postpartum depression research paper topics

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Postpartum Depression: Pathophysiology, Treatment, and Emerging Therapeutics

Affiliations.

1 Department of Psychiatry, University of Toronto, Toronto, Ontario M5G 2C4, Canada; email: [email protected].
2 Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario M5G 2C4, Canada.
3 Toronto General Hospital Research Institute, Toronto, Ontario M5G 2C4, Canada.
4 University Health Network Centre for Mental Health, Toronto, Ontario M5G 2C4, Canada.
5 Women's College Research Institute, Women's College Hospital, Toronto, Ontario M5G 2C4, Canada; email: [email protected].
PMID: 30691372
DOI: 10.1146/annurev-med-041217-011106

Postpartum depression (PPD) is common, disabling, and treatable. The strongest risk factor is a history of mood or anxiety disorder, especially having active symptoms during pregnancy. As PPD is one of the most common complications of childbirth, it is vital to identify best treatments for optimal maternal, infant, and family outcomes. New understanding of PPD pathophysiology and emerging therapeutics offer the potential for new ways to add to current medications, somatic treatments, and evidence-based psychotherapy. The benefits and potential harms of treatment, including during breastfeeding, are presented.

Keywords: allopregnanolone; emerging therapies; genetic aspects; pathophysiology; postpartum depression.

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Research article
Open access
Published: 27 January 2021

Postpartum depression symptoms in survey-based research: a structural equation analysis

Che Wan Jasimah Bt Wan Mohamed Radzi 1 ,
Hashem Salarzadeh Jenatabadi 1 na1 &
Nadia Samsudin 1 na1

BMC Public Health volume 21 , Article number: 27 ( 2021 ) Cite this article

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29 Citations

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Since the last decade, postpartum depression (PPD) has been recognized as a significant public health problem, and several factors have been linked to PPD. Mothers at risk are rarely undetected and underdiagnosed. Our study aims to determine the factors leading to symptoms of depression using Structural Equation Modeling (SEM) analysis. In this research, we introduced a new framework for postpartum depression modeling for women.

We structured the model of this research to take into consideration the Malaysian culture in particular. A total of 387 postpartum women have completed the questionnaire. The symptoms of postpartum depression were examined using the Edinburgh Postnatal Depression Scale (EPDS), and they act as a dependent variable in this research model.

Four hundred fifty mothers were invited to participate in this research. 86% of the total distributed questionnaire received feedback. The majority of 79.6% of respondents were having depression symptoms. The highest coefficients of factor loading analysis obtained in every latent variable indicator were income (β = 0.77), screen time (β = 0.83), chips (β = 0.85), and anxiety (β = 0.88). Lifestyle, unhealthy food, and BMI variables were directly affected by the dependent variable. Based on the output, respondents with a high level of depression symptoms tended to consume more unhealthy food and had a high level of body mass indexes (BMI). The highest significant impact on depression level among postpartum women was unhealthy food consumption. Based on our model, the findings indicated that 76% of the variances stemmed from a variety of factors: socio-demographics, lifestyle, healthy food, unhealthy food, and BMI. The strength of the exogenous and endogenous variables in this research framework is strong.

The prevalence of postpartum women with depression symptoms in this study is considerably high. It is, therefore, imperative that postpartum women seek medical help to prevent postpartum depressive symptoms from worsening.

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The number of people diagnosed with depression has been steadily increasing over the years. It affects the patient’s work performance, financial status, and interpersonal relationships [ 1 ]. Depression can be observed from the individual’s passive behavior such as loss of interest, feelings of guilt, low self-respect, sleep-deprived, poor appetite, constantly being unhappy, or showing signs of fatigue [ 2 , 3 ]. Living with depression causes a serious disability to the patient because it is associated with mental and behavioral disorders [ 4 ]. It is highly probable that this condition affects the patient’s physical well-being leading to increased morbidity and mortality [ 1 , 5 , 6 ]. In 2017, the World Health Organization (WHO) reported that over 300 million people suffered from depression [ 7 ]. However, previous studies showed that depression typically occurred among women, as opposed to men [ 8 ]. The primary reasons for depression among women were attributed to hormonal transition, such as puberty, pregnancy, and menopausal changes [ 1 ]. In particular, after giving birth, a woman needs extra care and should be given the right kind of health care priorities. Moreover, any unpleasant act can cause depression at this stage which will be devastating for the whole family [ 9 ]. Postpartum depression (PPD) was identified as the number one complication that plagued one in seven women [ 10 ]. It has been estimated that more than 20% of women globally suffer from PPD [ 11 ]. PPD usually occurs 6 to 8 weeks after childbirth, which may lead to a decrease in an individual’s daily performance [ 12 ]. Mothers are commonly faced with discomfort due to physical changes, poor sleeping quality, and various uncertainties related to their newborns in the postpartum stage [ 13 ].

Today, PPD has become a major worldwide health problem. Even so, many women with this mental illness were not medically diagnosed [ 12 ]. Several factors associated with PPD have been identified, although the specific causes remained unknown [ 11 ]. Previous studies have shown that depression and obesity were closely linked [ 14 , 15 ]. The risk of depression was increased by almost 37% due to obesity among women. It is quite common among women to gain excessive weight during pregnancy and the postpartum period [ 16 ]. Ertel et al. [ 17 ] and LaCoursiere et al. [ 18 ] also claimed that there was some evidence regarding pre-pregnancy obesity, which may lead to PPD. This claim was also supported by similar research conducted by Ruyak et al. [ 19 ]. Mgonja and Schoening [ 10 ] and Ezzeddin et al. [ 20 ] further placed emphasis on the issue by examining factors, aside from obesity, that could lead to the development of PPD; the factor included poor marital relationships, divorce, substance abuse, violence, other mental health diagnoses, low educational levels, unwanted or unexpected pregnancies, complicated labor, and a weak health care support system. This assertion by Mgonja and Schoening were reinforced by similar findings by Azale et al. [ 21 ], Zhao et al. [ 22 ], and Ukatu, Clare, and Brulja [ 11 ] who focused on factors leading to maternal depression. Hence, Bledsoe et al. [ 23 ] concluded that the negative outcomes from social, educational, health, and economic aspects tend to contribute a high possibility for the development of PPD among women. There is significant evidence that genetics and biochemical factors (brain chemistry), personality style, illness, and significant transitions in life, including adjusting to living with a new baby, may also contribute to PPD [ 24 , 25 ]. Postpartum depression has also been linked to women’s lifestyle choices, such as sleep quality [ 26 ], exercise [ 27 ], and prenatal smoking [ 28 ]. Dos Santos et al. [ 29 ] concluded that women who were diagnosed with maternal depression also experienced a higher risk of eating disorders during their pregnancies. Unhealthy eating habits developed among pregnant women because they were afraid to gain weight whenever they ate. Nevertheless, pregnant women with an eating disorder could have healthier food options, and some were concerned with their body shape rather than their body weight [ 30 ]. In other words, body dissatisfaction seemed to be a predictor of weight gain during pregnancy due to lifestyle factors (e.g., physical activity, diet, stress, and fatigue levels) [ 31 ]. In essence, a mother needs to have healthy food in order to supply the right kinds of nutrition to her unborn child [ 32 ].

Unfortunately, there were very few studies that investigated the impact of lifestyle and food intake by considering the body mass index (BMI), which may be associated with the PPD occurrence among women. Previous studies on PPD were infrequent; some utilized a modeling technique to measure the output and estimated the suggested indicators. Despite the contribution of these variables to PPD, a combined analysis of indicators involved in postpartum depression is surprisingly non-existent. A Structural Equation Modelling (SEM) analysis would allow the integration of variables such as demographic, lifestyle, and food intake in a conceptual model, which interrelates each of these variables to PPD. Therefore, in this research work, the authors aimed to analyze the factors, which contribute to PPD, and its relationship with socio-demographics, the lifestyle of postpartum women, healthy food intake, unhealthy food intake, and BMI range, which affects PPD by using SEM analysis.

Research framework

The authors designed a research framework that correlated to PPD, as shown in Fig. 1 . The conceptual framework of the research model includes an integrated model capable of providing an inclusive evaluation of the latent and observed variables within the SEM framework. The framework comprises socio-demographics as the initial independent variable and the depression level as the dependent variable. The remaining variables which acted as mediators were lifestyle, healthy food, unhealthy food, and BMI. As the BMI needed to be calculated based on the respondent’s weight and height, it was the only measured variable in our research framework. These variables have been taken into consideration the Malaysian culture because Malaysia is a multiracial country and have various ethnic groups [ 33 ]. Thus, we had chosen the variables wisely which were practical among Malaysian mothers.

The research framework provides a clear view of the study is carried out. By constructing the framework, it will lead this research to achieve its objective. This research framework was constructed using a combination of a theoretical framework with the addition of some new ideas to analyze the model. According to previous studies, socio-demographic variables played a significant role in establishing the relationship between the variables to postpartum women. These variables include with their lifestyles [ 34 ], healthy food intake [ 35 ], unhealthy food intake [ 36 ], BMI [ 37 ], and depression [ 38 ]. Lifestyle intervention during the postpartum period that give an impact on healthy food and unhealthy food intake [ 39 ], BMI [ 40 ], and depression [ 41 ] had also been investigated by other researchers.

Apart from that, food consumption among postpartum women has an interrelationship with BMI that claimed by research conducted by Kay et al. [ 42 ]. It was reported by Nathanson et al. [ 35 ] that healthy food intake closely associated with depression. Yet, Faria-Schutzer et al. [ 43 ] claimed that unhealthy food intake correlated with depression. Based on Ertel et al.’s [ 17 ] research, the postpartum BMI level can be affected by the depression level.

Materials and measurements

In this research, socio-demographics were measured as the initial independent variable, which includes four indicators, i.e., age group, educational background, working experience, and income household per month. The age range was classified into four groups: 21 to 25 years old, 26 to 30 years old, 31 to 35 years old, and over 35 years old. The educational background of the respondents was categorized as “Less than high school”, “High school”, “Diploma”, “Bachelor’s degree” and “Master’s degree or Ph.D.”. The respondents were asked about their working experience, which was categorized as “no job experience”, “1 to 3 years”, “4 to 6 years”, “7 to 10 years”, and “more than 10 years”. The last question in the socio-demographic section was based on to the monthly household income in Ringgit Malaysia (RM) and the responses were classified as “Less than RM 2,000”, “RM 2,000-RM 3,000”, “More than RM 3,000 to RM 4,000”, “More than RM 4,000 to RM 5,000”, and “Over RM 5,000”.

Apart from that,the authors measured lifestyle based on Nakayama, Yamaguchi’s study [ 44 ] in which the authors selected a few indicators such as the average working hours per day, physical activity per week, and average sleeping hours per day. Besides, daily screen time (e.g., TV, smartphone, tablet, etc.) was added to measure the lifestyle of the respondents in terms of social media, which corresponded to Khajeheian et al.’s research [ 45 ]. Regarding the average working hours per day, the responses consisted of five categories denoted by “none”, “less than 7 hours”, “7 to 8 hours”, “8 to 9 hours” and “more than 9 hours”. As for the frequency of physical activity per week, this was indicated as “none”, “1 time”, “2 times”, “3 times”, “4 times”, and “more than 4 times”. The average screen time per day was denoted as “less than 1 hour”, “1 to 2 hours”, “2 to 3 hours”, “3 to 4 hours”, and “more than 4 hours”. The average sleeping hours per day were indicated as “less than 6 hours”, “6 to 7 hours”, “7 to 8 h”, “8 to 9 h”, and “more than 9 h”.

In addition to the mediators, the authors considered healthy and unhealthy food separately in this study. Fruits, vegetables, and whole grains were selected as ‘healthy food’ variables, whilst fast food such as sweets, chips, and soft drinks was categorized as ‘unhealthy food’ [ 42 , 46 ]. The respondents were asked about their healthy and unhealthy food intake, and the responses were based on a five-point scale (“never”, “rarely”, “sometimes”, “mostly”, and “always”) which have been used in the previous studies [ 47 ].

WHO defined BMI as a simple index of weight-to-height of an individual and calculated according to the formula, BMI = ((weight in kilograms)/ (height in meters) 2 ) [ 48 ]. There are four categories of BMI based on the BMI range including “underweight for less than 18.5 kg/m 2 ”, “normal for ranges between 18.5 to less than 25.0 kg/m 2 ”, “overweight for ranges between 25.0 kg/m 2 to less than 30.0 kg/m 2 ” and “obese for ranges between 30.0 kg/m 2 and above” [ 49 ].

For the dependent variable, the authors measured the depressive symptoms using the Edinburgh Postnatal Depression Scale (EPDS) questionnaire to validate prenatal and postpartum occurrences [ 50 , 51 , 52 , 53 ]. Moreover, previous studies have shown that EPDS had been validated in Malaysian samples as well [ 54 , 55 ]. EPDS was calculated using a four-point scale (0–4) for each item to measure the frequency of the depressive symptoms developed in the postpartum period. A total of 10 items was used in the EPDS to estimate the depressive symptoms of respondents that needed to be answered. The total score for the EPDS questions was then grouped into four categories with a different interpretation. A 0–9 score was categorized as “normal”, scores of 10–11 were categorized as “slightly increased risk”, scores of 12 to 15 as “increased risk” and those more than 15 were listed as “likely depression” [ 56 ].

Structural equation modeling (SEM)

The SEM technique was chosen to be used in this research as it was recognized as a suitable method that would most likely help a researcher to understand better the latent variables concepts and the interactions within the model. Several previous studies had used the structural equation methodology [ 57 , 58 ] in their studies due to its features. The features of SEM technique include being:

Capable of estimating and examining the direct and indirect interrelationships which exist among the variables in the research study [ 59 ].

Capable of showing the relationship among dependent variables, which helps indicate the simultaneous estimation of more than one exogenous and endogenous variable [ 60 ].

For sampling, we used a cross-sectional analysis. The survey data was collected from each subject at one point in time. Based on Hair et al. [ 61 ], the required sample size depended on the number of latent variables in the study, including the number of indicators. In other words, a)100 respondents were needed due to five or less latent variables, of which each of the latent variables included at least three indicators, b) 150 respondents were needed due to seven or less latent variables, of which each of the latent variables included at least three indicators, c) 300 respondents were needed since seven or less latent variables existed, of which some of the latent variables had less than three indicators, d) 500 respondents were needed due to the existence of more than seven latent variables, of which some of the latent variables had less than three indicators. In this research framework, the authors had five latent variables, to be precise. Thus, the authors were required to consider at least 150 respondents for a suitable sample size.

The respondents were selected randomly using proportionate stratified random sampling and the data were collected for almost 6 months. The questionnaires were self-administered and have been distributed online, by sending respondents the link. However, for respondents who don’t have access to the internet, they were given the printed questionnaire to fill up. The authors distributed 450 questionnaires to postpartum women who were living in Kuala Lumpur, the most highly populated city in Malaysia. We excluded the women who are not living in Kuala Lumpur from the analysis. A total of 387 completed questionnaires were received from the respondents. The data were collected from nine maternal and child health clinics around Kuala Lumpur. The maternal and child health clinics that we went for data collection were in the neighborhood area which most of the patients are living nearby the clinics. We chose to collect the data at the maternal and child health clinics because it was easy to recognize mothers in their one-year postpartum period as mothers went to the clinics for medical check-ups. The respondents were selected randomly as long as they met the main criteria, i.e., in the first postpartum year of their latest pregnancy. The survey was conducted under the backingsof the University of Malaya’s Research Ethics Committee approval (UM.TNC2/RC/H&E/UMREC 127) and with the grant obtained from the University of Malaya (Grant No.: GPF066B-2018andGC002C-17HNE).

Table 1 shows the descriptive statistics of this research. The respondents are made up of Malays (43.7%), Chinese (34.9%), and Indians (21.4%), who were mostly around 31 years of age and older. The majority of participants were educated and gained an income of over RM 3000 per month with 1 to 10 years of working experience. Based on the weight and height provided by the respondents, 38.0% of participants were obese, 28.7% were overweight, 24.8% were normal, and 8.5% were underweight. Regarding lifestyle, only 26.1% of respondents did not take part in any physical activities. The average sleeping hours of the respondents were around 7 to 9 h, coupled with 8 to 9 h working day. The mean screen time hours recorded were 4.08 (SD: 0.85 h) per day. In terms of the food intake among postpartum women, the majority of respondents mostly consumed fruits, vegetables, whole grains, fast food, and sweets. Apart from that, a large number of respondents always consumed chips and soft drinks. Based on the calculated EPDS score, only 20.4% of the respondents were normal. Depression levels for the rest of respondents were 25.3% (slightly increased risk), 32.6% (increased risk), and 21.7% (likely depression).

Fornell and Larcker [ 62 ] claimed that the validity and reliability of a survey needed to fit the requirements of the SEM analysis. The validity is supposed to be tested based on the Cronbach’s alpha coefficient. Every latent variable in the research framework should be equal to or higher than 0.7. The Cronbach’s alpha value in this research was more than 0.7, which aligned with the conditions required to validate this research. To examine the reliability of the research work, a loading factor higher than 0.7 needed to be obtained for the latent variable indicator (see Table 2 ). In Table 2 , several indicators obtain a factor loading coefficient of less than 0.7, which means that these indicators need to be eliminated from the SEM analysis.

The reliability of the research also needed to be fitted with another test after the elimination of these unfit indicators. All latent variables should obtain an equal or higher coefficient than 0.5 of the average variances extracted (AVE). AVE analysis for latent variables in this research achieved more than 0.5. Thus, in this research work, the validity and reliability features are fulfilled. The suitability of the research model was tested using the model fitting analysis. The comparative fit index (CFI), normed fit index (NFI), relative fit index (RFI), incremental fit index (IFI), the goodness of fit index (GFI), and Tucker-Lewis index (TLI) coefficient of this research were above 0.9, which means that the research data was acceptable. The structural model in the SEM analysis helped to recognize the connection between research variables and the considered conceptual model. Figure 2 shows the output of the structural model for postpartum women. From the pre-established 14 relationships between the research variables, only five relationships, represented by the dashed black arrow, were deemed not significant.

Final output of structural model

Figure 2 presents that R-square is equal to 0.76. which means that 76% of depression variations depend on BMI, healthy food intake, unhealthy food intake, lifestyle, and socio-demographics among postpartum women. The rest, 24% of depression variation belongs to other variables that were not involved inside the model. Moreover, from 14 relationships among research variables, nine of them have significant relationships. Among the four latent variables and one measurement variable, two of the latent variables i.e. unhealthy food and lifestyle, have a significant relationship with depression. Additionally, BMI as the only measurement variable has a significant relationship with depression. The highest relationships belong to unhealthy food intake → depression (0.84), lifestyle → depression (0.81), and BMI → depression (0.79). Socio-demographics, as the main independent variable has a significant relationship with healthy and unhealthy food intakes and there is no significant relationship with the lifestyle, BMI, and depression. However, socio-demographics has an indirect effect on depression through food intake mediators (socio-demographics →unhealthy food intake → BMI → depression) and (socio-demographics →unhealthy food intake → BMI → depression). As a result, socio-demographics has no direct effect on depression but have an indirect significant effect. Besides, socio-demographics also do not have a significant direct effect on BMI. It means that postpartum women with any spectrum of socio-demographics including age, education, income, and job experience has no significant effect on their BMI and depression. The correlation of these indicators as a latent variable indicates that their BMI and depression will be significantly affected through their food intake. Meanwhile, Table 3 presents the p -value of the final output obtained was significant (approximately p -value < 0.05).

This paper aimed to introduce a new postpartum depression model, which is designed based on factors associated with depression symptoms using the SEM technique. The depression levels of postpartum women were set as the dependent variable, and socio-demographics were maintained as an independent variable. In this research framework, lifestyle, healthy food, unhealthy food, and BMI acted as mediators. Based on previous theories and frameworks of postpartum depression, the authors designed an improved study model, as shown in Fig. 1 . The authors succeeded in gathering the questionnaires from 387 women diagnosed with postpartum. The respondents were into their first postnatal year, which matched the previous research conducted by Kubota et al. [ 51 ].

For this research model, 14 out of nine relationships among the variables were significant, with a positive coefficient. In Fig. 2 , we simplified our research model output. Thus, the significant impact of socio-demographics on healthy and unhealthy food is 0.39 and 0.56, respectively. It can be interpreted that respondents who have more money, good education backgrounds, and longer work experience tend to consume more unhealthy food than healthy food. Previous research [ 63 ] has reported that working mothers tend to feed the family with fast-food as it is the easiest and fastest way to prepare the meal. Yet, some research also mentioned that working mothers had bettereating practices [ 64 ]. These show a very contradictory output from the prior studies. On the other hand, it is claimed by Zagorsky and Smith [ 65 ] that adults from different levels of socio-demographicspreferred to consume fast food. This claim is supported by similar research done by Fryar, Hughes, Herrick, Ahluwalia [ 66 ]. Good educational background was linked with a greater frequency of fast food consumption among women as well [ 67 ]. In this research, we obtained a result showing that a high level of socio-demographics chose to eat unhealthy food more. It is proven before that the rationale for people consuming fast food due to convenience and wanted to socialize [ 68 ].

The age group indicator was eliminated from the SEM analysis, as the coefficient of factor loading did not achieve the required standard value. Additionally, the lifestyle variable is significant in terms of affecting the dependent variable in this research model. Referring to the factor loading analysis in Table 2 , the lifestyle indicators show that the average screen time hour has the highest loading factor, followed by the average working hour indicator. Previous studies have shown a positive correlation between smartphone addiction and depression [ 69 ]. The lifestyle factor had a significant impact on both food intake categories. An increase in terms of lifestyle will promote an increase in depression levels and food consumption, in particular, unhealthy food. Berk et al. [ 70 ] summarized that poor lifestyle and unhealthy diet contributed to depression.

Apart from that, healthy and unhealthy foods show a significant correlation with BMI in the structural model. In previous studies, it was reported that food consumption contributed to the BMI range [ 70 , 71 ]. To be exact, the quantity of the food that we consumed affected the BMI level. This will occur when you are eating healthy food but in a substantial amount, which will consequently lead to an increase in the BMI level. So, to apply healthy eating behavior, it is better to know the number of calories needed for the individual’s body. Based on the factor loading analysis in Table 2 , the chips indicator had the highest coefficient among the indicators of other food categories. Previous studies also claimed that snacks (i.e., chips) have an impact on the BMI of postpartum women [ 71 ]. When a comparison was made between the food categories’ impact on BMI, unhealthy food has a higher significant coefficient than healthy food. Therefore, an increase in unhealthy food intake will also increase the BMI levels of respondents. In Malaysia, unhealthy foods are easy to find and mostly cheaper than healthy food. As in Kuala Lumpur, a lot of 24-h restaurants are available, especially fast-food premises [ 72 ]. Thus, with the availability of easy food at any hours, people with high socio-economic backgrounds sometimes do choose to eat unhealthy food too. Even though people are well aware of the effect of eating unhealthy foods, it depends on an individual on what they choose to consume.

Based on Fig. 2 , unhealthy food and BMI have a significant impact on the depression levels, which seem to directly affect the dependent variables. The prevalence of overweight and obesity among postpartum women in the research sample is noted to be among the highest. From this research, the respondents who eat more unhealthy food and has a high level of BMI are considered to have a high level of depression. Several studies have claimed that depression has a link with maternal obesity [ 73 , 74 ]. Body dissatisfaction in terms of image, shape, or weight among women would probably affect their mental health.

In the EPDS section, the 10-item questions included anhedonia, self-blame, anxiety, fear or panic, inability to cope, sleeping difficulty, sadness, tearfulness, and self-harm ideas [ 75 ]. The descriptive output found that the majority of the respondents suffered from an increased risk of depression levels. The result of depression levels among mothers indeed raised concerns, where they needed help but did not get any. However, in the factor loading analysis, there are three indicators of depression, that have been eliminated from the SEM analysis- Q3, Q5, Q8 (self-blame, fear or panic, and sadness, respectively). Although the descriptive statistics data consider the total score of the EPDS for all 10-items of the depression level measurement, it had decided to remove these indicators, as it had been included in the process of the postpartum depression modeling. The highest loading factor of depression item concerning the anxiety issue (Q4), and the lowest is the anhedonia issue (Q1). For these issues, this research would be an effective platform for medical professionals to keep updated and act towards postpartum women who might feel ashamed or afraid to seek help in preventing them from depression.

Physical activity intervention plays a part in weight loss which happens to be an alternative for the prevention and treatment of the depression symptoms [ 76 ]. Moreover, poor sleep incite less motivation to do exercise that leads to weight gain and also obesity-related problemsas well as sleep disturbances [ 77 ]. Promotingphysical activity in an individual’s lifestyle can also benefit in averting the potentialenhancement of chronic diseases for which body weight is a risk factor [ 76 ]. Consistent with previous literature [ 78 ], excessive weight gain probably happen alliance with low physical activity. When ones living with obesity or overweight, their engagement to workout is so frustrating due to discomfort complaints in terms of musculoskeletal and sweating [ 77 ]. Prior literature proves that physical activity was correlated with lower BMI and depression levels [ 79 ].

Based on Fig. 2 , it is observed that the highest coefficient among the variables is the impact of unhealthy food on the depression levels. This corresponded with a previous study by Barker et al. [ 80 ], whereby the levels of depression symptoms were linked to unhealthy food consumption [ 81 , 82 ]. Regarding the research model output, the indirect impact of unhealthy food on the depression levels with the BMI level was identified. Previous studies reported that people who were obese and depressed consumed more unhealthy food [ 83 ]. The R-square (R 2 ) for the structural model in this research was 0.76. In relative terms, 76% of the variations in depression level were related to socio-demographics, lifestyle, healthy food, unhealthy food, and BMI. Only 24% of the variations correlated with other factors. Thus, it can be concluded that the strength of exogenous and endogenous variables in this research is strong.

However, this research had several limitations, as well. The respondent’s weight and height were self-reported in this study, despite previous research works which have also utilized this method, and although it is valid [ 84 , 85 , 86 ], it can be a possible limitation of the study. Furthermore, physical activity that we measured was defined as regular exercise (e.g., fast walking, jogging, cycling, swimming), which were mentioned in the questionnaire. Being a mother had change women’s lifestyle especially to engage in leisure-time especially physical activity [ 87 ]. Women seem to be a lack of doing any physical activity because of time constraints and managing their kids [ 88 ]. Mothers without husbands or partners were less physically active compared to married mothers [ 89 ]. Besides, some of them might work out in different places such as home, gym, park, etc. This indicator is not the main concern in this study. But it is a part of measuring how active the respondents were during the postpartum period.

While the dietary assessment was measured only by using a five-point Likert-type scale. Different BMI category needs different amounts of calories per day. As this research based on self-administrated questionnaires, the Likert-type scale seems to be the easiest way for respondents to report their dietary measurements. Not everyone knows how specific much of the food they consume every day. Yet, we believe that there a lot of ways to measure food intake. For example, the measurement would be in servings [ 90 ] or using the MooDFOOD dietary guidelines [ 91 ] which been used by recent studies.

Apart from that, the measurement of the depression levels using EPDS was not a substitute for a clinical diagnosis. EPDS was used in this research to determine depression symptoms, which the respondent might face as a form of risk. We acknowledge that many people who suffer from depression did not seek medical help [ 4 ]. Medical treatment programs for depression can be effective in reducing depression levels.

In this study, SEM with cross-sectional data could analyze the influence of lifestyle, healthy, and unhealthy food intake on depression. Nevertheless, our research framework, which was presented in Fig. 1 , is not capable of studying the vice versa effect of depression on lifestyle, healthy and unhealthy food intake. To overcome this matter, we recommend future studies to apply dynamic SEM with longitudinal data. Figure 3 illustrates an example of dynamic SEM pertaining to our research framework.

Dynamic SEM framework

The main framework of this study was prepared based on the combination of previous studies in obesity and depression model. However, calorie intake, genetics, and fiber intake are some of the variables that could be obesity indicators that might have been encompassed in our analysis. There were limitations to collect this type of data for this study, and it would have required a different research structure that could not be added in the current research framework. Hence, the analysis of these indicators in future studies is recommended.

To conclude, this research examined the effects of depression levels in terms of socio-demographics, lifestyle, healthy food, unhealthy food, and BMI. Besides, the hypothesized model in the present study had been indicated as a suitable model for predicting the depression levels among postpartum women. Subsequently, depression levels affect people’s lives (e.g., personal matters, health, eating behavior), and it means clinical intervention is necessary to prevent depression symptoms from exacerbating. This research is the first study on postpartum women diagnosed with depression symptoms, which were carried out using SEM. The factors associated with depression were presented in the theoretical framework. The associated variables and theories were aligned with the Malaysian culture and the associated environment. Thereby, we believe that this research may be advantageous for future works on the postpartum depression modeling, particularly among public health and life science research scholars.

Availability of data and materials

The data are not publicly available due to the University of Malaya Research Ethics Committee rules and regulations. The data that support the findings of this research are available upon reasonable request from the corresponding author and with permission of the University of Malaya Research Ethics Committee.

Abbreviations

Postpartum depression

Structural Equation Modeling

Body mass index (BMI)

Edinburgh Postnatal Depression Scale

Ringgit Malaysia

Comparative fit index

Normed fit index

Relative fit index

Incremental fit index

Goodness of fit index

Tucker-Lewis index

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Acknowledgements

The authors would like to express gratitude to all participants for their cooperation during the research.

This research was supported by University of Malaya, Malaysia (Grant No.: GPF066B-2018andGC002C-17HNE). The funders had no role in study design, data collection, and analysis, decision to publish or preparation of the manuscript. No additional external funding was received for this study.

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Hashem Salarzadeh Jenatabadi and Nadia Samsudin contributed equally to this work.

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Department of Science and Technology Studies, Faculty of Science, University of Malaya, 50603, Kuala Lumpur, Malaysia

Che Wan Jasimah Bt Wan Mohamed Radzi, Hashem Salarzadeh Jenatabadi & Nadia Samsudin

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Conceived of and designed the study: H.S.J and N.S. Performed the methodology: H.S.J and N.S. Analyzed and interpreted the data: H.S.J. Wrote the manuscript text: H.S.J., C.W.J.W.M.R., and N.S. All authors reviewed the manuscript. All authors read and approved the final manuscript.

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Wan Mohamed Radzi, C.W.J.B., Salarzadeh Jenatabadi, H. & Samsudin, N. Postpartum depression symptoms in survey-based research: a structural equation analysis. BMC Public Health 21 , 27 (2021). https://doi.org/10.1186/s12889-020-09999-2

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Published : 27 January 2021

DOI : https://doi.org/10.1186/s12889-020-09999-2

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Postpartum Depression—New Screening Recommendations and Treatments

1 University of Massachusetts Chan Medical School, Worcester
2 UMass Memorial Health, Worcester, Massachusetts
Medical News & Perspectives What to Know About the First Pill Approved for Postpartum Depression Rita Rubin, MA JAMA
Comment & Response Screening Recommendations and Treatments for Postpartum Depression—Reply Tiffany A. Moore Simas, MD, MPH, MEd; Anna Whelan, MD; Nancy Byatt, DO, MS, MBA JAMA
Comment & Response Screening Recommendations and Treatments for Postpartum Depression Itamar Nitzan, MD; Raylene Philips, MD; Robert D. White, MD JAMA

Perinatal mental health conditions are those that occur during pregnancy and the year following childbirth, whether onset of the condition(s) predates pregnancy or occurs in the perinatal period. Perinatal mental health conditions are the leading cause of overall and preventable maternal mortality and include a wide array of mental health conditions including anxiety, depression, and substance use disorders. 1 , 2 Perinatal depression specifically affects 1 in 7 perinatal individuals. 3 While commonly referred to as postpartum depression, it is more accurately called perinatal depression because its onset corresponds with prepregnancy (27%), pregnancy (33%), and postpartum (40%) time frames. 3

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Research article
Open access
Published: 21 November 2019

Postpartum depression and associated factors among mothers who gave birth in the last twelve months in Ankesha district, Awi zone, North West Ethiopia

Solomon Shitu 1 ,
Biftu Geda 2 &
Merga Dheresa 2

BMC Pregnancy and Childbirth volume 19 , Article number: 435 ( 2019 ) Cite this article

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Postpartum depression is the most common complication of childbearing age women and is a considerable public health problem. The transition into motherhood is a difficult period that involves significant changes in the psychological, social and physiological aspects, and has increased vulnerability for the development of mental illness. More than 1 in 10 pregnant women and 1 in 20 postnatal women in Ethiopia suffer from undetected depression.

Community based cross sectional study was conducted among 596 postpartum mothers in Ankesha District, North West Ethiopia, from February 01 to March 2, 2018. One stage cluster sampling technique was employed to get the study participants. The objective was to assess the prevalence and associated factors of postpartum depression among mothers who gave birth in the last Twelve months in Ankesha District, Awi Zone, North West Ethiopia, 2018. The interviewer-administered questionnaire was used to collect data and Eden Burg Postpartum Depression Scale was used to assess postpartum depression with cutoff point ≥8. The data were entered into Epi data version 3.1 and exported to SPSS version 24 for analysis. All variables with P < 0.25 in the bivariate analysis were included in the final model and statistical significance was declared at P < 0.05.

In this study, a total of 596 study participants were involved making a response rate of 97.4%, the prevalence of postpartum depression was 23.7% with 95%CI: 20.3–27.2. From the participant mothers who are divorced/widowed/unmarried (AOR = 3.45 95%CI: 1.35–8.82), unwanted pregnancy (AOR = 1.95 95%CI: 1.14–3.33), unpreferred infant sex (AOR = 1.79 95%CI: 1.13–2.86), infant illness (AOR = 2.08 95%CI: 1.30–3.34) and low social support (AOR = 3.16 95% CI: 1.55–6.43) was independent predictors of postpartum depression.

Almost a quarter (23.7%) of women suffers from postpartum depression. Marital status, unwanted pregnancy, unwanted infant sex, infant illness, and low social support were independent predictors of postpartum depression. Therefore, integration of mental illness with maternal and child health care is important, information communication education and behavioral change communications on postpartum depression are better been given attention.

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Postpartum depression (PPD) is a term applied to describe depressive symptoms occurring during the first year of the postpartum period and is characterized by low mood, loss of enjoyment, reduced energy, and activity, marked functional impairment, reduced self-esteem, ideas or acts of self-harm or suicide [ 1 , 2 , 3 ]. The women’s change into motherhood is a difficult period that involves significant changes in the psychological, social and physiological aspects, and considered increase vulnerability for the development of mental illness [ 4 ].

Mental health affects progress towards the achievement of several Sustainable Development Goals (SDGs), such as the promotion of gender equality and empowerment of women, reduction of child mortality and improvement of maternal health. By 2030 one of the goals of SDG to reduce premature mortality by one third from non-communicable diseases through prevention and treatment and promote mental health and wellbeing [ 5 ].

About 14% of the global burden of disease has been attributed to neuropsychiatric disorders, mostly due to the chronically disabling nature of depression and other common mental disorders [ 6 ]. Eleven percent of the total burden of disease in Ethiopia can be attributed to mental health disorders [ 7 ]. More than one in 10 pregnant women and one in 20 postnatal women in Ethiopia suffer from undetected depression [ 7 ].

In lifetime, women experienced depression two times more likely than men due to their reproductive nature, caring and rearing of children [ 8 ]. Postpartum depression becomes serious public health concern in the developing world and is predicted to become the most common cause of disability by the year 2020 associated with increased mortality through suicide also; it contributes to other associated diseases [ 9 ].

It is one of the most common complications of childbearing and is associated with impairments in mother–infant interactions that can lead to severe consequences for the infant such as illness, developmental delay, and poor growth [ 3 , 6 , 8 ] . Therefore, this study was aimed to show the prevalence and factors associated with PPD among postpartum mothers live in Ankesha district, Awi Zone, North West Ethiopia.

Study area and period

Community based quantitative cross sectional study was conducted in Ankesha District from February 1 to March 2 / 2018. Ankesha District is one of the Districts in Awi Zone, Amhara regional state of Ethiopia. The District has 31 rural kebeles. The annual report from the Ankesha District office in 2016/17 indicated that the health coverage of the district was 81.4%, institutional delivery 72%, ANC coverage 88%, PNC coverage 58% and immunization coverage 82% [ 10 ].

Source population

All reproductive age group women who gave birth in the last 12 months in Ankesha district.

Study population

All reproductive age mothers who were living in the selected kebeles and gave birth in the last 12 months.

Inclusion criteria

All mothers who gave birth before the interview and residents at least 6 months in the study area.

Exclusion criteria

Those mothers who are seriously ill and unable to respond at the time of data collection and mothers who delivered less than 2 weeks before data collection period were excluded from the study.

Sample size determination

The separate sample size was calculated for each specific objective by using both single and double population proportion formula. The sample size of the first objective was greater than that of the second objective. So the final sample size was come up by adding a non-response rate of 10% to the larger sample size which is 554. Therefore, the calculated sample size for this study was 609. Because of cluster sampling the design effect of 1.5 was added to calculate the sample size for both first and second objectives.

Data collection method

The questionnaires to assess mother’s socio-demographic characteristics, economic status were adapted from the Ethiopian Demographic and Health Survey (EDHS) 2016. Economic status (wealth index) was computed using principal component analysis (PCA) [ 11 ].

Questionnaire to assess depression was assessed by using EPDS. The EPDS is a 10-item self-reporting scale based on a 1 week recall and is specifically designed to screen for PPD. Those women who scored 8 and above were categorized as depressed while women who scored below 8 were considered as none depressed [ 12 ]. Social support was measured using the Maternity Social Support Scale (MSSS). The scale contains six items and includes questions on family support, friendship network, and help from a spouse, conflict with a spouse, feeling controlled by a spouse, and feeling unloved by family. Each item measures a five-point Likert scale and a total score of 30 was possible. Social support is classified into three categories; high social support (for scores 24–30), medium social support (18–23) and low social support (below 18). The questionnaire is adapted from previous study on the association between social support and PPD [ 13 ]. Substance abuse of both women and husband was assessed by questionnaire adapted from Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria used to diagnose substance abuse [ 14 ]. A source of information about mental health was also included in the tool.

The data collectors were collected the data through face to face interview.

Dependent variable

Postpartum depression

Independent variable

Socio-demographic and economic factors, pregnancy/Obstetric related factors, social support, substance abuse of husband and women, infant sex, mothers’ infant sex preference, previous history of depression, source of information about PPD

Operational definition

Postpartum depressed.

Those postpartum mothers who score ≥ 8 cut off point of EPDS. From ten questions each of which has four choices resulting maximum score of 30 and a minimum 0 [ 15 ].

Normal postpartum (not depressed)

Those mothers who score < 8 cuts off point of EPDS [ 15 ]

Social support

Social support of the women was measured by MSSS and classified in to three categories;

❖ High social support (for scores 24–30)

❖ Medium social support (18–23)

❖ Low social support (below 18) [ 13 ].

Data quality control

The questionnaire was initially prepared in the English language and then translated into Amharic and local language “Awigna” by experts and back-translated to English to check the consistency. The questionnaire was checked for completeness before data entry into software. Proper coding and categorization of data were maintained for the quality of the data to be analyzed. Double data entry was done for its validity and compare to the original data. The pre-test was carried out on 5% of study subjects in one of the kebeles in the District which was not selected as the study kebeles.

Data processing and analysis

The data was coded, cleaned, edited and entered into Epi data version 3.1 to minimize logical errors, then the data was exported to SPSS window version 24 for analysis. The analysis was done by computing proportions and summary statistics. Then the information was presented by using simple frequencies, tables, pie charts and figures. Bivariate analysis and multivariate analysis was computed to see the association between each independent variable and the outcome variable by using binary logistic regression. The assumptions for binary logistic regression were checked and values below 0.25 in the Bi-variate analysis were considered as candidate variables for multivariate logistic regression [ 16 ] to control all possible confounders. The multi co-linearity test was done to see the correlation between independent variables by using the standard error. Hosmer-Lemeshow’s test was found to be insignificant and Omnibus tests were significant which indicates the model was fitted. The direction and strength of statistical association were measured by the odds ratio with 95% CI. The adjusted odds ratio along with 95% CI was estimated to identify factors for PPD by using multivariate analysis in binary logistic regression. In this study P -value < 0.05 was considered as statistically significant.

Socio-demographic characteristics

In this study, a total of 596 study participants were involved making a response rate of 97.4%. The mean age of the participants was 30.57 (SD ± 6.3) years. More than half 310 of the participants were between the age group of 25–34 years. Half (301) of participants were farmers in their occupation followed by housewives 206 (34.6%). Three forth 441 (74%) of the participant’s husbands were farmers. Two hundred eighteen (36.6%) participant families wealth index were in third quantile (Table 1 ) .

A larger proportion of participants 573 (96.1%) claimed they were Ortodox Christianity religion followers, whereas protestant religion consittuents 16 (3%) and other like traditional 7 (1.2%). Of the participants about two-third, 404 (67.8%) were no formal education followed by primary education 154 (25.8%) and secondary and above 38 (6.4%). From husbands of participants, more than three forth 444 (78%) have no formal education followed by primary, secondary and above with magnitude of 95 (16.7%) and 30 (5.3%) respectively.

Obstetrics characteristics

Two third (389) of participants were multiparous and 505 (84%) have two or more alive children. From the participants, 487 (81.7%) have no history of abortion. More than three fourth 475 of study participants replied that their current pregancny was wanted, and 446 (74.8%) participants attended ANC follow up at least once and 173 (38.8%) had four ANC follow up. Among 446 ANC attendee participants, 397 (89%) of them had not counseled about PPD. Thirty nine percent (234) of study participants was attended pregnant mothers monthly meeting during pregnancy, from those who attended the meeting only 15(6.4%) was discussed about PPD.

Nearly two-thirds of 373 (62.6%) were delivered by SVD. From participants, one forth (149) was given birth at home. Mothers who deliver at institution 258 (57.7%) was stayed less or equal to 1 day at institution. More than half 321 of the participant’s current infants were females. For 334 (56%) women the desired sex was male and 319 (53.5%) of the mother’s sex preference was not meet. Thirty-one percent (185) of infants were ill and from those, more than two-third 131 (70.8%) were treated by inpatient or outpatient. Of the participants, 111 (18.6%) was the previous history of neonatal loss. One hundred eleven (18.6%) participants were PNC follow up from those more than three forth 94 (85%) were not counseled about PPD. Postpartum home care was given by family for most 411 (69%) of participants followed by HEWs 105 (17.6%) and neighbors 80 (13.4%) (Table 2 ).

Previous history of depression

Almost all 581 (97.5%) had no history of mental illness. From the participants, more than three forth 549 (91%) had no previous history of depression. Five hundred seven (85%) of study participants had no family history of mental illness.

Substance abuse and social support

From the total study participants, almost all 578 (97%) were not substance abused. The husbands of participants 497 (87.4%) were not substance abused .

More than half 316 (53%) of participants social support was medium while 74 (12.4%) was high (Fig. 1 ).

Social support of study participants who delivered in the past 12 months in Ankesha District, North West Ethiopia, 2018 ( n = 596)

Prevalence of postpartum depression

In this study the proportion of women who had PPD was 141 (23.7%) with 95% CI: 20.3–27.2. Mean score of 6.69, (Std. Deviation ±4.33), Minimum cumulative score 0 (1), Maximum cumulative score 22 (1). Most of respondents 141 (23.7%) score 5 followed by 99 (16.6%) score 6.

Predictors of postpartum depression

Variables that fulfill the criteria in Bivariate analysis were marital status, parity, number of alive babies, unwanted pregnancy, delivery complication, mothers’ preference for the infant’s gender, illness of the infant, previous neonatal loss, previous history of depression, husbands substance abuse and social support. These variables were enterd in to a multivariate logistic regression model from that, marital status, unwanted pregnancy, mothers’s preference for the infant’s gender, infant illness and social support were statistically associated with PPD. Divorced/widowed/single participants were 3.45 times more likely to develop PPD than married (AOR = 3.45 95%CI: 1.35–8.82). Mothers whose preganacies were unwanted (AOR = 1.95 95%CI: 1.14–3.33) and those who got infant of unpreferred sex (AOR = 1.79 95%CI: 1.13–2.86) were found to be significant factors for postpartum depression.

Respondents whose baby was ill before data collection were two times more likely depressed than those who were not ill (AOR = 2.08 95% CI: 1.30–3.34). Mothers who had a previous history of depression were 3.7 times more likely depressed than their counterparts (COR = 3.73 95%CI: 2.086–6.67). Those participants with low social support were 3.16 times more likely depressed than those who had high social support (AOR = 3.16 95%CI: 1.55–6.43) (Table 3 ).

In this study, the prevalence of PPD was 23.7% (95% CI: 20.3–27.2). Factors like marital status, prim parity, unwanted pregnancy, delivery complication, number of live babies, unpreferred infant sex by the mother, infant illness, previous infant loss, previous history of depression, substance abuse of husband and social support were associated with PPD in Bivariate analysis. Marital status, unwanted pregnancy, unmet sex preference of the mother, infant illness and social support were independently associated with PPD.

In this study, nearly one-forth of the study participants suffered from postpartum depression. This finding was in line with the studies conducted in Pakistan (23%), Bangladesh (22%), North Gonder (24.1%) and Bahir Dar (21.5%) [ 17 , 18 , 19 ]. The result was slightly higher than studies conducted in Argentina (18.6%), Kenya (20%), Egypt (7.1%), Malawi (11%), Butajira (12.7%) and Eastern tigray (19%) [ 9 , 16 , 20 , 21 , 22 , 23 ]. But it was lower than studies conducted in China (27.37%), Basra (31.5%), India (48.5%) and Zimbabwe (33%) [ 24 , 25 , 26 ]. The possible reason for the variation of the result may be the difference in assessment tool and cut off point values used to classify mothers as depressed and not depressed. Population differences also may contribute to the variation because some studies were done in urban settings. Besides, it could also be due to the methodological difference, some of the studies used institution based study design with low sample size.

(Divorced/widowed/ unmarried) women were 3.45 times more likely to develop PPD than married. Possibly, those women are prone to social, economic, and psychological challenges, which in turn may aggravate the condition of depression. It may also be the fact that the issue of adverse life events of losing someone they like most, then both economical and social loss follows. This is inconsistent with studies conducted in Kenya and three zones of the Amhara region, Ethiopia [ 19 , 27 ].

Mothers who had unwanted pregnancy were two times more likely to be depressed than women whose pregnancy was wanted. This is in line with studies conducted in Mexico, India, India Bangalore, Egypt [ 21 , 26 , 28 , 29 ]. The reason may be due to pregnancy in itself is a major experience in women’s life, So it demands physiological, psychological, social adjustments and financial preparation. The social and economic burden resulting from unplanned pregnancies for which adequate preparation was not made might result in psychological distress. Also in our setting unwanted pregnancy is mostly associated with economical status and this can be lead to worrying for parents’ and the coming babies’ basic needs and better quality life.

The women whose infant sex not preferred by the mother were 1.75 times more likely to develop depression than those infant sex preferred. This finding is in line with studies conducted in Basra, Mexico, Kenya [ 25 , 28 , 30 ]. The reason may be due to the preferred sex of the mother is mostly preferred sex of the family as a whole, So if this is not meet there may be social isolation lead to stress and depression.

Respondents whose baby was ill before data collection were two times more likely depressed than those who were not ill. This finding is in line with studies done in India [ 26 ]. This might be since negative life events are most influential on an individual’s mental status. It also might be because they frightened about the lose of their infant. Also, economically payment for the baby’s treatment and if there is admission there is overcrowding of health institutions that may make the mother anxious and depressed.

Those participants with low social support were 3.3 times more likely depressed than those who had high social support. This finding agreed with many studies conducted in different areas like India, Arab, Sudan, two studies in Ethiopia [ 16 , 18 , 31 , 32 , 33 ]. The reason may be due to that not having social support makes them vulnerable to stress, loneliness and hopelessness. Also, those women who received a partner’s support during their postpartum period will empower them to deal with their home responsibility. In addition, the fact that social support plays a buffering role from stressful life events by providing resources, support, and strength during postpartum period.

As this study indicates socio-demographic factors like age, educational status, occupation and economic status of the mother were not significantly associated with PPD. This is contradicted with studies done in Basra, Iran, India [ 29 , 31 , 34 ]. The reason may be due to demographical and socio-cultural differences. Obstetric factors like complications during delivery, mode of delivery by cesarean section were not significantly associated in this study. This is incongruent with the study done in Argentina and Egypt [ 20 , 21 ]. This may be because there are some improvements in the health care systems on maternal health. Substance abuse of both women and husband were not significantly associated with PPD in this study. The finding differs from studies done in Canada, Mexico, Northern India, Bale zones, Oromia region of Ethiopia [ 12 , 20 , 28 , 31 , 35 ]. The reason may be due to culture protects the participants and their husbands from substance abuse.

Due to social isolation and stigma towards mental illness respondents might not respond correctly. The study might be subjected to recall bias because the mothers failed to remember previous conditions. Because of the cross-sectional study design, the study might not show cause and effect relationships.

One in five women in the study area suffers from postpartum depression. This sparkes light to health professionals to pay attention to the prevention and treatment of postpartum depression. Marital status, unwanted pregnancy, unpreferred infant sex by the mother, infant illness and poor social support were independently associated with postpartum depression.

Availability of data and materials

The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.

Abbreviations

Confidence Interval

Central Statistical Agency

Ethiopian Demographic Health Survey

Eden Burg Post Partum Depression Scale

Haramaya University

Integrated Emergency Obstetric and Surgery

Institutional Health Research Ethics Review Committee

Lower and Middle Income Countries

Maternity Social Support Scale

Principal Investigator

Post Partum Depression

Sustainable Development Goal

Statistical Package for Social Science

World Health Organization

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Acknowledgements

We would like to thank Wolkite University and Haramaya University for the technical support for the study. Special thanks to Ankesha District health office workers who gave support during data collection, data collectors and all mothers in the study area who participate in this study. We would also like to appreciate Haramaya University to make accessible our document on electronic media.

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SS has conceived of the study, carried out the overall design and execution of the study, performed data collection and statistical analysis and drafted the manuscript. BG, MD has participated in the revision of the design of the study, data collection techniques and helped the statistical analysis. All authors read and approved the final manuscript.

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Ethical clearance was obtained from Haramaya University, College of Health and Medical Sciences, Institutional Health Research Ethics Review Committee (IHRERC). A formal letter for permission and support was written to zonal health department of Awi from Haramaya University, and then from Awi zone health department to Ankesha District health office. Written and signed voluntary consent was obtained from all study participants prior to the interview.

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Shitu, S., Geda, B. & Dheresa, M. Postpartum depression and associated factors among mothers who gave birth in the last twelve months in Ankesha district, Awi zone, North West Ethiopia. BMC Pregnancy Childbirth 19 , 435 (2019). https://doi.org/10.1186/s12884-019-2594-y

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REVIEW article

Postpartum depression: current status and possible identification using biomarkers.

$\nYi Yu,$

1 Central Laboratory, Yangjiang People's Hospital, Yangjiang, China
2 Center for Analyses and Measurements, College of Chemical Engineering, Zhejiang University of Technology, Hangzhou, China
3 Institute of Cell Biology, Zhejiang University, Hangzhou, China

Postpartum depression (PPD) is a serious health issue that can affect about 15% of the female population within after giving birth. It often conveys significant negative consequences to the offsprings. The symptoms and risk factors are somewhat similar to those found in non-postpartum depression. The main difference resides in the fact that PPD is triggered by postpartum specific factors, including especially biological changes in the hormone levels. Patients are usually diagnosed using a questionnaire onsite or in a clinic. Treatment of PPD often involves psychotherapy and antidepressant medications. In recent years, there have been more researches on the identification of biological markers for PPD. In this review, we will focus on the current research status of PPD, with an emphasis on the recent progress made on the identification of PPD biomarkers.

Introduction

Postpartum depression (PPD) has raised a major public health concern. It has been estimated that about 15% of women within 1 year after childbirth may suffer from PPD ( 1 ). Like major depression, PPD is a disabling disorder. Significant negative effects of PPD on children, even after they grow into adulthood, have been documented in the literature. PPD-related suicide has become the second-leading cause of death for women in the postpartum period ( 2 ). While antidepressants have been effective in treating PPD in many cases, possible side effects of antidepressant medication have been of great concern. Therefore, it is crucial to identify PPD at an early stage.

Although, known since 400 BC, PPD it did not catch wide attention until about half a century ago. Over the past decades, there have been many research efforts and reviews in the field of PPD. Grace et al. ( 3 ) reviewed the literature and found that PPD confers small effects on cognitive development such as language and IQ. Behavioral effects may persist up to 5 years post partum and beyond. Dennis and McQueen ( 4 ) reported that women with depressive symptoms at the early stage of the postpartum period were associated with increased risk for negative infant feeding outcomes. The review by Blum ( 5 ) focused on the psychodynamics of PPD, and found that a triad of three common, specific emotional conflicts (dependency conflicts, anger conflicts, and motherhood conflicts) was typical of many women who develop PPD. Yawn et al. ( 6 ) found that among those evaluated programs between 2000 and 2010, only four studies included patient outcomes, and only two reported success in improving outcomes. O'Hara and McCabe ( 7 ) found that the results of most studies did not seem to converge, and the majority had a small sample size or suffered from a lack of proper controls. Anderson and Maes ( 8 ) reviewed the biological aspects of PPD, and suggested that tryptophan catabolites, indoleamine 2,3-dioxygenase, serotonin, and autoimmunity play a powerful role in immuno-inflammation and oxidative and nitrosative stress. Furthermore, decreased level of endogenous anti-inflammatory compounds together with decreased ω-3 poly-unsaturated fatty acids (PUFA) in the post-partum period may be a central cause for PPD. Kim et al. ( 9 ) conducted a review on the role of oxytocin in the treatment of PPD, and found that the results was inconsistent. Yim et al. ( 10 ) conducted a review on researches published between 2000 and 2013 on the predictors for PPD and found that the biological and psychosocial literatures were largely disconnected, and integrative analyses were rare to find. They reported that the strongest biological predictors for PPD risk were hypothalamic-pituitary-adrenal (HPA) axis dysregulation, inflammatory processes, and genetic vulnerabilities, while the strongest psychosocial predictors were severe life events, chronic strain, poor relationship quality, and family support. There are many other reviews on PPD in the literature, which can be classified mainly into two distinct categories: biological vs. psychosocial approaches. The former addressed the endocrine system, the immune system, and genetic factors ( 11 – 14 ), while the latter addressed stressors and interpersonal relationships ( 5 , 15 – 17 ). Reviews that covered both categories ( 18 , 19 ) are relatively rare.

In the present review, we shall emphasize on the literature on PPD in the past several years. There has been an increasing number of researches on the screening and diagnosis of PPD using biological markers. Several biomarkers have been identified using the modern technology of multi-omics. The omics-based biomarkers can provide a more quantitative and objective criterion for the diagnosis of PPD, compared with the questionnaire-based diagnosis.

Diagnosis of PPD

There remains a controversy regarding the criterion for the onset time of PPD ( 1 ). The Diagnostic and Statistical Manual of Mental Disorders revision 5 (DSM-5) of the US encompasses episodes that sets in during pregnancy ( 20 ) and that begin within 6 months of delivery. In clinical practice and in various studies in the literature, the onset time for PPD has been generalized to up to 1 year post-partum.

A clinical interview can be used to diagnose PPD, such as the Structured Clinical Interview for the DSM-IV ( 21 ). Alternatively, easy-to-use self-report measures such as questionnaires have also been widely used for clinical assessment. The most prominent and widely used is the Edinburgh Postnatal Depression Scale (EPDS) ( 22 ), which has been reported to be reliable, well-validated, and often more practical and cost-effective in wide-scale screenings for PPD risk ( 23 ). EPDS lays an emphasis on psychic symptoms of depression, so as to reduce the weight of common symptoms of most new mothers. Other commonly used questionnaire-based screening tools include two-item Patient Health Questionnaire (PHQ-2) ( 24 ) and 9-item Patient Health Questionnaire (PHQ-9) ( 25 ). PHQ-2 contains the first two items of the PHQ-9. A typical EPDS or PHQ-9 score of 10 or above is used as the cutoff for being PPD positive. Brief subscales of EPDS have also been designed ( 26 ), such as 3-item, 7-item and 2-item subscales. Other screening tools include the Hamilton Rating Scale for Depredession (HAM-D) ( 27 ), which was not designed for PPD specifically. The reliability of HAM-D varies significantly in different evaluations, ranging from 0.46 to 0.98 ( 28 ). Other scales for diagnosing related mood disorders, such as the Bipolar Spectrum Diagnostic Scale (BSDS) ( 29 ) for bipolar disorders (BD), may also become relevant when such disorders occur during the perinatal period.

Etiological Models of PPD

The exact causes of PPD are still unknown. Models of PPD can mainly be divided into two categories: biological vs. psychological models. Integrated models of both are rare. However, many existing studies suffer from relatively small sample sizes or lack of control (or both), and none of the models mentioned here is conclusive.

Biological Models

It is well-known that childbirth is accompanied by a dramatic decreases in several hormones, such as estradiol, progesterone, and cortisol. In withdrawal models , reproductive hormones ( 30 ) and stress hormones ( 31 ) rise dramatically during pregnancy and then drop suddenly upon delivery, and thus leads to system dysregulation and hence PPD ( 32 ). These models cannot explain how the hormonal withdrawal acts to cause depression in women, nor can they explain those depressive symptoms that begin during pregnancy before parturition.

In depression models , PPD is associated with dysregulation of stress hormones , particularly cortisol ( 12 ). Several recent reviews suggested that dysregulation of the HPA axis plays a main role in the development of PPD ( 33 , 34 ). Diminished dopaminergic function may also play a role in PPD ( 35 ). Sudden estradiol withdrawal could lead to dysregulation in brain dopaminergic pathways and hence PPD. Multiple neuroendocrine changes caused by pregnancy may also play a role in PPD development, including dysfunctional gamma-aminobutyric acid (GABA) signaling ( 36 , 37 ). PPD has also been found to be associated with low allopregnanolone levels during pregnancy ( 38 ). The involvement of GABA and allopregnanolone in PPD has also been hypothesized in other models of PPD pathophysiology ( 39 ).

Psychological Models

Psychological models emphasize the deleterious role of psychological stressors and underlying cognitive vulnerabilities and the ameliorating role of psychosocial resources. In these theories, pregnancy, childbirth, and new parenthood are stressors that cause women to develop PPD symptoms. One can find consistent support for these models in the psychological literature ( 32 , 40 , 41 ).

Integrated Models

An integrated model may bridge the biological and psychological theories. For example, in the stress vulnerability model, stress can cause PPD symptoms in women that have genetic, hormonal, and cognitive vulnerabilities ( 32 ). The bio-psycho-social-cultural model of Halbreich ( 42 ) is a combination of the stress vulnerability model with biological and cultural factors. There exists limited evidence in the literature that supports these integrated models.

Evolutionary Models

Models from an evolutionary perspective regard PPD as a consequence of modern civilization, due to psychological adaptation during the human evolution. Hagen ( 43 ) proposed that PPD could cause parents to reduce or eliminate investment in infants that may have health and development problems, and it also may help them negotiate greater levels of investment from others. Recently, Hahn-Holbrook and Haselton ( 44 ) proposed a “mismatch hypothesis” of PPD that dramatic cultural changes that have occurred over the past century leads to significant divergences from the typical lifestyles throughout human evolutionary history, and gives rise to the current high incidence rate of PPD, suggesting that PPD may be a “disease of civilization.”

Treatment of PPD

Psychological treatment usually happens in the form of counseling (or psychotherapy), either one-on-one with a psychologist or in a group setting ( 45 ), and has been extremely beneficial for many women. Some women can effectively recover from their depression through counseling alone, while others may have to undergo counseling in conjunction with the use of antidepressants. Thus far, strong support can be found in the literature that a variety of psychological treatments of PPD can be effective.

Medical treatment for PPD includes pharmacotherapy with antidepressants. In fact, antidepressant medication is the most common treatment for PPD ( 46 ). There have been extensive investigations of a broad spectrum of antidepressants in the treatment of PPD, and many have been found to be associated with symptomatic improvement ( 46 ), and to be as effective as usual care plus counseling ( 47 ). Recently, an allopregnanolone-based treatment for PPD, brexanolone, now commercially called Zulresso®, has been approved by the Food and Drug Administration (FDA) in the United States as a fast-acting, long-lasting antidepressant ( 48 ). In double-blind, randomized, controlled clinical studies, brexanolone injection has been observed to be associated with a rapid reduction at 60 h in depressive symptoms compared to placebo, and the reduction could sustain no <30 days with broad responses ( 49 ).

Regarding the drug exposure of the infant through breastfeeding, a few reviews ( 50 – 53 ) concluded that nortriptyline, paroxetine, and sertraline have the strongest safety performance during lactation.

It should be noted that PPD may share some common genetic and biological risk factors and biomarkers with other mood disorders such as the major depressive disorder (MDD) and the bipolar disorder (BD). In this sense, PPD may be viewed as a forming part of a unique mood spectrum ( 54 , 55 ). Accordingly, these common features may cause misdiagnosis. Indeed, patients with BD may sometimes be misdiagnosed as having MDD, leading to inappropriate treatment with antidepressant medication ( 29 , 56 ). The misuse of antidepressants in patients with BD without mood-regulators may induce (hypo)mania or rapid cycling and may increase the risk of illness recurrence ( 57 – 60 ). Therefore, to ensure proper treatment, extra caution must be excised to ensure proper diagnosis.

Psychosocial Risks Factors for PPD

A very large body of literature has addressed risk factors for PPD based on cross-sectional and prospective studies ( 45 ). According to several meta-analyses of risk factors for PPD ( 15 , 16 ), risk factors can be categorized based on the strength of their association with PPD. Depression and anxiety during pregnancy, postpartum blues, history of depression, neuroticism, stressful life events, poor marital relationship, and poor social support, low self-esteem, as well as some cognitive emotion regulation strategies ( 61 ) have been found to have a strong or moderately strong association. A large-scale population based study ( 62 ), using data on more than 700,000 deliveries in Sweden between 1997 and 2008, reported that the risk of PPD for women with a depression history was over 20 times higher than women without. On the other hand, low socioeconomic status (SES), single marital status, unwanted pregnancy, obstetrical stressors, and difficult infant temperament ( 63 , 64 ) have been reported to exhibit a relatively weaker association. Maternal attitudes ( 65 ), women's experience of a various related complications such preterm birth, prenatal hospitalization, emergency cesarean section, pre-eclampsia, and poor infant health ( 66 ), can also cause an elevated risk of developing PPD ( 67 – 69 ). These risk factors are more closely related to the social and psychological aspects rather than biological aspects.

Biological Predictors and Biomarkers for PPD

In recent years, more development has been made to identify the biological predictors for PPD. Substantial biological changes can be associated with pregnancy. Such changes are necessary in order to maintain normal pregnancy and fetal development, as well as successful labor and lactation. Upon parturition, the intricate balance that has developed during gestation to sustain the maternal-placental-fetal unit is suddenly no longer needed. Furthermore, the maternal system has to undergo a dramatic biological changes into the lactation phase within a short time. It may days or even months to re-establish a new biological balance. It is conceivable that failure to re-establish the balance properly and promptly may cause maternal mental health issues in return.

Genetic and Epigenetic Studies

It is generally hoped that investment of possible genetic causes of a psychiatric disorder may help to reveal the underlying pathophysiological mechanism, which can help to find cures or improved treatments. Studies revealed that there may exist an underlying genetic cause for PPD ( 70 ). Viktorin et al. ( 71 ) found that the heritability of perinatal depression was estimated at 54 and 44%, respectively, in twin and sibling samples, which means that about half of the variability in perinatal depression can be explained by genetic factors. This is substantially higher than the heritability of non-perinatal depression at 32%. Forty et al. ( 72 ) and Murphy-Eberenz et al. ( 73 ) reported that PPD with onset within 4 weeks post-parturm exhibits familiality in families with MDD. These studies suggest that, while it also has its own unique features, the genetic basis for PPD may partially overlap with that for other mood disorders.

Unlike MDD, there have been relatively fewer studies addressing genetic contribution to PPD. A partial summary of genetic association studies of PPD was tabulated by Payne ( 70 ). In these studies, various genes were investigated for their roles in PPD symptoms, such as those associated with the regulation of the HPA axis, sex hormones, and the effects of stress on the prefrontal cortex ( 1 ). Mahon et al. ( 74 ) examined the genetic etiology of postpartum mood disorders using genome-wide data. They found that genetic variations on chromosomes 1 and 9 may increase susceptibility to postpartum mood symptoms, for women who had a history of pregnancy and any best-estimate mood disorder diagnosis. Specifically, the genes HMCN1 and METTL13 may contain polymorphisms that confer susceptibility to postpartum mood symptoms. Nevertheless, these associations were not significant enough to sustain statistical corrections from multiple testing. Alvim-Soares et al. ( 75 ) found that a HMCN1 polymorphism (rs2891230) is associated with PPD symptoms, and the heterozygosity for this single nucleotide polymorphism (SNP) was associated with an increased risk of PPD, in a sample of 110 randomly selected, unrelated Brazilian women of European descent, assessed at 8 weeks postpartum. Their result seems to support the finding of Mahon et al., however, future studies with a larger sample size are certainly needed. Costas et al. ( 76 ) reported a significant association (with p = 0.002) between the SNP rs11924390 between SNP at the transcriptional start site of kininogen 1 and PPD during the first 32 weeks after delivery. Clear signatures of gene expression of mononuclear cells were found in woman with PPD symptoms as compared with healthy controls ( 77 , 78 ). The usefulness of this study, however, suffered from its small sample size. Further studies with a larger sample size are warranted in order to confirm these associations. Nonetheless, while these results differ, they are not inconsistent with one another.

The serotonin transporter gene (SER T) has been one of the most widely studied candidate gene associated with PPD ( 70 ). It has two primary polymorphisms, 5-HTTLPR and STin2VNTR ( 10 ). The former contains a 44-bp deletion or insertion in the promoter region, corresponding to the short and long allele variants, respectively. The latter polymorphism involves a variable number of tandem repeats (VNTR) in the second intron, among which the longer VNTRs have been found to be associated with mental health issues and depressive disorders. So far, studies have shown mixed results on the role of SER T polymorphisms in PPD. Lesch and Mössner ( 79 ) found that the short allele may be associated with higher risk of developing PPD. However, the long allele variant of the 5-HTTLPR (serotonin transporter, i.e., 5-HTT, linked polymorphic region) was also reported to be associated with PPD symptoms at 6 weeks ( 80 , 81 ) or within 1 year post-partum ( 82 ).

A weak link between estrogen receptor gene (ESR1) and PPD has been reported ( 76 , 83 ), which, however, failed to remain statistically significant when corrections for multiple tests were taken into account. It was also suggested that the role for ESR1 in the etiology of PPD could possibly be mediated through the modulation of serotonin signaling ( 83 ). Mehta et al. ( 84 ) found that women with PPD (with onset within 7 weeks after delivery) displayed an increased sensitivity to estrogen signaling in comparison with controls. While these studies indeed support the idea that estrogen plays a role in the development of PPD, they are far from being conclusive, partly because of the relatively small sample size in these studies.

Catechol-Omethyltransferase (COMT) and monoamine oxidase-A (MAO-A) are allelic gene variations in the monoaminergic system. They have been shown to be related to MDD. The former is involved in dopamine and noradrenalin metabolism, while the latter plays a role in the degradation of serotonin and noradrenaline in the brain ( 85 ). A few studies revealed that MAO-A and COMT may be associated with PPDs that have an onset within 8 weeks postpartum ( 75 , 81 , 86 ). Sacher et al. ( 87 ) found an association between PPD and greater MAO-A V T (an index of MAO-A density) in the prefrontal and anterior cingulate cortex, compared to healthy controls.

Oxytocin has been found to plays an important role in physiological and genetic systems that permit the evolution of the human nervous system and allow the expression of contemporary human sociality, and stress reactivity. It acts to allow the facilitation of birth, lactation, and maternal behavior ( 88 , 89 ). Decrease in the oxytocin level in plasma has been associated with PPD ( 90 , 91 ). Possible roles in PPD have also been investigated for polymorphisms of the oxytocin receptor (OXTR) gene, the oxytocin peptide gene ( 92 ), the glucocorticoid receptor gene and the CRH receptor 1 gene ( 93 ). However, only some weak, suggestive links have been reported. Jonas et al. ( 94 ) found that polymorphisms in OXT rs2740210 interacted with early life adversity to predict PPD. Bell et al. ( 95 ) found that for women who do not show depression during pregnancy, but possess the rs53576_GG genotype and exhibit high levels of methylation in OXTR, the risk of developing PPD was nearly three times that for women of lower methylation levels. Kimmel et al. ( 96 ) found that the cytosine-guanines (CpGs) located on chr3 at positions 8810078 and 8810069 were associated with PPD scores significantly for a cohort of 240 women without a psychiatric history. They also found a PPD specific negative correlation between DNA methylation in the region and serum estradiol levels. In addition, estradiol levels and OXTR DNA methylation exhibited a significant interaction to associate with the ratio of allopregnanolone (ALLO) to progesterone. Recently, King et al. ( 97 ) found that mothers with persistent perinatal depression (depressive symptoms both prenatally and postpartum) exhibited significantly higher overall OXTR methylation at 16/22 individual CpG sites. While these studies seem to support the link between (the epigenetic DNA methylation of) OXTA and the risk of developing PPD, it should be noted that these findings are mostly derived from small sample sizes, with variable depression rating scales and a lack of prospective measures of DNA methylation, and thus should be interpreted with caution.

The brain-derived neurotrophic factor (BDNF) system is known to play an important role in many neuronal functions ( 15 ). Serum BDNF was found to decline considerably across pregnancy from 1st through 3rd trimesters ( p ≤ 0.008) and subsequently to increase at postpartum ( p < 0.001), and lower serum BDNF in late pregnancy was reported to be associated with higher depressive symptoms ( 98 ), although low BDNF levels were found to persist even 2 months after birth ( 99 ). Aydemir et al. ( 100 ) and Gazal et al. ( 101 ) found that the BDNF levels in serum of PPD patients were lower than in healthy control subjects. Serum BDNF levels in PPD patients that had a suicide risk were significantly lower than those of women that did not show a suicide risk ( 102 ). Recently, Fung et al. ( 103 ) found an association between lower levels of serum BDNF in early pregnancy and antepartum depression. However, Figueira et al. ( 104 ) and Comasco et al. ( 80 ) did not find an association between PPD and the BDNF polymorphism Val66Met. Overall, clear evidence for the association between BDNF and PPD symptoms is yet to be found ( 10 ). This may be partly due to the fact that the normal serum level of BDNF is a non-monotonic function of time in the perinatal period. Thus the precising timing and its dynamics may be important. The lack of consensus in the literature may partly reflect the difference in experiment design in terms of timing and sampling strategy, besides the often small sample sizes.

Katz et al. ( 105 ) collected maternal RNA longitudinally from preconception through the third trimester of pregnancy in 106 women with a lifetime history of mood or anxiety disorders. They reported that mRNA expression of a number of glucocorticoid receptor (GR)-complex regulating genes was up-regulated over pregnancy, and women with depressive symptoms showed significantly smaller increases in mRNA expression of four of these genes. They also found that GR sensitivity diminished with increasing maternal depressive symptoms. A prospective pregnancy cohort study of 56 healthy women with singleton term pregnancies found that altered placental genes expression involved in glucocorticoid and serotonin transfer may function as potential gestational-age-specific marker of PPD risk ( 106 ). Further studies with a larger sample size are needed to replicate these findings.

Recently, by RNA sequencing the whole transcriptomes of peripheral blood mononuclear cells, Pan et al. ( 107 ) found that PPD was positively correlated with multiple genes involved in energy metabolism, neurodegenerative diseases and immune response, while negatively correlated with multiple genes in mismatch repair and cancer-related pathways. In addition, genes associated with appetite regulation and nutrient response were differentially expressed between PPD ( n = 56) and control subjects ( n = 27).

Epigenetics refers to changes in gene function that do not alter the DNA sequence itself. The main focus in this area has been mostly on DNA methylation, which can be modified by medication and stress, as well as reproductive hormones. There has been some progress in the identification of biomarkers for DNA methylation. Recent studies have implicated epigenetic processes in the pathophysiology of MDD ( 108 ). Guintivano et al. ( 109 ) and Kaminsky and Payne ( 110 ) observed enhanced sensitivity to estrogen-based DNA methylation reprogramming in those at risk for PPD and identified two potential biomarker loci at the HP1BP3 and TTC9B genes that predicted PPD. Using blood drawn during pregnancy, DNA methylation at two genomic locations with an area under the receiver operator characteristic (ROC) curve [area under the curve (AUC)] of 0.87 in antenatally euthymic women and 0.12 in a replication sample of antenatally depressed women, along with complete blood count data, produced an AUC of 0.96 across both prepartum depressed and euthymic women ( 109 ). Osborne et al. ( 111 ) found that TTC9B and HP1BP3 DNA methylation in early antenatal stage showed moderate association with the change in estradiol and ALLO levels over the course of pregnancy, suggesting that epigenetic variation at these loci may be important for mediating hormonal sensitivity, and that PPD is mediated by differential gene expression and epigenetic sensitivity to pregnancy hormones and thus modeling proxies of this sensitivity may enable accurate prediction of PPD. Osborne et al. ( 38 ) further found an association between lower ALLO levels in the second trimester of pregnancy and an elevated risk of developing PPD, which seem to have been confirmed by latest studies ( 39 , 49 , 112 – 114 ), and can be traced back to the two genes identified above. Indeed, this seems to have gathered more support than many other biomarkers. Very recently, Payne et al. ( 115 ) found that antenatal TTC9B and HP1BP3 DNA methylation may be used to predict both antenatal and postpartum depression.

A prospective study ( 109 ) of 93 pregnant women with a history of either MDD or bipolar disorder found significant correlation between PPD risk and 17β-estradiol (E2)-induced DNA methylation change, suggesting that an enhanced sensitivity to estrogen-based DNA methylation reprogramming exists in women at risk for PPD. Estradiol increases the rate of transcription of the OXTR gene ( 116 ), resulting in elevations of oxytocin levels in the uterus ( 117 ) and in numerous brain regions ( 118 ) while heterozygosity for the OXTR rs2254298 polymorphism can interact with early life adversity to yield the highest levels of symptoms of depression, physical anxiety, and social anxiety ( 119 ). Association between higher DNA methylation of the OXTR gene and decreased expression of the gene was also observed ( 120 ). A case control study ( 95 ) on the OXTR gene DNA methylation at CpG site-934 and genotype rs53576 and rs2254298 found that women with GG genotype had higher risk of developing PPD with increasing methylation level. The finding of King et al. ( 97 ) regarding OXTR methylation seem to suggest that the onset timing of PPD is also an important factor.

Overall, the above findings suggest that polymorphic variations in candidate genes within the monoaminergic system can have an effect on the estrogen receptor, the oxytocin peptide, the glucocorticoid receptor, and the CRH receptor 1 genes, and may act as potential biomarkers for PPD. However, further investigation is needed in order to determine whether the short or long allele of the 5-HTTLPR is associated with PPD risk and under what conditions. Nevertheless, the lack of consensus in these data from the literature highlights the complex relationship between epigenetics and PPD related neuroendocrine changes.

Reproductive hormones

The association between the reproductive hormones and PPD has been studied and reviewed, in terms of estrogens, progesterone, prolactin, oxytocin, and testosterone. Bloch et al. ( 121 ) found evidence that the reproductive hormones estrogen and progesterone play a role in the development of PPD. However, the data by Klier et al. ( 122 ) did not support the hypothesis of a role of sex hormones in the etiology of PPD. A review of about 200 studies by Serati et al. ( 123 ) found little evidence that supports estrogen withdrawal theories, or suggests that progesterone in late pregnancy or postpartum period predicts PPD symptoms.

Recent studies seem to suggest strong association between the progesterone level and PPD. The levels of ALLO was found to increase progressively throughout gestation, and drop rapidly upon parturition ( 37 , 124 , 125 ). As a metabolite of progesterone, ALLO is a neuroactive steroid measurable in peripheral circulation. Therefore, its levels vary proportionally with progesterone levels throughout gestation and after the delivery, and an association between ALLO and PPD were found, suggesting that hormonal regulation plays an important role in the development of PPD ( 124 ). Previously, Bloch et al. ( 121 ) found that women with a PPD history are more sensitive to mood-destabilizing effects of gonadal steroids than healthy controls. Rather than progesterone withdrawal upon delivery, it has been found that a low ALLO level during pregnancy predicts PPD ( 38 , 112 , 114 ). Such an association was also found in earlier studies ( 126 , 127 ). Timing may be an important factor when assessing potential biomarkers. Epperson et al. ( 128 ) reported that cortex GABA levels and plasma ALLO concentrations were reduced in two different groups of postpartum women, regardless of PPD diagnosis at 9 weeks or 6 months postpartum, compared to healthy follicular phase women, and that no correlation was found between cortical GABA concentrations and estradiol, progesterone, or ALLO levels. Smith et al. ( 129 ) found that the effect of neuroactive steroids on inhibition, which influence anxiety state and seizure susceptibility, depends not only on the subunit composition of the receptor but also on the direction of Cl − current generated by these target receptors.

Prolactin has physiological functions that are especially relevant in the peripartum period, and may act as an attenuation for behavioral and neuroendocrine stress responses during both pregnancy and lactation ( 130 ). Despite mixed evidence from different studies, two studies with a big sample size indeed suggested an negative correlation between PPD and prolactin ( 131 , 132 ).

The oxytocin signaling network has been of great interest as it can play an important role in mother-infant bonding and interactions. Recently, there have been investigations on the trajectories of oxytocin throughout the gestation and lactation periods, especially how they respond to the onset and development of PPD symptoms. It has been suggested that lower levels of oxytocin in both the gestation and postpartum periods may imply an elevated risk for developing PPD ( 9 , 90 , 91 ). Jobst et al. ( 133 ) found that plasma oxytocin levels significantly increased from week 35 of gestation to 6 months postpartum in all women. However, levels decreased from the 38th week of gestation to 2 days after delivery in women with PPD, whereas, they increased continuously in the healthy control group. This suggests that the time evolution pattern of oxytocin may be a predictor of PPD in the immediate postpartum period (within 2 weeks). In comparison, Massey et al. ( 134 ) found that oxytocin level interacted with past MDD to predict PPD symptom severity in the third trimester; a higher oxytocin level predicted greater PPD symptom severity in women with past MDD, but not in women without. Thul et al. ( 135 ) reviewed the literature on the relationship between both endogenous and synthetic oxytocin and PPD, and found that out of the 12 studies that focused on endogenous oxytocin, eight studies suggested an inverse correlation between plasma oxytocin levels and depressive symptoms.

There is mixed evidence for the association between testosterone levels in late pregnancy and PPD symptoms in the early postpartum stage. Women with PPD symptoms were reported to have higher serum testosterone levels in the late third trimester ( 136 ) and around 24 h postpartum than healthy controls ( 137 ). However, other studies have failed to find such an association ( 138 ).

The role of thyroid hormone in the development of perinatal mood disorder has also been investigated ( 139 ). It has been suggested that timing may be critical in the correlation between thyroid hormones and PPD, since the function of thyroid is to respond to the constant changes in other hormones across gestation. Kuijpens et al. ( 140 ) reported that the presence of thyroperoxidase antibody (TPOAb) during gestation was associated with the occurrence of subsequent depression during the postpartum period and as such can be regarded as a marker for depression. Elevations in thyroid stimulating hormone (TSH) upon delivery have been proposed to be a predictor for PPD 6 month post-parturm ( 141 ). However, in an earlier large cohort study, Albacar et al. ( 142 ) examined 1,053 postpartum Spanish women without a previous history of depression, and concluded that thyroid function at 48 h after delivery does not predict PPD susceptibility. Groer and Vaughan ( 143 ) found that pregnant TPO-positive women were more likely to develop PPD 6 months after delivery. A review ( 144 ) suggested that TPOAb in early to mid-pregnancy was associated with concurrent depression and may be predictive of PPD. Recently, Wesseloo et al. ( 145 ) found that women with an increased TPOAb titer during early gestation were at increased risk for self-reported first-onset depression, which suggested an overlap in the etiology of first-onset PPD and autoimmune thyroid dysfunction. Li et al. ( 146 ) found that PPD patients showed elevated serum levels of triiodothyronine, thyroxine, free triiodothyronine, free thyroxine along with diminished estradiol, progesterone, and TSH levels. It was proposed that it may not just be thyroid hormones alone, but rather thyroid in conjunction with other factors such as estrogens ( 10 ) or trauma history ( 147 ), that are implicated in PPD etiology. A consensus regarding the role of thyroid hormones as a biomarker is yet to be reached.

While strong evidence seems to have been found to support that a low ALLO level during pregnancy predicts PPD, it can be seen, however, that for most reproductive hormones, a consensus regarding their association with PPD is yet to be reached. Many studies are limited by small sample sizes. Furthermore, the dynamical changes of reproductive hormones during the perinatal period should also be taken into account. This will require that the timing for sampling and depression assessment be arranged in a more systematic and consistent manner, hopefully across different studies.

Stress Hormones

Stress hormones, particularly those of the HPA axis, have been implicated in non-puerperal depression ( 148 ). It was suggested that the hyporesponsiveness of the HPA axis may persist for several months postpartum ( 149 ). There is strong evidence that the HPA axis plays an important role in perinatal depression, both during gestation and postpartum. Groer and Morgan ( 131 ) reported that depressed mothers had a down-regulated HPA axis, in that the salivary cortisol level was lower in PPD patients than in healthy controls. Similar to reproductive hormones, the levels of stress hormones also increase during pregnancy from the first to third trimester and then decrease abruptly upon parturition. In contrast, the neuropeptide corticotropin-releasing hormone (CRH) often increases exponentially in the process of pregnancy ( 150 ), mainly because CRH is also produced by the placenta ( 151 ). This also leads to an increased level of adrenocorticotropic hormone (ACTH) and cortisol over the course of pregnancy ( 152 ). The CRH level drops quickly upon parturition, when the placenta is discharged. Yim et al. ( 153 ) found that at a critical period in midpregnancy, placental CRH (pCRH) is a sensitive and specific early diagnostic test for PPD; at 25 weeks' GA, pCRH was a strong predictor of PPD, and the trajectories of pCRH in women with PPD are significantly accelerated from 23 to 26 weeks' GA. Hahn-Holbrook et al. ( 154 ) found that steeper increases in placental CRH from 29 to 37 weeks' gestation predicted more depressive symptoms postpartum. Iliadis et al. ( 155 ) reported an association between high CRH levels in gestational week 17 and the development of PPD symptoms, among women without depressive symptoms during pregnancy. On the contrary, Meltzer-Brody et al. ( 34 ) found that higher mid-pregnancy placental CRH was not associated with an increased risk of PPD. Glynn and Sandman ( 156 ) showed that depressive symptoms at 3 months postpartum were associated with elevated mid-gestational pCRH levels and also accelerated trajectories of pCRH, but pCRH was not predictive of PPD at 6 months postpartum. They concluded that elevated pCRH level during pregnancy may act as a marker of risk of developing PPD. Overall, the result on CRH as a viable biomarker is mixed so far, possibly due to limitations of small sample sizes and different timing for sampling and assessment of the PPD symptoms.

Alteration in the HPA axis is a robust biomarker of anxiety and depression, and significant mood symptoms in pregnancy was shown to be associated with altered diurnal cortisol in pregnancy ( 157 ). Labad et al. ( 158 ) found that women with postpartum thoughts of harming the infant had higher ACTH levels, when compared to those women without intrusive thoughts, and a dysregulation of the HPA axis may play a role in the etiology of postpartum thoughts of harming the infant. Jolley et al. ( 159 ) found higher ACTH and lower cortisol levels in women with PPD at 6 and 12 weeks postpartum when compared with controls. Women with PPD were found to have greater ACTH stress reactivity to cold pressor test (CPT), and a significantly elevated ACTH concentration level at 8 weeks postpartum in response to CPT ( 160 ), as well as a markedly blunted plasma ACTH response to serial ovine CRH tests at 3, 6, and 12 weeks postpartum ( 161 ), and it was suggested that the suppressed ACTH response to ovine CRH might serve as a biochemical marker of the postpartum “blues” or depression ( 161 ). Together, these findings again suggested that dysregulation of the HPA axis may be associated with PPD. However, a comparative study found no differences in the HPA axis reactivity in terms of the cortisol and ACTH response, e.g., the cortisol/ACTH ratio, to pharmacologic test and psychological challenges during the luteal phase between current euthymic postpartum women with a history of either PPD or MDD and controls ( 162 ). We note that the sample sizes for the last four studies were fairly small, with 12, 34, 17, and 15 × 3 (15 in each group), respectively. Further investigations with larger sample sizes and better designs are needed to reconcile these findings.

As for β-endorphin, Yim et al. ( 163 ) found that among women who were euthymic at 25 weeks' GA, those who developed PPD had higher β-endorphin levels throughout pregnancy than women without PPD symptoms, and suggested that β-endorphin may play an important role in the pathophysiology of PPD and may thus be a useful early predictor of PPD symptoms in women who show no depressive symptoms in mid-pregnancy. They also reported that around 25 weeks' gestation was a crucial time for assessing PPD symptoms. However, postpartum blood samples were taken only at 9 weeks for assessment of β-endorphin levels, and self-report was used to evaluate the depressive symptoms.

Parcells ( 164 ) found that cortisol levels directly correlated with maternal depression, anxiety, and stress. Recent studies found that women with PPD had higher salivary evening cortisol at 6 weeks postpartum ( 165 ), elevated hair cortisol levels in the first to third trimesters ( 166 ), or lower levels of evening cortisol in the immediate peripartum period ( 167 ), compared to healthy controls. Corwin et al. ( 168 ) found that cortisol levels, together with family history of depression and interleukin (IL)-8/IL-10 ratio, were significant predictors of PPD symptoms. However, a recent survey ( 169 ) showed that most studies reported no association between maternal cortisol and antenatal depression, and that among studies that reported an association, second-trimester and third-trimester cortisol assessments more consistently reported an association. The link between cortisol levels and postpartum or perinatal depressions is far from conclusive, and thus more future investigations are warranted.

Among stress hormones, it is less controversial that alteration of the HPA axis is a robust biomarker for PPD. However, results on CRH, ACTH and cortisol levels are rather mixed, and further studies are needed on these hormones as well as β-endorphin.

Immunological/Inflammatory Studies

The function of the immune system is to protect the body from foreign substances (as well as other pathogenic organisms) ( 10 ). However, the fetus should not be attacked during pregnancy even though it is necessarily genetically distinct and carries paternal antigens that are foreign to the maternal immune system. Thus this constitutes a big challenge for the maternal immune system. Although, it is not yet clear how it maintains the proper balance of proinflammatory cytokines [e.g., IL-6, IL-1β, tumor necrosis factor-alpha (TNF-α)] and anti-inflammatory cytokines (e.g., IL-10), it can be expected that the immune system will have more activities during the perinatal period. A growing body of literature suggests that inflammatory responses have an important role in the pathophysiology of depression ( 170 ). In addition, prolonged HPA axis hyperactivity activated by proinflammatory cytokines (IL-1, IL-6, and TNF-α) is one of the mechanisms underlying cytokine-induced depression ( 171 ), even in perinatal episodes ( 172 ).

It has been found that puerperal women usually have significantly higher levels of proinflammatory cytokines during the last trimester of pregnancy, and are also at higher risk for depression ( 173 ). Other stressors also cause proinflammatory cytokine levels to rise at such a time. Breastfeeding may attenuate stress and modulate the inflammatory response. Overall, the proinflammatory state during the late pregnancy and the early postpartum period plays an important role in the development of PPD ( 173 ). IL-6 is the most commonly studied cytokine, and has been consistently identified as being elevated in depression. An earlier study ( 174 ) found that the levels of serum IL-6 and its receptor (IL-6R) were significantly higher in the early puerperium than before delivery, and women who developed depressive symptoms in the early puerperium had significantly higher serum IL-6 and IL-6R concentrations than those without. Corwin et al. ( 175 ) reported an increase in IL-1β on Day 14 and Day 28 postpartum in women with PPD, compared to levels in euthymic women, suggesting an association between symptoms of PPD and elevated levels of IL-1β during the first month postpartum. Boufidou et al. ( 176 ) found that cytokine IL-6 and TNF-α levels in the cerebrospinal fluid (CSF) and TNF-α levels in serum were positively associated with depressive mood during the first 4 days postpartum and also at sixth week postpartum. Krause et al. ( 177 ) found that regulatory T cells in pregnancy strongly predicted PPD. Corwin et al. ( 168 ) found that family history of depression and cortisol AUC and the IL8/IL10 ratio both on day 14 were significant predictors of PPD. Liu et al. ( 178 ) found that elevated serum IL-6 at delivery was associated with development of PPD during the 6 months post partum. In a longitudinal study ( 179 ), the IL-6 and IL-10 levels measured in the third trimester were found to be a significant predictor of PPD. However, the evidence is mixed for the link between PPD and proinflammatory cytokines ( 10 ). For example, serum leptin levels at delivery were found earlier ( 180 ) to be negatively associated with self-reported depression during the first 6 months after delivery, but were significantly greater in women with PPD than in healthy controls at 3 months post-partum ( 181 ). However, a similar association was not found between serum IL-6 levels at delivery and later PPD symptoms.

Other proinflammatory cytokines (and their receptors) have also been investigated, as potential biomarkers for PPD. Groer and Morgan ( 131 ) found that women with PPD had lower serum levels of Interferon-gamma (IFN-γ) and a lower IFN-γ/IL-10 ratio in both serum and in whole blood stimulated cultures. Fransson et al. ( 182 ) found that mothers with depression had higher TGF-β2 concentrations in their breast milk than mothers without depression. They also found associations between maternal IL-6, IL-8 and cord IL-6, IL-8, IL-10, IL-13, and IL-18 levels and depressive symptoms in the first 5 days postpartum in women who delivered preterm. Clara Cell Protein (CC16), an endogenous anticytokine, may also be related to PPD. Maes et al. ( 183 ) found that parturients who developed PPD had significantly lower serum CC16 concentrations than women who did not. Bränn et al. ( 184 ) found that among 70 inflammatory markers, five were significantly elevated in women with PPD, including TNF ligand superfamily member (TRANCE), hepatocyte growth factor (HGF), IL-18, fibroblast growth factor 23 (FGF 23), and C-X-C motif chemokine 1 (CXCL1).

Mixed evidence has been found for the linkage between the C-reactive protein (CRP) and PPD. The review by Lambert and Gressier ( 185 ) suggested that the dosage of some inflammation biomarkers, including CRP, at the very end of pregnancy or immediately after delivery could predict PPD. Bränn et al. ( 186 ) found that the signal transducing adaptor molecule-binding protein (STAM-BP), axin-1, adenosine deaminase (ADA), sulfotransferase 1A1 (ST1A1), and IL-10 were lower in late pregnancy among women with PPD, and proposed a summary inflammation variable for predicting PPD. So far, further studies are needed to address inconsistencies in different results regarding the role of inflammatory processes in the development of PPD.

Overall, evidence for (anti-)proinflammatory cytokines as a diagnostic and predictive biomarker for PPD is mixed, which calls for more systematic studies in the future.

Biomarkers From Biochemical Studies

Identification of nutritional and biochemical markers for PPD diagnosis has gained attention lately. Wójcik et al. ( 187 ) revealed a correlation between the severity of depressive symptoms and decreased serum zinc concentration third day after delivery in PPD patients. Roomruangwong et al. ( 188 ) found that lower serum zinc (and higher CRP) levels strongly predicted prenatal depression and physio-somatic symptoms, which all together predicted postnatal depressive symptoms.

The role of vitamin D in the development of depression has been studied in recent years, because it has regulatory functions in the immune system, and thus may act effectively as a neurosteroid. Christesen et al. ( 189 ) conducted a review on the impact of vitamin D on pregnancy, and found that a decreased vitamin D level during pregnancy may lead to PPD in one study and preeclampsia in several studies. In an exploratory study ( 190 ), a significant relationship over time was found between low 25-hydroxyvitamin D (25(OH)D) levels and high EPDS scores. Brandenbarg et al. ( 191 ) found that low early-pregnancy vitamin D status was associated with elevated depressive symptoms in pregnancy. Gur et al. ( 192 ) found that lower maternal 25(OH)D3 levels were associated with higher levels of PPD at all time points, and thus may be a factor affecting the development of PPD. Similarly, Robinson et al. ( 193 ) also reported that low vitamin D during pregnancy is a risk factor for the development of PPD symptoms. A cross-sectional study ( 194 ) found that higher dietary vitamin D intake was significantly associated with a lower prevalence of depressive symptoms during pregnancy. A recent prospective study found an association between lower prenatal log 25(OH)D and significantly more severe PPD symptoms, among women with higher levels of inflammatory markers ( 195 ). In a controlled study, Fu et al. ( 196 ) found an association between lower serum 25(OH)D levels measured 24 h after delivery and PPD. Fortunately, these findings seem to be in agreement with each other.

In a prospective cohort study of 238 pregnant women, Teofilo et al. ( 197 ) found that HDL-cholesterol concentrations were inversely associated with EPDS scores during pregnancy. In a prospective study of 266 Dutch women, Van Dam et al. ( 198 ) did not find an association between rapid serum cholesterol decline and the risk of developing PPD.

The PUFA status in late pregnancy was studied in a large sample of women, and only a weak link between PUFA in late pregnancy and PPD risk was reported ( 199 ). In a community-based prospective cohort, Markhus et al. ( 200 ) found that the DPA content, DHA content, ω-3 index, ω-3/ω-6 ratio, total PUFA score, and the ω-3 PUFA score were all inversely correlated with the EPDS score. Sallis et al. ( 201 ) found a weak positive correlation between ω-3 fatty acids and PPD. In another study, no association between plasma PUFAs and PPD was found ( 202 ).

For vitamin B12 and folate, a cross-sectional study reported no association between depressive symptoms and blood levels of vitamin B12 and folate ( 203 ). Lewis et al. ( 204 ) did not find strong evidence that folic acid supplementation can reduce the risk of depression during first 8 months of pregnancy. Another study found significantly higher homocysteine levels in women with PPD than in healthy controls, suggesting that the level of serum homocysteine might be a risk biomarker for PPD ( 205 ).

An increased kynurenine level has also been reported to be associated with the induction of depression. Depressive and anxiety symptoms in the early puerperium are associated with increased catabolism of tryptophan into kynurenine ( 206 ), and the increases in plasma kynurenine and the kynurenine/tryptophan (K/T) ratio were positively correlated with the anxiety and depression scores in the puerperium.

There have been some studies on gut microbiome as potential biomarkers recently ( 207 ). The coordination between the gut, the central nervous system, and the neuroendocrine and neuroimmune axes is referred to as the gut-brain axis ( 208 ). There are not many studies and thus not much has been known, regarding what role the gut-brain axis may play in the development of PPD. In a study of nearly 400 pregnant women ( 209 ), it was found that probiotic supplementation with Lactobacillus rhamnosus HN001 in pregnancy and postpartum period reduces the prevalence of PPD.

In summary, biochemical studies seem to suggest that low serum 25(OH)D levels during pregnancy may be a biomarker for PPD. Evidence for other biochemical markers for PPD is either mixed, very weak or negative, including levels of serum cholesterol, PUFA status, vitamin B12 and folate, kynurenine level, and gut microbiome.

Omics-Based Biomarker Studies

Biomarker identification in neuropsychiatric disorders such as PPD and MDD can have important advantages and benefits, in terms of prediction and accurate diagnosis of a disease, and may provide more accurate and reliable information which can guide the selection and development of a cure or treatment. Gadad et al. ( 210 ) conducted a review on various omics approaches for identifying biomarkers of neuropsychiatric disorders. Many of the biomarkers mentioned in the review can be identified using multi-omics, which includes genomics, epigenomics, transcriptomics, proteomics, metabolomics, and lipidomics. These omics technologies have been actively applied in studies on MDD. See, e.g., the review by Sethi and Brietzke ( 211 ). Given the strong similarity between PPD and MDD, these omics technologies can in principle be quickly applied to the identification of biomarkers for PPD.

Metabolomics has recently been applied to unravel the serum metabolomic profile of PPD ( 212 ). Serum metabolomes of a group of women ( n = 10) with PPD and a healthy control group ( n = 10), all from Greece, were analyzed for targeted metabolomics using mass spectrometry. In the PPD group, increased levels of five metabolites were found, such as glutathione-disulfide, adenylosuccinate, and ATP. The data showed that molecular changes related to PPD were indeed detectable in peripheral material, and thus these changes may serve as diagnostic biomarkers.

A metabolomic profiling of morning urine samples of women with PPD, postpartum women without depression (PPWD), and healthy controls (HCs) was recently characterized using gas chromatography-mass spectroscopy ( 213 ). Twenty two (22) differential metabolites (14 up regulated and 8 down regulated) were found to separate PPD subjects from HCs and PPWD. Meanwhile, a panel of five potential biomarkers – formate, succinate, 1-methylhistidine, α-glucose and dimethylamine – was identified, which could be used to effectively distinguish PPD subjects from HCs and PPWD. Recently, using Liquid Chromatography Coupled to Quadrupole Time-of-Flight Mass Spectrometry, Zhang et al. ( 214 ) found that the urine metabolomic profiles of patients with PPD were different from those of HCs. Ten differentiating metabolites were found as main contributors to this difference.

So far, there have been far fewer studies on the identification of biomarkers for PPD than for MDD. Nevertheless, we expect that multi-omics technologies will be widely used in identifying biomarkers for PPD in future studies. Indeed, given the enormous advantages of the omics, they should be a major direction of PPD research in the future.

It should be cautioned that, due to possible partial overlap in genetic and biological risk factors and biomarkers among PPD, MDD and BD, a panel of multiple biomarkers may be needed to avoid misdiagnosis.

Conclusions

PPD is a serious health issue for new mothers and has negative consequences on both the mothers and the children. Its high prevalence rate raises strong public health concerns. PPD is likely to be influenced by a multitude of risk factors, including biological, psychosocial, and even environmental factors. There have been various etiological models for PPD. However, no consensus has been reached so far. Typical treatments for PPD include psychotherapy and phamacotherapy, in the form of psychotherapy/counseling and antidepressant medications. While the US FDA has recently approved the first antidepressant medication for PPD, this medicine, Zulresso, has turned out to be extremely expensive, and thus is out of the reach for most PPD patients. This makes preventive measures more important, to protect one from developing PPD.

There has been increasing effort in the diagnosis of PPD using predictors, from both psychosocial and biological aspects. Furthermore, there are a variety of researches on PPD biomarkers so far, using different methods and approaches for characterizing and assessing PPD. While biomarker identification has shown a lot of promise for PPD research, nevertheless no biomarker is ready for clinical use as of today. From etiologic point of view, (epi)genetics and hormones may play a more fundamental role than biochemicals in the development of PPD. Nonetheless, biochemicals may as well be the right signatures or indicators that can be used for diagnosing and predicting PPD. Biomarkers in genetics and epigenetics may have a big potential for personal risk prediction. Several hormones, neurosteroids, and biochemicals have been identified in preliminary studies as potential biomarkers for predicting PPD, but further studies and substantiation are needed before they can be put into clinical use. So far, there are strong inconsistencies in various findings regarding predictors and biomarkers of PPD. These inconsistencies presumably have to do with the limited sample sizes, inconsistent depressive rating scales and timing for sampling, and inconsistent designs across different studies, as well as the high complexity of PPD. Further large-scale, integrative studies are needed to fully understand PPD. Given the objectiveness of biomarkers, we expect that the identification of biomarkers of PPD will be an important subject in future research. Despite that the application of multi-omics to the study of PPD has just begun recently, we strongly believe that modern multi-omics technologies will have a great potential in this arena.

While many studies have found associations or correlations between certain risk factors, predictors, or biomarkers and PPD, these correlations do not necessarily tell whether these risk factors, predictors, and markers are consequences or causes of PPD. A correct etiological model which is subject to comprehensive testing is crucial for uncovering the underlying cause of PPD and for developing the right medication and cure for PPD.

Finally, we end this review by presenting a brief speculative model for the etiology of PPD, based on the findings summarized hereinabove. The hormonal withdrawal theory has largely been proved to be wrong, as the hormonal withdrawal is a normal process every pregnant woman has to undergo upon parturition. This is a desired and necessary biological change that is adapted to pregnancy and parturition, as a result of human evolution. However, for a portion of women the biological system may not perform as perfectly as expected, due to the high complexity of human body and a wide range of genetic and epigenetic variations, as well as environmental, psychosocial and biological factors. In other words, for those the body does not fulfill and cope with the hormonal withdrawal in a perfect manner, depressive disorders to various degrees may develop. Thus, the ultimate goal of studying various predictors and biomarkers for PPD will be to catch such an imperfection at an early stage so that it can be remedied or prevented in time.

Author Contributions

YY completed the literature survey and manuscript writing. J-CL initiated and oversaw the project. H-FL, JC, Z-BL, Y-SH, and J-XC participated in the discussion and the manuscript preparation. All authors contributed to the article and approved the submitted version.

This work was supported in part by the Science Technology Department of Zhejiang Province, China (Project for Applications of Technology, Grant No. 2017C37004), National Natural Science Foundation of China (Grant No. 81772266), and Guangzhou Science and Technology Project (Grant No. 201804010369).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Keywords: postpartum depression, postnatal depression, biological markers, biomarkers, multi-omics

Citation: Yu Y, Liang H-F, Chen J, Li Z-B, Han Y-S, Chen J-X and Li J-C (2021) Postpartum Depression: Current Status and Possible Identification Using Biomarkers. Front. Psychiatry 12:620371. doi: 10.3389/fpsyt.2021.620371

Received: 22 October 2020; Accepted: 19 May 2021; Published: 11 June 2021.

Reviewed by:

Copyright © 2021 Yu, Liang, Chen, Li, Han, Chen and Li. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Ji-Cheng Li, lijichen@zju.edu.cn

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

89 Postpartum Depression Essay Topic Ideas & Examples

🏆 best postpartum depression topic ideas & essay examples, 👍 most interesting postpartum depression topics to write about, ⭐ good research topics about postpartum depression, ❓ postpartum depression research questions.

Activity During Pregnancy and Postpartum Depression Studies have shown that women’s mood and cardiorespiratory fitness improve when they engage in moderate-intensity physical activity in the weeks and months after giving birth to a child.
Technology to Fight Postpartum Depression in African American Women I would like to introduce the app “Peanut” the social network designed to help and unite women exclusively, as a technology aimed at fighting postpartum depression in African American Women.
The Postpartum Depression in Afro-Americans Policy The distribution of the funds is managed and administered on the state level. Minnesota and Maryland focused on passing the legislation regulating the adoption of Medicaid in 2013.
Breastfeeding and Risk of Postpartum Depression The primary goal of the research conducted by Islam et al.was to analyze the correlation between exclusive breastfeeding and the risk of postpartum depression among new mothers.
Postpartum Depression in African American Women As far as African American women are concerned, the issue becomes even more complex due to several reasons: the stigma associated with the mental health of African American women and the mental health complications that […]
Postpartum Depression Among the Low-Income U.S. Mothers Mothers who take part in the programs develop skills and knowledge to use the existing social entities to ensure that they protect themselves from the undesirable consequences associated with the PPD and other related psychological […]
In-Vitro Fertilization and Postpartum Depression The research was conducted through based on professional information sources and statistical data collected from the research study used to further validate the evidence and outcome of this study.
Postpartum Depression and Its Impact on Infants The goal of this research was “to investigate the prevalence of maternal depressive symptoms at 5 and 9 months postpartum in a low-income and predominantly Hispanic sample, and evaluate the impact on infant weight gain, […]
Postpartum Depression: Statistics and Methods of Diagnosis The incorporation of the screening tools into the existing electronic medical support system has proved to lead to positive outcomes for both mothers and children.
Postpartum Psychosis: Impact on Family By the ties of kinship, the extended families of both parents are often intricately involved in the pregnancy and maybe major sources of support for the pregnant woman.
Postpartum Depression: Treatment and Therapy It outlines the possible treatment and therapy methods, as well as the implications of the condition. A 28-year-old patient presented in the office three weeks after giving birth to her first son with the symptoms […]
A Review of Postpartum Depression and Continued Post Birth Support In the first chapter – the introduction – the problem statement, background, purpose, and nature of the project are mentioned. The purpose of the project is to explain the significance of managing postpartum depression by […]
Postpartum Depression: Understanding the Needs of Women This article also emphasizes the need to consider and assess the needs of the mother, infant as well as family members during the treatment of PPD.
Postpartum Depression and Acute Depressive Symptoms It is hypothesized that the authors of the study wished to establish, with certainty, the effect of the proposed predictors for the development of PPD.
Postpartum Depression and Its Peculiarities The major peculiarity of PPD in terms of its adverse effects is that it is detrimental to both the mother and the newborn child.
Supporting the Health Needs of Patients With Parkinson’s, Preeclampsia, and Postpartum Depression The medical history of the patient will help the doctor to offer the best drug therapy. Members of the family might also be unable to cope with the disorder.
Postpartum Depression and Comorbid Disorders For example, at a public hospital in Sydney, Australia, the psychiatrists used a Routine Comprehensive Psychosocial Assessment tool to study the chances of ‘low risk’ women developing the postpartum symptoms.
Correlation Between Multiple Pregnancies and Postpartum Depression or Psychosis In recognition of the paucity of information on the relationship between multiple pregnancies and postpartum depression, the paper reviews the likely relationship by understanding the two variables, multiple pregnancies and postpartum depression, in terms of […]
Acknowledging Postpartum Depression: Years Ago, There Was
Postpartum Depression and Crime: The Case of Andrea Yates
Baby Blues, Postpartum Depression, and Postpartum Psychosis
Postpartum Depression and Parent-Child Relationships
Cheryl Postpartum Depression Theory Analysis
Cognitive Therapy for Postpartum Depression
Postpartum Depression: An Important Issue in Women’s Health
The Relationships Between Depression and Postpartum Depression
Postpartum Depression: Causes and Treatments
How Postpartum Depression Predicts Emotional and Cognitive Difficulties in 11-Year-Olds
Economic and Health Predictors of National Postpartum Depression Prevalence
Postpartum Depression (PPD): Symptoms, Causes, and Treatment
Fathers Dealing With Postpartum Depression
Postpartum Depression and the Birth of a New Baby
Risk of Postpartum Depression in Women Without Depression in Pregnancy
Intimate Partner Violence During Pregnancy and Postpartum Depression in Japan
Managing Postpartum Depression Through Medications and Therapy
Early Identification Essential to Treat Postpartum Depression
Screening for Postpartum Depression and Associated Factors Among Women in China
Postpartum Depression and Anxiety Disorders in Women
Postpartum Depression and Child Development
Association Between Family Members and Risk of Postpartum Depression in Japan
Postpartum Depression and Its Effects on Mental Health
Baby Blues, the Challenges of Postpartum Depression
How Postpartum Depression Affects Employment
Postpartum Depression During the Postpartum Period
Evidence-Based Interventions of Postpartum Depression
Proposed Policy for Postpartum Depression Screening and Treatment
Sleep Deprivation and Postpartum Depression
The Causes and Effects of Postpartum Depression
The Main Facts About Postpartum Depression
The Postpartum Depression and Crime Relations
Sleep Quality and Mothers With Postpartum Depression
Postpartum Depression and Its Effects on Early Brain
Fetal Gender and Postpartum Depression in a Cohort of Chinese Women
Postpartum Depression and Postnatal Depression Psychology
The Problem of Postpartum Depression Among Canadian Women
Postpartum Depression and Its Effect on the Family Experience
Mothers With Postpartum Depression for Breastfeeding Success
Postpartum Depression and Analysis of Treatments and Health Determinants
How Are Neuroactive Steroids Related to Major Depressive Disorder and Postpartum Depression?
What Are the Emotional and Behavioral Changes During Postpartum Depression?
Does Postpartum Depression Affect the Child’s Development?
When Does Postpartum Depression Lead to Psychosis?
How to Recognize Postpartum Depression?
What Is the Role of the Mother, Child, and Partner in Postpartum Depression?
Is There an Association Between Family Members and the Risk of Postpartum Depression in Japan?
What Are the Most Common Signs of Postpartum Depression?
How Does Postpartum Depression Affect Parent-Child Relationships?
What Type of Therapy Is Most Widely Used for a Person Suffering from Postpartum Depression?
Can Postpartum Depression Cause Autism?
What Is a Gender Perspective on Postpartum Depression and the Social Construction of Motherhood?
How Are Postpartum Depression and Related Factors Screened Among Women in China?
What Are the Economic and Medical Projections of the Prevalence of Postpartum Depression?
Is There a Difference Between Postnatal and Postpartum Depression?
What Is the Biggest Risk Factor for Postpartum Depression?
How Are Fetal Gender and Postpartum Depression Related in a Cohort of Chinese Women?
What Factors Contribute to the Development of Postpartum Depression?
Is Postpartum Depression a Long-Term Disability?
What Are the Causes and Consequences of Postpartum Depression?
How Is Postpartum Depression Diagnosed?
What Is Postpartum Depression and How Does It Affect Newborns and Mothers?
Is Psychotherapy the Best Treatment for Postpartum Depression?
What Should Be the Knowledge of Nurses in the Diagnosis of Postpartum Depression?
How Does Postpartum Depression Affect the Family Experience?
What Is the Relationship Between Sleep Quality and Postpartum Depression in Mothers?
Can Postpartum Depression Be Managed with Medication and Therapy?
What Treatment Options Are Available for People with Postpartum Depression?
How Long After Childbirth Can Postpartum Depression Occur?
Are Physical Activity Interventions Effective in the Treatment of Postpartum Depression?
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Published: 10 September 2024

Incidence of postpartum depression among women with postpartum haemorrhage in Kano, northern Nigeria

Fatimah Isma’il Tsiga-Ahmed 1 , 2 ,
Musa Usman Umar 3 , 4 ,
Aishatu Lawal Adamu 1 , 2 ,
Sahabi Kabir Sulaiman 5 ,
Amole Taiwo Gboluwaga 1 , 2 , 6 ,
Rabiu Ibrahim Jalo 1 , 2 ,
Usman Muhammad Ibrahim 7 ,
Aminatu Kwaku Ayaba 2 ,
Zainab Datti Ahmed 8 ,
Surayya Murtala Sunusi 2 ,
Nafisat Tijjjani Abdullahi 2 ,
Hajara Shehu Kabir 4 ,
Stephen Mohammed Abu 5 &
Hadiza Shehu Galadanci 6

npj Women's Health volume 2 , Article number: 32 ( 2024 ) Cite this article

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The burden of postpartum depression (PPD), an important but largely neglected cause of maternal morbidity, is often increased by the presence of common co-morbidities, such as postpartum haemorrhage (PPH). Additionally, stress and the absence of social support can amplify PPD risk. Understanding the relationship between these conditions will help identify at-risk women and allow prompt intervention. Using a prospective cohort design, we recruited 72 women who had experienced PPH and another 72 women who had not within 24 h of delivery to assess the risk of PPD among them. The cumulative incidence of PPD among all participants was 15.3% (19/124). There was insufficient evidence to suggest that women with PPH have a higher risk of PPH than women without PPH (OR: 1.32; 95% CI: 0.55–3.13). Poor social support and high perceived stress increased the risk of PPD. We recommend screening for PPD among women with high perceived stress and low social support.

Mapping global prevalence of depression among postpartum women

Perinatal depression and anxiety of primipara is higher than that of multipara in Japanese women

Perinatal depression and mental health uptake referral rate in an obstetric service

Introduction.

Postpartum depression (PPD) is a mood disorder that manifests as a feeling of melancholy and disinterest, which occurs within the first four weeks of delivery and may last up to a year after childbirth 1 , 2 . PPD affects approximately 1 in 7 new mothers globally, with an estimated prevalence of 17.7% in the first year following delivery 1 , 3 . The frequency of PPD varies between African countries, albeit higher than values found in high-income settings. In Nigeria, rates ranging from 10.7% to 44.39% have been documented in various sub-geographical regions 2 . PPD has been linked to suicide in the mother, impaired mother-infant bonding, as well as a negative influence on the child’s emotional and cognitive development 4 , 5 . Akin to PPD, postpartum haemorrhage (PPH) is a worldwide public health priority, resulting in over 70,000 annual maternal deaths globally 6 , 7 . Globally, about 14 million people experience PPH annually 6 , and it is the leading preventable cause of maternal mortality and morbidity, globally. In sub-Saharan Africa, PPH is responsible for between 30% and 50% of maternal deaths 8 , and in Nigeria, PPH is estimated to account for nearly a quarter (23%) of maternal deaths 9 .

In addition to the potentially fatal outcomes, PPH has also been linked with increased maternal morbidity, particularly due to improved survival associated with improving maternal health services. Notably among these PPH-related consequences are mental illnesses, including anxiety, post-traumatic stress disorder and postpartum depression (PPD) 10 . A recent review and metanalysis involving nine studies reported that PPH was strongly linked to a higher risk of developing postpartum depression. More specifically, compared to women without PPH, the risk of PPD was raised by 27% in women with PPH 5 . Similarly, a population-based longitudinal study from the United Kingdom found a substantial correlation between PPH and a higher incidence of postnatal depression and posttraumatic stress disorder (PTSD) in the first year after delivery. The prevalence of PND was 5.34%, and that of PTSD was 0.20% among women who had PPH 11 . Several other studies have documented a similar relationship between PPH and PPD 12 , 13 , 14 , 15 , 16 .

The development of PPD is linked to the physiological changes of the postpartum period, characterised by profound changes in placental and maternal hypothalamic hormones, a decline in circulating blood volume, and alterations in metabolism 17 , 18 . PPH is a pathologically stressful event that can in addition to reducing blood volume, also lead to endocrine imbalance, a documented aetiologic factor for PPD 18 . The most common consequences of PPH are anaemia and trauma. Furthermore, clinical symptoms of PPH, such as fatigue, reduced cognitive abilities, and emotional instability, can lead to increased stress levels that alter the hypothalamic–pituitary–adrenal (HPA) axis function, leading to increased vulnerability to mood disorders 18 . Consistent with a role for HPA axis dysfunction in PPD, levels of the stress hormones are altered in patients with PPD.

Postpartum haemorrhage and postpartum depression are common and serious public health problems associated with maternal and child distress 5 . Although PPD is the most common psychiatric disorder during the 5 years after delivery 19 , the relationship between this disorder and the traumatic experience of postpartum haemorrhage is under-studied, in developing countries like Nigeria. Most studies exploring the relationship between PPH and PPD are from high-income settings. Given the prevalence of PPH and over 7 million births occurring in Nigeria annually 20 , over a million women will experience PPH, and many will suffer its health sequelae. Therefore, there is a need to investigate this relationship further. This study aimed to recruit women with and without PPH within 24 h of delivery and follow them up to estimate the incidence of PPD at 6, 10 and 14 weeks postpartum and to evaluate the effect of social support and perceived stress on the risk of PPD.

At the end of the study period, complete data on 124 women was analysed, giving a response rate of 82.7%. Eleven women from the PPH group and thirteen from the comparative group were excluded because they either did not fulfil the inclusion criteria or had incomplete data. There were 63 women who had PPH and 61 women without PPH, the majority of whom were from Gwale LGA (26.2% non-PPH and 28.6% PPH respondents). The respondent’s ages ranged from 18 to 44 years, with a mean and standard deviation (SD) of 27 ± 5 years. All but two women (98.39%, n = 122) were married, 76.61% ( n = 95) were from a monogamous setting, and 30.65% ( n = 38) had post-secondary education. The husbands’ mean age ± SD was 39 ± 7 years, and 52.83% ( n = 65) were educated up to tertiary level.

Among respondents who had PPH, the quantity of blood loss ranged from 500 to 1500 mls (IQR 500,1000 mls). Approximately a third of the respondents (31.75% < n = 20) were transfused after PPH, and only one woman (1.59% < n = 1) had a hysterectomy secondary to PPH. Among all respondents, a sizeable number had strong social support (62.90%, n = 78), and the majority of the respondents reported experiencing moderate levels of perceived stress (59.68%, n = 74). Baseline characteristics are presented in Table 1

At the conclusion of follow-up, the overall cumulative incidence of postpartum depression among all respondents was 15.32% ( n = 19); 17.46% ( n = 11) among women who had PPH and 13.11% ( n = 8) among women who did not have PPH. The incidence was highest in both groups on the first visit, despite insufficient evidence to support a difference between the groups (Table 2 ).

The distribution of PPD by baseline characteristics and risk factors for PPD is presented in Table 3 . Among all respondents, the incidence of PPD was higher among respondents who were less than 25 years (84.21%) and from monogamous households (78.95%). There was insufficient evidence of a difference in the incidence of PPD between women who had PPH and those who did not, and this relationship was maintained even after adjusting for the effects of age, parity, perceived stress and social support. Nonetheless, perceived stress and social support were found to be independent risk factors for PPD after adjusting for these variables. Compared to women who had low perceived stress, the odds of PPD were approximately three times in those who had moderate stress [AOR: 2.60, 95% CI: 1.10–13.20] and 4 times among those with high perceived stress [AOR: 4.20, 95% CI: 1.04–18.55]. Similarly, respondents with strong [AOR: 11.68, 95% CI: 4.03–18.74] and moderate social support [AOR: 6.20, 95% CI: 1.22–13.60] had higher odds of PPD compared to those with poor support.

On stratified analysis, we did not observe evidence of effect modification of both perceived stress (P = 0.266) and social support (0.601) on the relationship between PPH and PPD ( Table 4 )

This is a prospective cohort study of women with and without PPH who were followed up until 14 weeks postpartum in order to evaluate the incidence of PPD. The findings of our study show that the overall cumulative 14-week incidence of PPD for all respondents was 15.32%(17.46%, and 13.11% for women with PPH and without PPH respectively).

The incidence of PPD was not significantly different between women who had PPH and those who didn’t, and this lack of association persisted even after controlling for age, parity, perceived stress and social support. After controlling for these confounders, the only independent risk factors for PPD were perceived stress and social support. Social support and perceived stress, however, did not modify the relationship between PPH and PPD.

Our findings reveal that approximately 1 in 5 women who had postpartum haemorrhage in Kano develop PPD, a value higher than the 13.11% risk of PPD obtained from women who did not have PPH. The risk of PPD among both groups of women obtained in this study is akin to findings from China, where puerperal women with PPH were more likely to screen positive for postpartum depressive symptoms than those without PPH (16.4% vs 11.7%) 13 . Values from around the world, however differing from ours, also showed higher rates of PPD among women who had PPH as opposed to those who did not; from France (35% vs 15%) 21 , from Sweden (2.0% vs 1.9%) 14 . and from the UK (5.34% as opposed to 4.75%). 11 . Even though these results were consistent, the variances seen could have been caused by different inclusion criteria and methodological variations. For instance, one study defined PPD as having a value of EDPS score of 11 or above 21 , another defined PPH as losing >1000 mls 13 , while the third study limited its study group to term births with a non-anomalous pregnancy 14 . Two recent metanalyses revealed pooled evidence which showed that women with PPH are at increased risk of PPD compared with women without PPH 5 , 22 .

Over a third of the women who experienced PPH in this study reported high perceived stress relative to those who did not. Additionally, having high perceived stress was associated with increased odds of PPD. Epidemiological data has linked the occurrence of traumatic birth events, including PPH to higher stress levels 10 , 23 , 24 , 25 . Our results are in keeping with a review which reported a pooled incidence of PTSD after traumatic childbirth of 19.4% (95% CI 11.9–26.5%) 26 . Postpartum haemorrhage can have a profound psychological impact on mothers leading to feelings of fear, anxiety, helplessness, and loss of control. Witnessing or experiencing a life-threatening event during childbirth can trigger symptoms of post-traumatic stress disorder (PTSD) or contribute to general feelings of distress 12 . These psychological factors are closely linked to the development of postpartum depression. Thus, it is unsurprising that more than half of the PPD cases among women who experienced PPH were those with high perceived stress. The physical consequences of PPH, such as fatigue, weakness, anaemia, and the need for medical interventions like blood transfusions or surgery, can contribute to postpartum physical recovery challenges. This physical trauma and stress can exacerbate feelings of emotional distress and increase the risk of developing postpartum depression, pre-term deliveries and a pre-existing medical condition prior to pregnancy.

Our findings revealed an inverse relationship between social support and PPD. A significant number of our study participants among both groups had strong social support, however, there were more women with poor social support among those who had PPD. In line with our discovery, strong social support has been seen to positively influence the occurrence of PPD in African communities 2 , 27 , 28 . Social support plays a crucial role in promoting individual well-being, resilience, and community cohesion. In Africa, social support encompasses a rich tapestry of familial, communal, religious, and cultural practices that contribute to individual and collective well-being. African communities often exhibit strong bonds of solidarity and reciprocity, where neighbours, friends, and community members come together to support one another. In addition, family is central to social support in Africa, with strong kinship ties serving as the primary source of support. Extended family networks provide emotional, financial, and practical assistance to mothers after childbirth. This may further explain why women from monogamous homes in this study had a higher risk of PPD.

A major strength of this study is its prospective design. The prospective design allowed us to correctly estimate blood loss during delivery, a major flaw identified from previous studies, disentangle the temporal direction of association between PPH and PPD and assess the risk of PPD over time at three follow-up periods postpartum. Our study had some limitations, and the results must therefore be interpreted with caution. While all measures were put in place to reduce bias due to loss of follow-up, a negligible number of respondents could not be located after assessing the baseline information. A major source of potential bias in cohort studies arises from the degree of accuracy with which subjects have been classified with the outcome status. To avoid this, all staff collecting information underwent rigorous training with continuous supportive supervision. We also measured both PPH and PPD objectively using standardised tools.

We investigated the risk of PPD among women with and without PPH. Our findings showed insufficient evidence to suggest that women with PPH have a higher risk of PPH than women without PPH. However, perceived stress and social support were significantly associated with the development of PPD. We recommend the provision of holistic postpartum care that addresses both physical and emotional recovery needs as well as integrating mental health screening and support services into routine postpartum visits, alongside medical assessments.

This study is a multicenter prospective cohort study carried out in two tertiary hospitals (Aminu Kano Teaching Hospital and Murtala Muhammad Specialist Hospital) and one secondary hospital (Sabo Bakin Zuwo Maternity Hospital) within Kano, northern Nigeria. Kano state is one of the most populous states in Nigeria, with an estimated population of >14 million in 2022. Kano State is also among the states with poor maternal and child health indices, with a maternal mortality ratio of 1025 deaths per 100,000 live births (compared to the National figure of 576 per 100,000) 29 , and a high total fertility rate of over 6.5 births per woman 30 .

Aminu Kano Teaching Hospital (AKTH) and Murtala Muhammad Specialist Hospital (MMSH) serve as referral centres serving people from Kano and neighbouring states, while Sabo Bakin Zuwo Maternity Hospital (SBZMH) mainly serves people from within the Kano metropolis. The average number of annual births is 3800, 14,000 and 4000 in AKTH, MMSH and SBZMH, respectively.

The study population included women who gave birth in the three designated hospitals between April 13th 2023, and July 30th 2023, irrespective of parity and age. The study only comprised eligible women who were Kano residents, had a live birth, and received prenatal care in these facilities. In addition, women who had undergone a caesarean section, had a severe illness or had a history of mood disorders were excluded.

Prior data indicate that the incidence of PPD is 16% in Kano 2 . We hypothesise an absolute difference of 20% between our two study groups, based on observed difference of 20% found in a similar study 21 . Thus, a sample size of 75 for each group (total sample of 150), will achieve a power of 80% to observe a difference in incidence risk of 20% between women with and without PPH at 5% level of significance.

Baseline sociodemographic data, medical and obstetric history were obtained using a structured interviewer-administered questionnaire and other clinical data were obtained from the hospital records.

A Hausa-translated version of the Edinburgh postnatal depression scale (EDPS) was used to screen for PPD 31 . The EDPS is a 10-item, widely used, efficient and easy-to-use scale for identifying women at risk of postpartum depression 32 . Responses are scored between 0 and 3 based on the severity of the symptom, and the sum of the points for the 10 elements determines the final score, which can reach a maximum of 30. The EPDS is not a diagnostic tool but rather a means to identify the presence of a depressive symptom. The validity of EDPS has been tested in different settings, including Nigeria 33 , 34 , and has also been translated into several languages, including the Hausa Language 31 , 33 , 35 .

This study employed the Mini International Neuropsychiatric Interview (MINI) version 7.0.2 for DSM-5 to diagnose depressive disorders among the participants 36 . MINI is a short, standardised, structured instrument of choice often used for quick psychiatric evaluation in clinical and research settings. It covers a range of psychiatric disorders, including mood disorders, anxiety disorders, psychotic disorders, substance use disorders, and more. Studies have confirmed the validity and reliability of MINI 37 . Adopted by mental health practitioners and health organisations in over 100 countries, the MINI is the most extensively used psychiatric structured diagnostic interview instrument globally and has been verified and translated into more than 70 languages 36 . The scoring of the MINI entails determining whether or not specific criteria for a range of psychiatric disorders are present. Usually, responses are categorised as “Yes”, denoting the presence of symptoms or “No”, denoting their absence.

Social support was evaluated using the Oslo Social Support Scale (OSSS-3). The OSSS-3 is a brief measure designed to assess perceived social support, especially in population-based surveys and clinical contexts and has been recommended as a tool to assess social support in Nigeria 38 , 39 . Respondents score each of the three items on a Likert scale, which captures various facets of social support. The scores for each item are typically summed, with higher scores indicating greater perceived social support.

Perceived stress was measured using the Perceived Stress Scale. The Perceived Stress Scale (PSS-10) is a 10-item widely used psychological instrument for measuring the perception of stress in individuals over the past month. The PSS-10 covers various aspects of stress, including unpredictability, lack of control, and coping ability. Respondents rate their answers on a Likert scale, typically ranging from 0 (never) to 4 (very often). The PSS can be self-administered, making it appropriate for surveys. The total score can range from 0 to 4, with higher scores on the PSS indicating a higher level of perceived stress 40 .

The primary outcome, postnatal depression, was evaluated at 6, 10 and 14 weeks using the Edinburgh postnatal depression scale and the Mini International Neuropsychiatric Interview version 7.0.2 for DSM-5. Initial screening was conducted using the EDPS, and as recommended, a score of 9 or higher on the EDPS was the threshold for administering the MINI to establish the diagnosis of postpartum depression 31 . Confirmation of a major depressive disorder, as well as categorisation into current, past or recurrent, was made using the elements A1 to A6 on the A module of the MINI version 7.0.2.

The primary exposure, primary postpartum haemorrhage, was defined using the WHO description i.e. excess bleeding from the uterine cavity associated with childbirth in the quantity of 500 mls or more within 24 h of delivery 41 .

Other exposures included were social support classified as poor social support (score of 3–8), moderate social support (9–11) and strong social support (12–14) and perceived stress defined as low perceived stress (scores from 0 to 13), moderate stress (14 to 26), and high stress (scores from 27 to 40).

Explanatory variables were sociodemographic characteristics of the respondents, past medical history, obstetric history, and information regarding the most recent birth, including clinical findings, were also included as explanatory variables.

Selection of exposed group began with midwives in the delivery rooms of the three facilities being trained on how to quantify the volume of blood loss within 24 h of delivery. Under-buttock plastic calibrated drapes were used immediately after a woman delivered to collect blood around delivery time. Subsequently, sanitary towels were collected and weighed and specially formulated charts were used to calculate blood loss based on weight. Two nurses (research assistants) visited the delivery unit daily to identify women who had lost more than 500 mls within 24 h using the blood loss chart. Any woman who met the inclusion criteria was then enrolled as a participant in the exposed group. For each woman recruited into the exposed group, one woman who fulfilled the inclusion criteria but had not lost up to 500 mls of blood within 24 h was selected using a random sampling technique for recruitment into the unexposed group. This was done using randomly generated numbers from a tablet form within the list of the women without PPH who delivered that day.

Upon recruitment, baseline information was collected from participants of both groups. Clinical data and information on perceived stress and social support were also obtained.

All respondents were followed up for 14 weeks and the time for data collection was made to coincide with the second, third and fourth immunisation visits, which are at 6, 10 and 14 weeks. Index date of follow up was the date of the delivery. For participants who did not show up, phone calls were made, and they were visited in their homes.

Two nurses at the well-child clinic where women come for routine childhood immunisation collected data on the outcome (PPD). The EPDS was administered to each participant during the first visit, and those with a score of 9 and above were further evaluated using the MINI. Participants with scores less than 9 had the EPDS re-administered during the next visit, and the procedure was repeated until the last visit (at 14 weeks).

We utilised STATA version 15.0 (StataCorp LLC, College Station, TX, USA) for data analysis. Background characteristics were presented using frequencies and proportions as well as means and their corresponding standard deviations (SD) or median and interquartile range as appropriate. We estimated the cumulative incidence of PPD as the total number of PPD cases at the end of follow-up divided by the number of respondents followed up from the beginning of the study. We fitted logistic regression models to report the crude odds ratio (OR) and 95% confidence interval (CI) for the factors associated with PPD among all respondents and then employed a multivariable logistic regression modelling to report the adjusted odds ratio (aOR) and CI for the independent risk factors for PPD. We adopted a backward selection approach to modelling, beginning with a complete model that included all relevant variables and sequentially removing variables with a p -value > 0.20 and no established theoretical relevance. The likelihood ratio test was used to identify better models. The final model included our primary exposure to PPH status, age, parity, perceived stress and social support. We employed Mantel Haenszel (MH) odds to stratify the effect of PPH on PPD by perceived stress and social support and presented the ORs and CIs for each category.

Ethical approval for this study was obtained from the Health Research Ethics Committees of the Kano State Ministry of Health (SHREC/2022/3366) and Aminu Kano Teaching Hospital (NHREC/28/01/2020/AKTH/EC/3355). Permission to conduct the study was sought from the management of the three hospitals. Every respondent provided signed informed consent, and the provisions of the Helsinki declarations were adhered to.

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Acknowledgements

The project was supported by an institutional-based research grant, TETFund grant TETF/DR&D/CE/UNIV/KANO/INR/2020/V0L1, and the Fogarty International Centre (FIC) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) of the U.S. National Institutes of Health (NIH) award number 1D43TW011544. The findings and conclusions are those of the authors and do not necessarily represent the official position of the FIC, NIAAA, NIH, the Department of Health and Human Services, or the government of the United States of America.

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Fatimah Isma’il Tsiga-Ahmed, Aishatu Lawal Adamu, Amole Taiwo Gboluwaga & Rabiu Ibrahim Jalo

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Fatimah Isma’il Tsiga-Ahmed, Aishatu Lawal Adamu, Amole Taiwo Gboluwaga, Rabiu Ibrahim Jalo, Aminatu Kwaku Ayaba, Surayya Murtala Sunusi & Nafisat Tijjjani Abdullahi

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F.I.T., U.M.U., A.T.G., Z.D.A. and H.S.G. conceived and designed the study. F.I.T., S.M.A., S.M.S., N.T.A. and H.K.S. collected data. R.I.J., A.A.K., S.M.A. and S.K.S. performed a literature search. F.I.T., A.L.A. and R.I.J. performed the statistical analysis. F.I.T., U.M.I., A.T.G. and A.L.A. drafted the paper. Z.D.A., U.M.U. and S.K.S. assisted with data interpretation and critically reviewed the paper for intellectual content. A.A.K., S.M.S. and N.T.A. revised the paper. All authors contributed to and approved the paper.

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Tsiga-Ahmed, F.I., Umar, M.U., Adamu, A.L. et al. Incidence of postpartum depression among women with postpartum haemorrhage in Kano, northern Nigeria. npj Womens Health 2 , 32 (2024). https://doi.org/10.1038/s44294-024-00031-1

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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

Postpartum Support International

American Foundation for Suicide Prevention

Health Resources and Services Administration

National Women’s Health Center

Psychology topics: Women and girls
Psychology topics: Depression

StatPearls [Internet].

Postpartum depression.

Karen Carlson ; Saba Mughal ; Yusra Azhar ; Waquar Siddiqui .

Affiliations

Last Update: August 12, 2024 .

Continuing Education Activity

Postpartum depression (PPD) is a prevalent and potentially severe mood disorder that affects approximately 1 in 7 women within the first year after childbirth. PPD stems from a combination of hormonal changes, genetic predisposition, and environmental factors, yet up to 50% of cases remain undiagnosed due to the stigma surrounding the condition and patients' reluctance to disclose symptoms. Unlike the transient "baby blues," PPD is more severe, often manifesting as persistent sadness, low self-esteem, sleep disturbances, anxiety, and difficulties bonding with the baby. Effective recognition and management of PPD are essential for optimizing the health outcomes of the parent and infant.

This activity describes the evaluation of postpartum depression and how to differentiate it from other mood disorders that may occur in the postpartum period. Participants learn to identify the various etiologies and clinical presentations of PPD, as well as the underlying biochemical and psychological pathways. This activity also emphasizes the importance of routine screening using tools like the Edinburgh Postnatal Depression Scale and also highlights the roles of psychotherapy, support groups, and safe medications in treatment. Collaborating with an interprofessional healthcare team is highlighted, helping participants enhance their ability to implement best practices for treating and preventing PPD, ultimately improving patient outcomes. Regulatory guidelines are also covered to ensure a standardized approach to PPD care.

Identify the specific signs and symptoms of postpartum depression, including persistent sadness, low self-esteem, sleep disturbances, anxiety, loss of appetite, and difficulty bonding with the baby.
Differentiate postpartum depression from other mood disorders that may occur in the postpartum period, such as the "baby blues," postpartum psychosis, and generalized anxiety disorder, by understanding their unique clinical presentations and durations.
Apply the latest evidence-based guidelines and best practices for managing postpartum depression, staying updated with current research and clinical recommendations to optimize patient outcomes.
Apply interprofessional team strategies to improve care coordination and outcomes for patients with postpartum depression.
Introduction

Postpartum depression (PPD) is a mood disorder that affects individuals within 1 year after childbirth. According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), postpartum depression is now included in the term perinatal depression. [1] A major depressive episode that begins during pregnancy or within 4 weeks after delivery is classified as peripartum depression. This term encompasses both prenatal and postpartum depression. The DSM-5 does not recognize PPD as a separate entity. Instead, PPD is included within the broader diagnosis of peripartum depression. [2] Unlike the "baby blues," which typically resolve within a few weeks, PPD is more severe and can last for months if untreated.

Depression symptoms, including persistent sadness, lack of interest, low self-esteem, sleep disturbances, loss of appetite, anxiety, irritability with a hostile attitude towards infants, self-blame, and feelings of humiliation characterize PPD. People with PPD may also experience changes in sleeping and eating patterns, difficulty bonding with their baby, and feelings of hopelessness or worthlessness. [3] Recognizing and addressing PPD is crucial for the health and well-being of the patient and their baby. If left untreated, PPD can interfere with the ability to care for the child and may contribute to long-term developmental issues in the child (eg, emotional and behavioral problems). PPD can also strain family relationships and increase the risk of suicide. [4]

Screening for PPD should be a routine part of postpartum care, utilizing tools such as the Edinburgh Postnatal Depression Scale (EPDS) to identify those at risk. Treatment typically involves a combination of psychotherapy, support groups, and medication, including antidepressants, which can safely be used during lactation. Up to 50% of PPD cases remain undiagnosed due to patient reluctance to disclose symptoms, partly because of the stigma around PPD, which includes fears of abandonment and lack of support upon disclosure. [5] Raising awareness about PPD, reducing stigma, and ensuring access to mental health resources are essential steps in supporting new parents and promoting healthy family dynamics.

The exact cause of PPD is not fully understood, but potential underlying etiologies contributing to the development of this condition include hormonal changes, genetic predisposition, and psychosocial stressors. The rapid drop in estrogen and progesterone levels after delivery, coupled with the stress and sleep deprivation that often accompany caring for a newborn, can trigger depressive episodes in susceptible people.

In a meta-analysis of 33 studies, gestational diabetes, having boy infants, a history of depression, and epidural anesthesia use were noted as risk factors. However, further research is needed to assess the true significance of these reported risk factors, especially the sex of the infant and the use of epidural anesthesia. [3] Besides hormonal, other changes in many metabolic pathways may be associated with the development of postpartum depression, including alterations in energy metabolism, the purine and amino acid cycles, steroid and neurotransmitter metabolism, and exposure to xenobiotics. [6]

Postpartum Depression Risk Factors

Factors associated with a high risk of developing postpartum depression include:

Psychological : A personal history of depression and anxiety, premenstrual syndrome, a negative attitude towards the baby, the reluctance of the baby's sex, and a history of sexual abuse
Obstetric risk factors : A high-risk pregnancy, hospitalization during pregnancy, and traumatic events during childbirth that include emergency Cesarean section, in-utero meconium passage, umbilical cord prolapse, preterm or low birth weight infant, and low hemoglobin
Social factors : Lack of social support, domestic violence in the form of spousal abuse (eg, sexual, physical, or verbal), smoking, and young maternal age during pregnancy [6]
Lifestyle : Poor eating habits, decreased physical activity and exercise, vitamin B6 deficiency (via its conversion to tryptophan and, later on, serotonin, which, in turn, affects mood), and lack of sleep; exercise decreases low self-esteem caused by depression and increases endogenous endorphins and opioids, which brings positive effects on mental health and improves self-confidence and problem-solving capacity. [7]
Family history of psychiatric disorders : Recent studies have shown that a family history of psychiatric disorders is a risk factor for developing postpartum depression. This increased risk is likely due to genetic and environmental factors during childhood and later life associated with a lack of social support, which is a risk for PPD. [8]
Epidemiology

Depression is the most common psychiatric condition of the peripartum period. Moreover, PPD is associated with an increased risk of parental suicide, which is the second most common cause of mortality postpartum. [9] PPD affects 6.5% to 20% of postpartum individuals globally. [10] The incidence varies based on contributing factors, including the country's cultural environment and economic conditions. Different studies have found varying risk factors for postpartum depression, resulting in little consistency between studies. [3] According to studies, depression occurs more commonly in adolescents, patients who deliver premature infants, and those living in urban areas. In a meta-analysis, the prevalence of postpartum depression was the highest in China, at 21.4%. In comparison, the prevalence in Japan was 14%, and the prevalence in the United States was 8.6%. The average time of onset of postpartum depression is 14 weeks postpartum. [3] Overall, Black and Hispanic patients tend to report the onset of symptoms within 2 weeks of delivery, unlike White patients, who more frequently report the onset of symptoms later.

Pathophysiology

The pathogenesis of PPD is currently unknown but is likely multifactorial. [10] Genetic, hormonal, psychological, and social life stressors have been suggested to play a role in PPD development. [11] [12] [13] The role of reproductive hormones in depressive behavior suggests neuroendocrine pathophysiology for PPD. Ample data advocating that changes in the reproductive hormones stimulate the dysregulation of these hormones in sensitive individuals has been documented. The pathophysiology of PPD can be caused by alterations of multiple biological and endocrine systems, for example, the immunological system, the hypothalamic-pituitary-adrenal axis (HPA), and lactogenic hormones.

The HPA is known to be involved in the disease process of postpartum depression. The HPA axis causes the release of cortisol in trauma and stress; with HPA axis dysfunction, the release of catecholamines is decreased, leading to a poor stress response. HPA-releasing hormones increase during pregnancy and remain elevated up to 12 weeks postpartum. Recent evidence suggests that PPD is linked to the gamma-aminobutyric acid (GABA) neurotransmission system. The imbalance in GABA, the chief inhibitory neurotransmitter in the brain, likely plays a role in causing PPD. [10]

The rapid drop in reproductive hormones like estradiol and progesterone following delivery can be a potential stressor in patients who are susceptible, and these changes can lead to the onset of depressive symptoms. Elevated cortisol levels and low tryptophan levels may be noted. [6] Oxytocin and prolactin also play an essential role in the pathogenesis of PPD. These hormones regulate the milk let-down reflex and the synthesis of breast milk. Failure to lactate and the onset of PPD are often observed to coincide. Low levels of oxytocin are particularly observed in PPD and unwanted early weaning. During the third trimester, lower levels of oxytocin are associated with increased depressive symptoms during pregnancy and following delivery. [14]

History and Physical

PPD is diagnosed when at least 5 depressive symptoms are present for at least 2 weeks. Most experts include the onset of symptoms that occur up to 12 months postpartum. [15] The following 9 symptoms in affected people may be present almost daily and represent a change from the previous routine; however, a PPD diagnosis should include either depression or anhedonia:

Depressed mood (subjective or observed) is present most of the day
Loss of interest or pleasure (anhedonia), most of the day
Sleep disturbances (insomnia or hypersomnia)
Psychomotor retardation or agitation
Worthlessness or guilt
Loss of energy or fatigue
Suicidal ideation or attempt and recurrent thoughts of death
Impaired concentration or indecisiveness
Change in weight or appetite (eg, a weight change of 5% over 1 month)

The symptoms can lead to significant distress and impairment. Furthermore, these symptoms are not attributable to substance use or a medical condition. A psychotic disorder does not cause the episode, nor has there been a prior manic or hypomanic episode. [9] The International Classification of Diseases-10 describes a depressive episode as follows:

In typical mild, moderate, or severe depressive episodes, the patient has a depressed mood with a decrease in activity and energy.
Capacity for enjoyment, interest, and concentration is reduced. The patient feels tired after minimum effort, with sleep disturbance and a decreased appetite. Guilt, worthlessness, lowered self-esteem, and lowered self-confidence are commonly present.
Somatic symptoms, including anhedonia, unusual waking in the very early morning, agitation, weight loss, loss of libido, decreased appetite, and marked psychomotor retardation are noted. These symptoms may vary daily and are not responsive to a change in circumstances.
A depressive episode may be classified as mild, moderate, or severe, depending on the severity and number of the symptoms.

The signs and symptoms of PPD are identical to nonpuerperal depression with an additional history of childbirth. Symptoms include depressed mood, loss of interest, changes in sleep patterns, change in appetite, feelings of worthlessness, inability to concentrate, and suicidal ideation. Women may also experience anxiety. Patients with PPD may also have psychotic symptoms, which include delusions and hallucinations, such as voices saying to harm infants. PPD may lead to poor maternal-infant bonds, failure of breastfeeding, harmful parenting practices, marital discord, as well as worse outcomes concerning the child's physical and psychological development. The remission of symptoms reduces the risk of behavioral and psychiatric problems in the offspring. A prior episode of PPD increases the future risk of major depression, bipolar disorder, and PPD. Past personal and family histories of PPD and postpartum psychosis should also be noted.

The American College of Obstetricians and Gynecologists (ACOG), the American Academy of Pediatrics (AAP), and the American Academy of Family Medicine (AAFP) all recommend screening every patient for postpartum depression using the EPDS. [3] During the evaluation, the inclusion of drug and alcohol history, smoking habits, and all prescription and over-the-counter drug medications is essential. PPD screening should be performed during pregnancy and postpartum. [16]

Several screening tools are available, though the most frequently used is the EPDS, a 10-item questionnaire completed by patients within a few minutes. A score ≥13 is associated with an increased risk of developing PPD and provides the basis for additional clinical assessment. The objectives of the clinical evaluation are to constitute the diagnosis, assess suicidal and homicidal risks, and rule out other psychiatric illnesses. [17]

Treatment / Management

Prevention of postpartum depression in high-risk patients using counseling and cognitive behavioral therapy, as well as interpersonal therapy, has been effective. Clinicians should identify and implement these interventions as preventative measures for high-risk patients. [15]

Antidepressant Medications

The first-line treatment for peripartum depression is psychotherapy and antidepressant medications. Psychotherapy is the first-line treatment option for patients with mild to moderate peripartum depression. A combination of therapy and antidepressant medications is recommended for moderate to severe depression. Referral to a behavioral health resource may also be recommended. [15] ACOG recommends using selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and tricyclic antidepressants for PPD medical therapy. [9]

Selective serotonin reuptake inhibitors are the first choice medications for PPD. Consideration should be given to switching to serotonin-norepinephrine reuptake inhibitors or mirtazapine if selective serotonin reuptake inhibitors are ineffective. Sertraline or escitalopram are good first-line choices for medical therapy. Sertraline has extensive and reassuring safety research. Fluoxetine and paroxetine, if previously used effectively for a specific individual, may be considered despite an increased risk of neonatal adaptation syndrome. As such, the treatment for patients who have had successful medical therapy with an antidepressant in the past should be allowed to resume that effective medication during or after pregnancy. [15]

The goal of treatment for PPD is remission or resolution of symptoms of depression. The same screening tool should be used to track symptoms. An improvement of 50% or more defines a treatment response. Algorithms may be used to help in adjusting dosages of medications with continued use of the Patient Health Questionairre-9 or EPDS. Inadequately or untreated mental health conditions are associated with perinatal risks, as are any pharmacologic agents; the risks of both need to be recognized. The lowest effective dose of medication should be used to achieve illness remission. However, avoiding undertreatment, which is common in obstetrics, is critical. Polypharmacy and switching medications should be avoided if remission is possible with the use of a single agent. [15] Although benefits may be reported within 1 week of the start of oral therapy, symptom improvement may take 4 to 8 weeks. [9]

Once an effective dose is reached, continued treatment for at least 6 to 12 months is recommended to prevent relapse of symptoms. [18] Discontinuation of medical therapy during pregnancy or in the postpartum period results in a high risk of recurrence and is not recommended; also, discontinuing medication in the third trimester to mitigate the risk of neonatal adaptation syndrome is not recommended. Additionally, abrupt discontinuation of both selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors is associated with complications unless a progressive taper over 2 to 4 weeks is used. Discontinuation symptoms may include gastrointestinal upset, agitation, anxiety, headache, dizziness, fatigue, sleep disruption, tremors, myalgias, and electric-like shocks. [15]

Pharmacologic recommendations for people who are lactating should include discussing the benefits of breastfeeding, the risks of antidepressant use during lactation, and the risks of untreated illness. Repetitive transcranial magnetic stimulation is a treatment that may provide an alternative option for people who breastfeed and are concerned about their babies being exposed to medication. The risk of breastfeeding while taking a serotonin reuptake inhibitor is relatively low, and patients can be encouraged to breastfeed while on antidepressants. After 12 weeks, cognitive behavioral therapy, sertraline monotherapy, and combination therapy were helpful. The cognitive behavioral therapy monotherapy group found the most accelerated initial gains after treatment startup.

Neurosteroid Therapy

Brexanolone, an intravenous neurosteroid that positively acts at the GABA-A receptors, was approved by the Food and Drug Administration (FDA) in March 2019, specifically for PPD. Brexanolone may be considered for use with moderate to severe depression in the third trimester or postpartum. Patients must be enrolled in the Risk Evaluation and Mitigation Strategy Program. [19] Brexanolone has a rapid onset of action but is hard to access and may be cost-prohibitive. No data supports its safety with breastfeeding or efficacy beyond 30 days of use. Inpatient monitoring for increased sedative effects, sudden loss of consciousness, and hypoxia during infusion is required. [9] [15]

Brexanolone, an analog of allopregnanolone, a metabolite of progesterone, was the first medication approved by the FDA for the treatment of moderate to severe postpartum depression. [19] Brexanolone is administered intravenously as a continuous 60-hour infusion lasting approximately 2.5 days. Multiple clinical trials demonstrate that brexanolone is usually well-tolerated in women with moderate to severe PPD and can provide a rapid beneficial response. [20] [21] Breastfeeding is not recommended during and for 4 days after brexanolone infusion therapy. More clinical trials are needed to assess further the long-term safety and efficacy of brexanolone in treating PPD. [15]

Zuranolone, a neuroactive steroid like brexanolone, is also a GABA-A receptor modulator that was FDA-approved on August 4, 2023, for PPD management. A 50-mg oral dose every night is given with a fat-containing (700 cal; 30% fat) meal for 14 days. Zuranolone may be used alone or in combination with oral antidepressants. The onset of action is rapid, from hours to days, which helps give more immediate relief. Because of the central nervous system depression seen with zuranolone, patients should be counseled that their driving ability may be reduced. Also, zuranolone has been suggested to produce harmful effects on the fetus during pregnancy and lactation. Overall, zuranolone is well tolerated and has minimal side effects. [10] The most common adverse event reported by over 26% of patients was somnolence. [22] Because safety and effectiveness have not yet been studied, zuranolone is not recommended to be continued for longer than 14 days.

Nonpharmacologic Therapies

Transcranial magnetic stimulation is a noninvasive procedure that uses magnetic waves to stimulate and activate nerve cells in a targeted area of the brain. [23] These cells are underactive in people with major depression. Transcranial magnetic stimulation is usually done once a day for 4 to 6 weeks to be effective. This therapy may be used in patients who are not responding to antidepressants and psychotherapy. Generally, transcranial magnetic stimulation is safe and well-tolerated, but some side effects can include headaches, lightheadedness, scalp discomfort, and facial muscle twitching. Some serious side effects are rare, including seizures, hearing loss if ear protection is not adequate, and mania in people with bipolar disorder. [24] Although early results are promising, future studies are needed to address the benefits of transcranial magnetic stimulation for PPD. [23]

Patients with severe PPD may not respond to psychotherapy and pharmacotherapy. For patients refractory to 4 consecutive medication trials, electroconvulsive therapy (ECT) may be recommended. ECT is beneficial in patients with psychotic depression, with intent or plans on committing suicide or infanticide, and refusal to eat, leading to malnutrition and dehydration. [25] [26] Several observational studies have suggested ECT as a safer option for lactating patients as there are fewer adverse events for the mother and the infant. [27] [28] Other authors are not as supportive of ECT use for PPD.

Differential Diagnosis

Differential diagnoses that should also be considered when evaluating postpartum depression include:

Baby blues: Baby blues most commonly occur within a week after delivery and resolve within a few days, around day 10 to 14 postpartum. Approximately 50% to 75% of patients experience baby blues, which are temporary and require no treatment. Symptoms may include crying bouts, sadness, anxiety, irritability, sleep disturbance, appetite changes, confusion, and fatigue. The baby blues does not affect daily functioning or the ability to care for the baby. However, severe postpartum baby blues is associated with a risk for PPD. [29]
Hyperthyroidism and hypothyroidism: These conditions can also lead to mood disorders. Thyroid disorders can be assessed by testing thyroid-stimulating hormone levels.
Postpartum anxiety, adjustment disorder, or posttraumatic stress disorder: Postpartum anxiety focuses on excessive worry. Adjustment disorder includes emotional and behavioral responses to the stress of childbirth, which are less severe and shorter in duration than PPD. Posttraumatic stress disorder involves trauma-related symptoms due to a traumatic birth experience.
Postpartum psychosi s: Postpartum psychosis is defined as the onset of psychosis during the first 4 weeks postpartum. Most women do not have a known history of psychiatric disorders, but some have had bipolar disorder in the past. Usually, onset is within 3 to 10 days postpartum but may occur over 4 weeks postpartum. Postpartum psychosis is a psychiatric emergency with potential suicide and infanticidal risk. A patient can experience hallucinations, agitation, unusual behavior, disorganized thoughts, and delusions. This is a rare disorder, occurring in only 1 to 2 per 1000 pregnancies, and presents with an acute onset of manic or depressive psychosis within the first few days or weeks after delivery. [15]

Dose adjustments may be needed based on monitoring symptoms through clinical assessment, validated screening tools, or both. Due to increased renal clearance, increased distribution volume, and changes in enzyme activity with advancing gestation, an increase in medication dose during pregnancy may be required. Empiric down-titration of psychiatric medications in the third trimester is not recommended as neonatal outcomes were not improved, and the associated risk of worsening mental health conditions was noted. [15]

A pivotal factor in the duration of PPD is delayed treatment. Approximately 25% of patients with perinatal depression will have symptoms for 3 years after giving birth. [15] PPD has repercussions beyond possible physical harm to the child. Data reveal that the condition also affects parent-infant bonding. Often, the child is treated inappropriately with a negative attitude that can significantly impact the child's growth and development. Children born to patients with PPD have been found to exhibit marked changes in behavior, altered cognitive development, and early onset of depressive illness. More importantly, these children may struggle with obesity and dysfunction in social interactions.

Complications

PPD affects the parents and the infant and can lead to a chronic depressive disorder if untreated. Even if treated, PPD can be a risk for future episodes of major depression. Moreover, PPD is a stressful event for the entire family, as children may be affected also. Children of parents who have untreated depression can develop behavioral and emotional problems, including language development delays, which are commonly seen, sleeping problems, eating difficulties, excessive crying, and attention-deficit/hyperactivity disorder.

When untreated, PPD is associated with negative consequences for those who are postpartum, including disrupted health behaviors, relationships, physiology, and parenting. This results in a risk for the fetus, the partner, and the whole family. [15] Therefore, ACOG does not recommend withholding or stopping psychiatric medications due to pregnancy status alone. [15]

Deterrence and Patient Education

Deterrence and education are critical components in addressing PPD. Proactive education about PPD should begin during prenatal care, with clinicians informing expectant mothers and their families about the signs, symptoms, and potential risks associated with this condition. By increasing awareness, new mothers can recognize the onset of PPD early and seek timely intervention. Education programs can include prenatal classes, informational brochures, and discussions during regular medical appointments. Additionally, integrating mental health screenings into postpartum checkups can help in early detection and management.

Support systems, including counseling services and support groups, should be readily accessible to new mothers, providing a safe space for them to share experiences and receive professional guidance. By fostering an environment of understanding and support, the stigma associated with PPD can be mitigated, encouraging more women to seek help. Ultimately, comprehensive deterrence and educational strategies are essential in reducing the incidence and severity of postpartum depression, ensuring healthier outcomes for mothers and their infants.

Pearls and Other Issues

Before delivery, many patients who are at risk of developing PPD can be identified. These patients, along with their families, should be provided with information and education regarding PPD prenatally. The information should be reinforced during postpartum hospitalization and after discharge. [5] Childbirth education classes teach new parents to seek help and the support that they might need for childbirth. By teaching patients and their partners about the signs and symptoms of PPD, educators can increase the chance that the patient with this condition receives proper treatment.

Screening for depressive symptoms can be done during pregnancy. This screening can identify women who are at increased risk for developing PPD. Exclusive breastfeeding has a positive effect on reducing depressive symptoms from childbirth to 3 months. PPD can be prevented when parents are given positive parenting lessons and when the parent-infant bond is promoted and increased. This can be achieved through social support from family and clinicians.

Enhancing Healthcare Team Outcomes

To enhance patient-centered care, outcomes, patient safety, and team performance related to PPD, an interprofessional approach involving physicians, advanced practitioners, nurses, pharmacists, and other health professionals is crucial. Due to the high morbidity of PPD, current efforts emphasize prevention. Nurses are in a primary position to identify patients at high risk for postpartum mood disorders even before delivery. During admission, nurses can identify patients with a history of depression or postpartum blues and monitor those who develop depression during pregnancy. These patients require education on available treatments and support from the postpartum nurse or primary care clinician. Coordination with therapists and referrals to psychiatrists for antidepressant treatment may be necessary.

Pharmacological and nonpharmacological prophylaxis are used with variable success, but evidence shows that postpartum parents who are treated have better bonding experiences with their infants. Additionally, untreated parental depression can lead to mood and behavior problems and obesity in children. Despite awareness, many patients remain untreated due to a lack of follow-up. Therefore, the role of the postpartum visiting nurse is critical in ensuring ongoing support and care. Effective interprofessional communication and care coordination among clinicians are essential in identifying, monitoring, and treating PPD, ultimately improving patient outcomes and safety.

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Disclosure: Karen Carlson declares no relevant financial relationships with ineligible companies.

Disclosure: Saba Mughal declares no relevant financial relationships with ineligible companies.

Disclosure: Yusra Azhar declares no relevant financial relationships with ineligible companies.

Disclosure: Waquar Siddiqui declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

Cite this Page Carlson K, Mughal S, Azhar Y, et al. Postpartum Depression. [Updated 2024 Aug 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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COMMENTS

A Comprehensive Review on Postpartum Depression
Postpartum depression (PPD) has a significant negative impact on the child's emotional, mental as well as intellectual development if left untreated, which can later have long-term complications. Later in life, it also results in the mother developing obsessive-compulsive disorder and anxiety. Many psychological risk factors are linked with PPD.
A Comprehensive Review of Motherhood and Mental Health: Postpartum Mood
Postpartum mood disorders, including postpartum depression (PPD), anxiety disorders, and even rare but severe cases of postpartum psychosis, can cast a shadow over what is meant to be a joyous time. The significance of this topic lies in the potential long-term consequences of untreated postpartum mood disorders, affecting not only the mother ...
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Postpartum Depression
The estimated prevalence of postpartum depression ranges from 6.5 to 12.9% or even higher in lower-income and middle-income countries. 1,4,5 Some studies have shown increased rates of depression ...
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On August 4, 2023, the US Food and Drug Administration (FDA) approved zuranolone for postpartum depression. In a comprehensive definition that encompasses perinatal depression, postpartum depression occurs during pregnancy or within 1 year after childbirth. It is a depressive episode during which people experience feelings of sadness, guilt, and worthlessness; sleep disturbances; often ...
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Postpartum depression (PPD) is a significant health issue for many new mothers in the weeks and months following a child's birth. ... Submit Paper. Close Add email alerts. You are adding the following journal to your email alerts. ... Busser D., Ganann R., McMillan T., Swinton M. (2008). Women's care-seeking experiences after referral for ...
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Frontiers
1 Central Laboratory, Yangjiang People's Hospital, Yangjiang, China; 2 Center for Analyses and Measurements, College of Chemical Engineering, Zhejiang University of Technology, Hangzhou, China; 3 Institute of Cell Biology, Zhejiang University, Hangzhou, China; Postpartum depression (PPD) is a serious health issue that can affect about 15% of the female population within after giving birth.
Paternal Postpartum Depression and Associated Factors Among Partners of
In 2020, the pooled prevalence of paternal postpartum depression among fathers was 9.76% worldwide during the first year of their childbirth (Rao et al., 2020).The Global Burden of Diseases Study analyzed the data from 17 low- and middle-income countries (LMICs) and indicated that the prevalence of paternal postnatal depression was 18.4% (GBD 2015 Disease and Injury Incidence and Prevalence ...
The effectiveness of postpartum interventions aimed at improving women
Meta-analysis for postpartum depression was performed for the 8 RCTs, with 1320 participants, ... are needed on this research topic . To maintain this systematic review up-to-date, we searched Cochrane Central Register of Controlled Trials for any trial registered between August 2020 to August 2022, but found no novel study on this research ...
89 Postpartum Depression Essay Topic Ideas & Examples
Activity During Pregnancy and Postpartum Depression. Studies have shown that women's mood and cardiorespiratory fitness improve when they engage in moderate-intensity physical activity in the weeks and months after giving birth to a child. Complementary Therapy for Postpartum Depression in Primary Care. Thus, the woman faced frustration and ...
Incidence of postpartum depression among women with postpartum ...
The burden of postpartum depression (PPD), an important but largely neglected cause of maternal morbidity, is often increased by the presence of common co-morbidities, such as postpartum ...
Consequences of maternal postpartum depression: A systematic review of
A total of 122 studies (out of 3712 references retrieved from bibliographic databases) were included in this systematic review. The results of the studies were synthetized into three categories: (a) the maternal consequences of postpartum depression, including physical health, psychological health, relationship, and risky behaviors; (b) the infant consequences of postpartum depression ...
Postpartum depression: Causes, symptoms, risk factors, and treatment
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.
Postpartum depression risk factors: A narrative review
Postpartum depression is a debilitating mental disorder with a high prevalence. The aim of this study was review of the related studies. In this narrative review, we report studies that investigated risk factors of postpartum depression by searching the database, Scopus, PubMed, ScienceDirect, Uptodate, Proquest in the period 2000-2015 published articles about the factors associated with ...
Postpartum Depression Causes, Symptoms, and Treatments
Postpartum depression resources Postpartum Support International (PSI) — PSI helps people with postpartum depression find help and local services. The American Academy of Family Physicians offers a wide range of information on postpartum depression.; U.S. Department of Health and Human Services Office on Women's Health has an excellent FAQ on postpartum depression.
Postpartum Anxiety & Depression, Explained
Postpartum anxiety and postpartum depression often go hand in hand, with numerous patients meeting the criteria for both. The symptoms of postpartum anxiety, which include excessive worrying about the new baby and a belief that you can't handle motherhood, will often transition into postpartum depression, bringing on feelings of hopelessness ...
Postpartum Depression
Postpartum depression (PPD) is a mood disorder that affects individuals within 1 year after childbirth. According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), postpartum depression is now included in the term perinatal depression.[1] A major depressive episode that begins during pregnancy or within 4 weeks after delivery is classified as peripartum depression.

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Postpartum Depression—New Screening Recommendations and Treatments

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Postpartum Depression: A Review

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