Postpartum depression (PPD)

Sad mother cuddling baby
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How common is postpartum depression?

Postpartum depression (PPD) is a common problem. It's now though by some that as many as one in four moms is affected by it (Almond 2009, Cox et al 1993). The Canadian rate has been estimated at anywhere from 6% to 13% of moms experiencing the condition (CPS 2004, Lanes et al 2011) .

PPD can sometimes be confused with the baby blues. If you get the baby blues, you will feel miserable, weepy, tired and tense during the first few days after giving birth. This is thought to be because of huge hormonal changes in your body. With the right support, you should feel better within a few days (MIND 2008a). However, PPD, unlike the baby blues, is considered a mental illness that requires treatment.

How will I know I have PPD?

The signs and symptoms are different for every mom, but you are likely to feel:
  • a sense of hopelessness
  • guilty
  • exhausted
  • miserable
  • tearful
  • lonely
  • anxious
  • trapped
All moms have at least one of these feelings some of the time. But if you're overwhelmed by them and they don't get better with time, you could have PPD.

Usually, PPD develops when your baby is between four and six weeks old (CKS 2009), but sometimes it starts months after he was born (DA 2003). You may have been really enjoying looking after your baby and then find depression creeps up on you. If you were depressed while you were pregnant your baby's arrival may not help to lift your depression.

What causes PPD?

We don't understand why some women become depressed and others don't. It could be down to brain chemistry or how you react to the hormonal changes happening in your body (CKS 2009). Sometimes, the things you have to face every day just get on top of you. Although the scientific literature is conflicted on the connection, certain circumstances may make it harder for you to cope, such as:
  • Previous depression or mental health problems, or depression during pregnancy.
  • Not having a supportive partner, or not having family or friends living close by.
  • Troubles with money, housing, work or your relationship.
  • A difficult birth and health problems for you afterwards.
  • Having a baby who was born prematurely or is not well.
  • Finding it hard to breastfeed
  • A discrepancy between your expectations of labour and birth, parenthood or breastfeeding--and the reality
  •  Sad memories being stirred up, such as the death of one of your parents when you were a child.
    (CKS 2009, RCP 2007)
You don't need to have these factors to experience PPD. Having these factors in your life don't mean that you will get PPD, either. You can find out more in our article about the causes of PPD.

How is PPD treated?

The important thing to remember about PPD is that with the right help, you will get better. PPD can be treated. As more evidence is gathered about what works best, and how to best balance the risks of a therapy with the need for treatment for your own health and that of your baby, experts are coming out with more specific recommendations on what to try first in different types of depression (MacQueen et al, 2016, Parikh et al, 2016). Your treatment could include:

Talking therapies

Talking to your partner or a friend might help, but it can sometimes be difficult for them to understand what you are going through. Your doctor, public health nurse, or your midwife would be a good place to start.

Your doctor may be able to refer you to a support group, counsellor, social worker or psychotherapist. She also may be able to arrange for you to have cognitive behavioural therapy (CBT), which may be covered by provincial health plans. CBT works on your thinking patterns to help keep things in perspective and avoid seeing experiences in an unrealistically negative or catastrophic light. There are other forms of psychotherapy that may be covered and that may be appropriate for you as well. CBT and interpersonal psychotherapy are the most recommended first-line psychological treatments during pregnancy.

You might be referred to a psychologist, who is able to provide psychotherapy, or a psychiatrist, who can provide therapy and/or antidepressant medication (NICE 2007, MIND 2008). Because there are risks to using an antidepressant in pregnancy, psychotherapy is now recommended as the first-line treatment for depression in women who are pregnant or breastfeeding (Parikh et al, 2016), so you will likely try this first except if your depression is considered "severe", in which case antidepressants will probably be tried right away, normally still along with psychotherapy.

Antidepressants

Antidepressants work by balancing the chemicals in your brain. The most commonly prescribed antidepressants raise levels of the hormone serotonin or other brain chemicals to lift your mood, help you to sleep and to feel less irritable. Between five and seven out of every 10 women who take antidepressants find their PPD symptoms ease within a few weeks of starting treatment (CKS 2009). The first few pills will make no difference, and you need to be patient. It may take up to six weeks to notice a real improvement, though, and sometimes you need to try a few antidepressants to find one that works for you. It is a process that may require a lot of patience!

A number of different antidepressants have been commonly prescribed for depression during pregnancy, but the evidence now points to several that are better choices. If you need any antidepressant, you will probably be offered
  • citalopram (Celexa)
  • sertraline (Zoloft)
  • escilatopram (Lexapro)
Antidepressants are not always effective. They often cause side-effects, which may go away over time. The evidence that exists on the use of antidepressants for postpartum depression suggests that they are better than placebo, but even this evidence is of low quality. Given this, it is best to combine antidepressants with another form of therapy such as CBT. The medication can also pass into your breast milk, although in very small amounts. If your baby seems sleepy or irritable after you have taken antidepressants, talk to your doctor.

Many moms who take antidepressants do breastfeed because it improves their confidence and strengthens their bond with their baby. Feeling close to your baby can help you tackle PPD (CKS 2009).

If you are thinking of taking antidepressants, talk to your doctor to get a clear understanding of the risks and benefits involved. You can then make an informed decision about which is the safest option for you and your baby. Tell your doctor if you have any side-effects from antidepressants and follow his advice before you stop taking them (MIND 2008b). You usually take them for an extended period (9 months, for example), and you need to gradually reduce the dosage (tapering) according to your doctor's instructions, once you and your doctor agree that it's time to stop.

How can I help myself?

Try to get lots of rest

Sleep if you can, and have a rest if you can't. If someone will look after your baby for a couple of hours, have a warm drink, put on some soothing music, snuggle down and relax. Try to nap when your baby is sleeping, or use the time in a way that feels fulfilling for you. Even if there are chores to do, it may be wiser to rest (MIND 2008). Accept help when it is offered.

Eat a healthy, well-balanced diet

With all the new demands on your body, good nutrition is very important. Try not to go for long periods without eating. This will help you to avoid dips in your blood sugar level. Food fuels your energy and immune system, so a balanced diet will stop you becoming tired and run down (CKS 2009). Not getting enough calories (don't forget that you'll need more than usual if you are breastfeeding!) may result in fatigue (ARHP, 2013).

Do some gentle exercise

Although it may be the last thing you feel like doing, exercise will help you to feel better both physically and mentally. Don't be too ambitious. Just going for a walk with your baby can help. You may have signed up for yoga or Pilates classes while you were pregnant. You could carry on with this type of gentle, relaxing exercise now (MIND 2006), or gradually resume your pre-pregnancy exercise routine.

Meet other moms

Having a baby can make you feel isolated at the best of times, but if you have PPD you can feel particularly alone. The Canadian Mental Health Association has local chapters where staff or volunteers can help you find local resources including groups focusing on PPD. It'll help to share your experiences with other moms going through a similar experience (MIND 2008). Read our parents' tips about ways to meet other new moms.

Be kind to yourself

You need to take care of yourself to take care of your baby. Don't load yourself up with things that really don't need to be done. Put off making big decisions. Try to be realistic about what you can achieve and don't forget to treat yourself (MIND 2008).

How can my partner, friends and family help?

It can sometimes be hard for those closest to you to understand how bad you feel. But they have an important part to play in supporting you. Tell them what you are going through. Give them any information you have about PPD. This will help them to help you. Your partner may also be depressed, and understanding how to support you could help him to feel better, too.

Don't be afraid to ask loved ones for help. A little practical support, such as helping around the house, can go a long way towards lifting your depression. You may feel overwhelmed and have trouble even figuring out what will be helpful. Try to be open to offers of help, as they may really be what you need. Even the odd hour of babysitting, so you can have time alone or with your partner, will help to refresh you (APNI 2007). You could ask your loved ones to read our article about how to help someone with PPD.

Can I prevent PPD?

The short answer is that we don't know. Some doctors think that if you have regular injections of the hormone progesterone after giving birth, your risk of PPD will lessen. The evidence for this isn't strong, but you may want to discuss this or other options with your doctor while pregnant or when considering pregnancy if you have a history of depression or PPD. Ask your doctor for more information (APNI 2007). There are some clinics (such as one at Mt. Sinai hospital in Toronto) that specialize in PPD and will see women at risk of PPD during their pregnancy and after the birth. Ask your doctor about whether there are any services like these in your area.

Take good care of yourself while you're pregnant, try to reduce your stress levels (CKS 2009) and accept all the help you are offered. The more support you have during your pregnancy, the stronger and more confident you are likely to feel when you have your baby.

Visit the BabyCenter Canada community to talk to other moms who know how you are feeling.


References


This article was written using the following sources:

Almond P. 2009. Postnatal depression: a global public health perspective. Perspectives in Public Health 129 (5): 221-227. rsh.sagepub.com [Accessed September 14, 2016]

APNI. 2007. Post natal depression. The Association of Post Natal Illness. apni.org [pdf file, accessed December 2009]

ARHP. 2013. Postpartum Counseling. Association of Reproductive Health Professionals. www.arhp.org [Accessed September 1, 2016].

Bandolier. 2001. Healthy post-natal care.. www.medicine.ox.ac.uk [Accessed December 2009]

CKS. 2009. Postnatal depression. Clinical Knowledge Summaries. www.cks.nhs.uk [Accessed December 2009]

Cox JL, Murray D, Chapman G. 1993. A controlled study of the onset, duration and prevalence of postnatal depression. The British Journal of Psychiatry 163: 27-31. bjp.rcpsych.org [Accessed August 27, 2016]

CPS et al. 2004 (version reaffirmed 2015). Maternal depression and child development. Paediatr Child Health 2004;9(8):575-83 www.cps.ca [Accessed August 27, 2016].

DA. 2003. Depression during and after pregnancy Depression Alliance. www.depressionalliance.org [pdf file, accessed December 2009]

Dennis, C-L, Hodnett ED. 2007. Psychosocial and psychological interventions for postpartum depression. Cochrane Database of Systematic Reviews. www.onlinelibrary.wiley.com [Accessed August 26, 2016].
 
Lanes, A, Kuk J. and Tamim H.2011. Prevalence and characteristics of postpartum depression symptomatology among Canadian women: A cross-sectional study. BMC Public Health. www. bmcpublichealth.biomedcentral.com [Accessed August 26, 2016].

MacQueen et al, 2016. Canadian Network for Mood andAnxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management ofAdults with Major Depressive Disorder: Section 6. Special Populations: Youth,Women, and the Elderly. The Canadian Journal of Psychiatry / La RevueCanadienne de Psychiatrie 2016, Vol. 61(9) 588-603  journals.sagepub.com [accessed December 26th, 2016].


MIND. 2006. How to look after yourself. National Association for Mental Health. www.mind.org.uk [pdf file, accessed December 2009]

MIND. 2008a. Understanding postnatal depression. National Association for Mental Health. www.mind.org.uk [pdf file, accessed August 16, 2016]

MIND. 2008b. Making sense of antidepressants. National Association for Mental Health. www.mind.org.uk [pdf file, accessed August 16, 2016]

NICE. 2007. Antenatal and postnatal mental health: the NICE guideline on clinical management and service guidance. National Institute of Clinical Excellence. guidance.nice.org.uk [pdf file, accessed December 2009]

Parikh et al. 2016. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 2. Psychological Treatments: Psychological Treatments The Canadian Journal of Psychiatry / La RevueCanadienne de Psychiatrie 2016, Vol. 61(9) 1-16 journals.sagepub.com [accessed December 26th, 2016]..

RCP. 2007. Postnatal depression The Royal College of Psychiatrists. www.rcpsych.ac.uk [Accessed August 16, 2016]

SIGN. 2002. Postnatal depression and puerperal psychosis: a national clinical guideline. Scottish Intercollegiate Guidelines Network. www.sign.ac.uk [pdf file, accessed December 2009]

Worsley AJ. 2000. In Lee A, Inch S, Finnigan D eds. Therapeutics in pregnancy and lactation. Abingdon: Radcliffe Medical Press, 101-116
Katie MacGuire
Katie MacGuire is an award-winning journalist and entrepreneur. She created an extensive library of evidence-based maternal health articles for BabyCenter Canada.

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