

Predictions of exposure to pollutants were made at the level of the census tract where the subject lives, for the period between the beginning of the follow-up (January 1, 2009) and the day before the diagnosis of the mental illness.

In the context of pollution studies, the CoDa methodology 51 , 52 , 53 , 54 , 55 identifies patterns of varying relative importance of pollutants 48 , 56 , 57 , 58 which can later be associated to potential health risks 59 . The CoDA methodology makes it possible to study the relative importance of pollutant concentrations, that is, how pollutants behave relative to one another, beyond the information provided by total pollution levels. This is crucial for understanding air pollution. The commonest tool within the CoDa methodology is the log-ratio transformation, the simplest of which is the log-ratio between pairs of pollutant concentrations 53 .

For instance, Mota-Bertran et al . 48 identified three substantial trade-offs among the pollutants defined at the beginning of this section: NO 2 versus O 3 , and SO 2 versus NO 2 and O 3 . In other words, the log-ratios with the highest variance were ln(O 3 /NO 2 ), ln(NO 2 /SO 2 ), and ln(O 3 /SO 2 ). The CoDa approach is tailored to studying these forms of joint variability, rather than considering one pollutant individually and rather than considering only overall pollution levels.

The specification of a composition as an explanatory variable was first developed by Aitchison and Bacon-Shone as the so-called log-contrast model, and indicates the increase of which pollutants, at the expense of the decrease of which other, is related to the incidence of a disease 60 . For this purpose, the right-hand side of the model equation must include:

The constraint \({\upbeta }_{1}+{\upbeta }_{2}+{\upbeta }_{3}{+\upbeta }_{4}+{\upbeta }_{5}=0\) ensures that total pollution is constant, as required for the interpretation of compositional effects as trade-offs. In other words, the increases of some pollutant concentrations in relative terms are only possible when decreasing some others. For ease of estimation, the so-called additive log-ratio transformation 60 can be applied to introduce said constraint by setting log-ratios with a common denominator. These log-ratios can be used as variables in any statistical model:

where \({\upbeta }_{5}\) is obtained either as \({\upbeta }_{5}={-\upbeta }_{1}-{\upbeta }_{2}-{\upbeta }_{3}-{\upbeta }_{4}\) or by rerunning the model with a different pollutant in the denominator 61 .

The CoDa approach does not imply disregarding the absolute pollution levels. Apart from considering the relative importance of air pollutants, some form of total air pollution can be added to the compositional information by means of a \(\mathcal{T}\) -space 62 , 63 , 64 , 65 , also known as CoDa with a total. The composition extracts the relative importance of air pollutants to each other, while the total T speaks of global levels of air pollution. This total is best defined as the so-called multiplicative total, in other words, the product of air pollutant concentrations 48 , 65 , 66 .

The total refers to increasing all pollutant concentrations in absolute terms by a common factor and can be specified by adding the γ coefficient to the right-hand side of the model equation:

For interpretation, the effects of pollutant concentrations can be decomposed into the log-contrast part and the total part as:

with \({\upbeta }_{1}+{\upbeta }_{2}+{\upbeta }_{3}{+\upbeta }_{4}+{\upbeta }_{5}=0\) . This decomposition provides complementary views on pollution and mental health which are made possible by the \(\mathcal{T}\) -space. Firstly, the \(\beta\) coefficients are interpreted as trade-offs: positive \(\beta\) \(\text{s}\) indicate pollutants whose relative increase is related to a greater incidence of mental disorders when coupled with relative decreases in pollutants with negative \(\beta {\text{s}}\) , the total remaining constant. Secondly, the \(\upgamma\) coefficient relates the incidence of mental disorders to increases in the overall pollution level while keeping its composition constant, in other words, when multiplying all pollutant concentrations by a common factor. Thirdly, the sums \(\beta + {\upgamma }\) relate mental disorders to the increase of the absolute concentration of each pollutant while leaving the absolute concentrations of all other pollutants constant, which implies both an increase in the relative importance of the pollutant and an increase in the total pollution. This interpretation is the only one available in standard pollution modelling. The CoDa approach with a total adds to this the decomposition of the sums \(\beta + {\upgamma }\) into \(\beta\) and \(\upgamma\) .

Because the numbers of cases of ADHD and eating disorders are small, in these two disorders we simplified Eq.  4 , by dropping the log-ratios and taking only the total pollution \(\gamma (\text{ln}\left({\text{PM}}_{10}\right)+\text{ln}\left({\text{NO}}_{2}\right)+\text{ln}\left({\text{O}}_{3}\right)+\text{ln}\left(\text{CO}\right)+\text{ln}\left({\text{SO}}_{2}\right) )\) into account. This simplification improved the stability of the estimates.

We used the following covariables.

Gender: binary variable indicating girls (1) or boys (0).

Age: standardized to zero mean and unit standard deviation.

Number of chronic diseases: including bronchitis (7.5%), asthma (6.4%), neoplasms (2.3%) and others (chronic obstructive pulmonary disease, hypertension, and ischemic cardiomyopathy).

Glucose intolerance: binary variable indicating if the subject has glucose intolerance (1) or not (0).

Obesity: binary variable indicating if the subject is obese (BMI ≥ 30 kg/m 2 ) (1) or not (0).

Alcohol consumption: binary variable indicating if the subject consumes alcohol (1) or not (0).

Tobacco consumption: binary variable indicating if the subject is a smoker or was a former smoker (1) or not (0).

A proxy variable for individual socioeconomic level: categorical variable that shows the different levels of pharmaceutical co-payment present in Catalonia 67 . The following categories were defined for the economic contribution: up to 10% (Lowest socioeconomic level, reference category); 40% (medium socioeconomic level); and 50% or more (Highest socioeconomic level). The first category contains incomes below 18,000 EUR/year, the second between 18,000 and 100,000 EUR/year and the third above 100,000 EUR/year.

Average income (EUR). Average from 2015 to 2019 observed at census-tract level 68 and transformed into quartiles (lowest quartile as reference category).

Data analysis

We specified a generalized linear mixed model (GLMM) for each health outcome, with binary response from the binomial family:

where the subindexes \(i\) and \(t\) indicate the subject and the year, respectively; Y it indicates the mental health problem of the subject i at year t (0 absence, 1 presence); pollutant k,it denotes the exposure to PM 10 , NO 2 , O 3 , CO, and SO 2 in relative terms; T it denotes the exposure to overall pollution as in Eq.  3 \(; {\eta }_{i} \text{and} S\left({census\_tract}_{i}\right)\) denote random effects (explained below); and \(\beta s\) and \(\gamma\) are the coefficients of the explanatory variables and covariables ( \({e}^{\beta }\) is the relative risk associated with each covariable).

We considered two random effects in the models. First, \({\eta }_{i}\) is a random effect indexed on the subject. This random effect is unstructured (independent and identically distributed), and captures individual heterogeneity, i.e., unobserved confounders specific to the subject and invariant in time.

Second, we included the structured random effect S(census_tract i ) to control spatial dependency: census tracts that are close in space show more similar incidence than those that are not.

The spatially structured random effect S(census_tract i ) is normally distributed with zero mean and a Matérn covariance function:

where \({\text{K}}_{\nu }\) is the modified Bessel function of the second type and order. \(\nu >0\) is a smoother parameter, \({\sigma }^{2}\) is the variance and \(\kappa >0\) is related to the range ( \(\rho =\sqrt{8 \nu }/\kappa\) ), the distance to which the spatial correlation is close to 0.1 69 .

As can be seen, we introduced many unobserved variations into the GLMMs for each of the observations. This prevents using a frequentist approach. For this reason, inferences were made with a Bayesian perspective and the INLA approach 49 , 50 . We used priors that penalize complexity (called PC priors). These priors are robust in the sense that they do not have an impact on the results 70 . All analyses were carried out using the free software R (version 4.2.2) 71 , through the INLA package 49 , 50 , 72 .

Ethical approval and consent to participate

The use of the data included is authorized by the Catalan Health Institute (ICS) and the Data Analysis Program for Health Research and Innovation (PADRIS) which ensure the pseudo-anonymization of the information. When linkage with other public data sources is required, ICS or PADRIS act as a Trusted Third Party (TTP) to execute the linkage and provide the new data set already pseudoanonymized; otherwise, informed consent of patients is needed to access their personal data, using the same TTP. The data are managed in a secure server following all the present legal requirements of the General Data Protection Regulation (European Union) 2016/679 and of the Council of 27 April 2016 and the Spanish Organic Law 3/2018 of 5 December on the protection of personal data and guarantee of digital rights.

Data availability

Due to the ethical (in accordance with the protocol approved by the Research Ethics Committee CEI Girona—October 10, 2019-) and legal (the provisions of the General Data Protection Regulation -European Union- 2016/679; the Council of 27 April 2016; the Spanish Organic Law 3/2018 of 5 December on the protection of personal data and guarantee of digital rights; and the Agreement for the transfer of anonymized health data between the Department of Health, the Catalan Health Service, the Catalan Institute of Health, the Blood and Tissue Bank, the University of Girona and the Fundació Salut Empordà) reasons, there are restrictions on the transfer of data to third parties and they are not publicly available. However, the data (appropriately anonymized) will be available, after approval of the research proposal plan and with a signed data access agreement, upon reasonable request to the corresponding author. Code will be available at www.researchprojects.es .

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Acknowledgements

This study was carried out within the ‘Cohort-Real World Data’ subprogram of CIBER of Epidemiology and Public Health (CIBERESP). We appreciate the comments of two anonymous reviewers of a previous version of this work who, without doubt, helped us to improve our work. The usual disclaimer applies.

This work was supported by the AGAUR of Generalitat de Catalunya (grant numbers 2020 FISDU 00238, and 2023 CLIMA 00037); MCIN/AEI and the ERDF A way of making Europe (grant number PID2021-123833013); and the Department of Research and Universities of Generalitat de Catalunya (grant number 2021 SGR 01197). The funding sources did not participate in the design or conduct of the study, the collection, management, analysis, or interpretation of the data, or the preparation, review, and approval of the manuscript.

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Anna Mota-Bertran, Germà Coenders, Marc Saez & Maria Antònia Barceló

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A.M., G.C., and M.S. had the original idea for the paper and designed the study. The bibliographic search and the writing of the introduction were carried out by A.M. The data were provided by M.A.B. and by P.P. The methods and statistical analysis were chosen and performed by M.S. and G.C. AM created the tables. All authors wrote the results and the discussion. The writing and final editing was done by all authors. All authors reviewed and approved the manuscript.

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Mota-Bertran, A., Coenders, G., Plaja, P. et al. Air pollution and children’s mental health in rural areas: compositional spatio-temporal model. Sci Rep 14 , 19363 (2024). https://doi.org/10.1038/s41598-024-70024-2

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Received : 14 November 2023

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DOI : https://doi.org/10.1038/s41598-024-70024-2

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