What You Need To Know About Postpartum Depression

PPD, baby blues, and postpartum psychosis each have their own symptoms, as well as shared features, which are set out below.

Baby blues

Baby blues symptoms typically appear four to five days after birth and can include:

• Anxiety

• Sadness

• Mood swings

• Irritability and impatience

• Feeling overwhelmed

• Crying

• Trouble concentrating

• Loss of appetite

• Trouble sleeping

Postpartum depression

The symptoms of PPD are the same as symptoms of other types of depression. PPD symptoms usually appear within three months of giving birth and can include:

• Severe mood swings, anxiety, or panic attacks

• Extreme sadness or excessive crying

• Feeling irritable, short-tempered, or angry

• Getting too much or too little sleep

• Overeating or undereating

• Extreme exhaustion

• Inability to complete daily tasks

• Diminished ability to think clearly

• Inability to concentrate or make simple decisions

• Withdrawal from family and friends

• Loss of interest in things you used to enjoy

• Feelings of worthlessness, shame, or inadequacy

• Feeling out of control, overwhelmed, and hopeless

• Difficulty bonding with and taking care of your baby

• Intense fear of being a bad mother

• Wanting to “just give up”

• Thoughts of suicide, infanticide, or harming yourself or your baby (if you are experiencing this, you should seek to contact your doctor immediately)

Postpartum psychosis

Postpartum psychosis may begin with feelings of restlessness, irritability, and being unable to sleep, which can evolve into much more serious symptoms. These include:

• Hallucinations

• Delusions

• Loss of inhibitions

• Obsessive thinking

• Erratic and unusual behavior

• Confusion and disorientation

• Feeling intensely suspicious or fearful

• Swinging between manic and depressive moods

• Violent thoughts of harming yourself or your baby

Seeking help

Postpartum depression is a common medical/psychiatric condition. Experiencing the symptoms of PPD, baby blues, or postpartum psychosis has nothing to do with how good a mother you are or how much you love your child.

If you are experiencing symptoms, it is important to contact your doctor as soon as possible for diagnosis and the right treatment to help you recover. Remember to be kind and gentle with yourself while you work through the recovery process with the support of your loved ones and trained healthcare providers.

There is no specific known cause of PPD, but several factors can contribute to its development. Pregnancy and childbirth involve dramatic physical and emotional transformations for a mother. When these changes occur too suddenly or intensely for a mother to adapt to them, they may experience symptoms of postpartum depression.

Physiological issues

A major contributor to the development of PPD is the physiological changes that occur during pregnancy and childbirth, including the following:

• Hormonal fluctuations – During pregnancy, levels of estrogen and progesterone are higher than usual. Shortly after giving birth, a mother's hormone levels return to pre-pregnancy levels. These abrupt biochemical changes can lead to depression.

• Low thyroid hormone levels

• Lack of sleep

• Drug or alcohol abuse

• Underlying medical conditions

• Vitamin/mineral deficiencies  

Emotional issues

The inherently stressful nature of pregnancy and childbirth can be exacerbated by emotionally challenging circumstances such as:

• Recent divorce or death of a loved one

• Serious health problems for you or your child

• Conflict with your spouse or partner

• Social isolation

• Financial problems

• Lack of emotional support

Social pressure

Many women feel societal pressure to have the “perfect” pregnancy and birth, and to be the “perfect mother”, but this is rarely the case. The contrast between the unattainable ideal and reality can lead to feelings of confusion, guilt, frustration, and hopelessness – symptoms of depression. This contrast can make us feel even worse when we see the carefully curated facade of “perfect parents” on social media.

Risk factors for developing postpartum depression

Some women are more likely than others to experience PPD, based upon risk factors such as:

• Personal history of PPD or other types of depression 

• Family history of PPD 

• Diagnosis of bipolar disorder

• Giving birth to twins or triplets

• Premature birth

• Medical complications during delivery

• Health problems in you or your newborn

• Difficulty breastfeeding

• Dissatisfaction with your spouse/partner

• Mixed feelings about the pregnancy

• Financial problems

• Childcare challenges

• Real or perceived lack of support

• Physical, emotional, or sexual abuse

• Recent stressful life events, such as a job loss or death in the family

• Problems with drugs or alcohol

Diagnosing postpartum depression

While a doctor can provide a preliminary diagnosis, they will likely refer you to a psychiatrist or psychologist for a full diagnosis. These mental health professionals will diagnose you by reference to The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), which is the official manual used to diagnose mental disorders. It defines depression "with peripartum onset" as a major depressive episode that occurs during pregnancy or within four weeks after birth.

To be considered a major depressive episode, you must have experienced at least two weeks of persistent low mood, as well as at least four of the following symptoms:

• Increased or decreased appetite

• Sleep disturbance

• Psychomotor agitation or retardation

• Always feeling tired

• Feelings of worthlessness

• Low concentration

• Suicidal thoughts

When depression happens in the context of pregnancy or childbirth, it's considered postpartum depression.

Edinburgh Postnatal Depression Scale (EPDS)

There's no body scan or blood test that can determine whether you have PPD. As it is a mood disorder, the best way to diagnose PPD is via a mental health questionnaire – a PPD screening test that identifies which mood-related symptoms you may have.

The questionnaire used by many health professionals is the Edinburgh Postnatal Depression Scale (EPDS), which includes ten questions about your experience over the previous seven days. Your answers to these ten questions help your doctor to determine if you're experiencing symptoms of or are at risk of PPD.

Blood tests to check for underlying conditions

There are some physical health conditions that can cause symptoms that are similar to those of PDD, including hypothyroidism. For this reason, your doctor may also order a blood test that measures your thyroid hormone levels to make sure that your thyroid is a gland and rule out any underlying issues.

There are a variety of effective treatments for PPD, baby blues, and postpartum psychosis, which all aim to relieve physical and psychological stress and support mental and emotional well-being.

Baby blues

If you're experiencing the symptoms of baby blues, some simple lifestyle shifts can help you to feel better. For instance:

• Diet – Eat a healthy diet full of fresh fruits and veggies, whole grains, fatty fish, and healthy oils¹ to nourish your body. 

• Sleep – Get as much sleep as you can, and rest when your baby is napping.

• Exercise – Take a walk once a day for gentle exercise, fresh air, and sunshine.

• Support – Ask for support when you need it, and try to accept it when it is offered.

• Stress – Don't sweat the small stuff, such as household chores that can wait until later. Focus on the health and happiness of you and your baby, and try to be present in each moment.

Postpartum depression

The standard treatment for PPD includes either psychotherapy or medication or a combination of the two, depending on the severity of your symptoms:

• Psychotherapy or counseling – Cognitive behavioral therapy (CBT) and mindfulness-based cognitive therapy can both provide effective support, either on their own or in conjunction with medication.

• Antidepressant medication – Selective serotonin reuptake inhibitors (SSRIs) are often used to treat moderate to severe cases of PPD.

Treatment-resistant postpartum depression

The following are uncommon forms of treatment that are only used if the standard therapies described above are not effective:

• Transcranial magnetic stimulation – This non-invasive procedure uses magnetic waves to stimulate and activate nerve cells. It doesn't interfere with breastfeeding and involves no medications.

• Electroconvulsive therapy (ECT) – This procedure is performed under the close supervision of a psychiatrist and is only recommended if other treatments have not been effective or are not safe to use. It involves the application of controlled electrical energy to brain tissue while you are under anesthetic. ECT tends to only be recommended if you experience symptoms of psychosis.

• Hormone therapy – If there's evidence of estrogen deficiency, your doctor may recommend transdermal estrogen therapy². This must be balanced out by simultaneous progestogen use. If estrogen is started before breastfeeding is well-established, it may affect milk supply.

• Brexanolone (Zulresso) therapy – Your doctor may prescribe brexanolone, which is a synthetic version of the hormone allopregnanolone. It can be effective in relieving symptoms of PPD but is generally only used when other treatments (SSRIs, CBT, and even ECT) have been unsuccessful.

Are antidepressants safe to use while breastfeeding?

If you're breastfeeding, it's important to discuss with your doctor whether it is safe to take antidepressants or other medication to treat PPD.

One study³ published in the Journal of the American Board of Family Practice concluded that, of the more frequently studied antidepressant drugs in breastfeeding women, paroxetine, sertraline, and nortriptyline have not been found to have adverse effects on infants. Fluoxetine, however, should be avoided in breastfeeding women.

Treatment for postpartum psychosis

If you have postpartum psychosis, you will most often receive inpatient treatment in the hospital or a specialized psychiatric unit called a mother and baby unit (MBU) where both you and your baby are taken care of. As a mother, you will be treated until your mood has stabilized and the doctor is certain you are no longer a risk to yourself or your newborn.

Inpatient treatment may include:

• Medication – Antipsychotics, mood stabilizers, and antidepressants are the types of medicines typically prescribed to help resolve postpartum psychosis.

• Psychological therapy – CBT and mindfulness-based cognitive therapy can help to resolve mental and emotional challenges by changing the way that you think and act.

• Electroconvulsive therapy (ECT) – If all other treatments have failed, your doctor may consider ECT.

• Support groups – Some inpatient programs organize support groups and other opportunities for you to connect with others who have also experienced postpartum psychosis.

Natural treatments for postpartum depression

In addition to the standard treatments of therapy and medication, you may wish to explore complementary health approaches to help address PPD.

The following treatments have been shown to be effective in managing PDD:

• Restorative yoga (e.g., the Kaiut Method)

• Mindfulness meditation

• Massage

• Iron supplementation

• Omega-3 fatty acids

• Infant massage

The following treatments have been not been specifically shown to be effective in managing PDD but no negative consequences have been identified through their use:

• Acupuncture

• Naturopathy

• Aromatherapy

• Bright light therapy

• Saffron supplementation

Omega-3 fatty acids

Among the available complementary therapies, omega-3 supplementation deserves special mention. When you are pregnant, your supply of omega-3 essential fatty acids is continually transported (primarily from your brain) through the placenta to the developing fetus. If you are not regularly replenishing your omega-3 supply, you can develop a deficiency that can leave you exhausted and increase your risk of developing PPD.

People who regularly consume large amounts of omega-3s are less likely to be depressed than those who are deficient in this essential fatty acid.

To keep omega-3 levels high, you can supplement with krill oil, salmon oil, or cod liver oil capsules. Excellent dietary sources of omega-3 include:

• Leafy greens (spinach, kale, chard)

• Wild-caught salmon

• Albacore tuna

• Sardines

• Mackerel

• Walnuts

• Chia seeds

• Anchovies

• Egg yolks

Discuss your diet with your doctor during pregnancy, as they may advise you to increase or avoid consumption of certain foods.

Lifestyle changes

Many of the natural therapies discussed above go hand-in-hand with leading a healthy lifestyle. The following lifestyle factors can help to prevent or reduce the symptoms of PPD:

• Maintain a healthy diet – Eat a diet full of fresh fruits and vegetables, whole grains, high-quality protein, probiotics (yogurt, kefir, miso, kimchi), and healthy fats (olive, avocado, coconut, almond, sesame, butter/ghee) to nourish your brain and nervous system.

• Enjoy gentle exercise – Aim to engage in daily exercise for physical and mental benefits. It could be as simple as a gentle walk, 20 minutes on an exercycle, or a restorative yoga class.

• Spend time outdoors – Fresh air and sunshine can go a long way to lift your spirits, as well as ensure you get adequate vitamin D which has mood-boosting benefits.

• Avoid alcohol – Alcohol consumption can increase your risk of developing PPD. Instead, enjoy healthier drinks such as herbal tea, juices, or kombucha.

• Meditate – Even ten minutes of breath meditation or mindfulness can encourage connection with your inner peace, clarity, and wisdom and help you to relax.

You may be able to prevent or reduce your risk of developing PPD during pregnancy and after giving birth.

Before pregnancy

By becoming familiar with the risk factors and symptoms of PPD before you become pregnant, you will be better able to identify the warning signs of depression during pregnancy or after childbirth, and when to seek help.

It's important to speak with your doctor if you have a history of depression and are planning on getting pregnant, or have recently found out that you are pregnant.

During pregnancy

To help prevent or reduce the risk of PPD during pregnancy, it's important to:

• Monitor how you are feeling, and keep your doctor informed about any changes

• Seek counseling/therapy or join a support group if recommended by your doctor

• Take antidepressants or other medication if recommended by your doctor

• Maintain a healthy lifestyle by taking care of your diet, sleep, exercise, and emotional needs

After birth

After giving birth, it is recommended that you see your doctor for an early postpartum check-up. They can assess you for symptoms of PPD and address them before they worsen.

Increasing your awareness of PPD is the first step to preventing or reducing its symptoms, seeking treatment, and being able to support your or a loved one’s recovery as quickly as possible.

If you're pregnant or have recently given birth, reach out to family and friends for support, and look for local support groups in your local area.

The following organizations also offer a wealth of resources for supporting you and your newborn:

• Postpartum Support International

• 2020 Mom Project

• U.S. Health and Human Services

• Postpartum Progress U.S. state-by-state PPD support

The following statistics show how common the conditions of PPD, baby blues, and postpartum psychosis are:

• PPD – Affects up to 15% of mothers (about one in seven).¹ PPD also occurs in approximately 8-10% of fathers.²

• Baby blues – 70-80% of mothers experience some form of baby blues.³

• Postpartum psychosis – An estimated 1-2 out of every 1,000 women experience postpartum psychosis after giving birth. The condition is rare and usually occurs within two to three days of delivery.⁴

PPD usually begins within three months after giving birth.⁵ Without treatment, postpartum depression can last months or even years.⁶

Who is most at risk of postpartum depression?

PPD affects women of all ages, races, and ethnic groups, but there are differences among demographics:

Race or ethnicity

One study⁷ found that PPD was most prevalent (16.6%) in American Indian/Alaska Native women and least prevalent (7.4%) in Asian women. Prevalence in Black, White, Hispanic, Native Hawaiian/Pacific Islander, and multiracial women was all within the range of 10-15%.

Age

The risk of PPD increases with age.⁸ However, adolescent mothers are twice as likely as adult mothers to experience PPD.⁹