Postpartum blues: a clinical syndrome and predictor of postnatal depression?

Maternity Blues: A Narrative Review

Puerperium is a period of great vulnerability for the woman, associated with intense physical and emotional changes. Maternity blues (MB), also known as baby blues, postnatal blues, or post-partum blues, include low mood and mild, transient, self-limited depressive symptoms, which can be developed in the first days after delivery. However, the correct identification of this condition is difficult because a shared definition and well-established diagnostic tools are not still available. A great heterogenicity has been reported worldwide regarding MB prevalence. Studies described an overall prevalence of 39%, ranging from 13.7% to 76%, according to the cultural and geographical contexts. MB is a well-established risk factor for shifting to more severe post-partum mood disorders, such as post-partum depression and postpartum psychosis. Several risk factors and pathophysiological mechanisms which could provide the foundation of MB have been the object of investigations, but only poor evidence and speculations are available until now. Taking into account its non-negligible prevalence after childbirth, making an early diagnosis of MB is important to provide adequate and prompt support to the mother, which may contribute to avoiding evolutions toward more serious post-partum disorders. In this paper, we aimed to offer an overview of the knowledge available of MB in terms of definitions, diagnosis tools, pathophysiological mechanisms, and all major clinical aspects. Clinicians should know MB and be aware of its potential evolutions in order to offer the most timely and effective evidence-based care.

Predictors of postpartum depression among an obstetric population in South-Western Nigeria

Background: Perinatal maternal depression is the most common mood disturbance associated with pregnancy. It has grave consequences on both maternal health and wellbeing of offsprings, albeit usually neglected in low- and middle-income countries.Objective: To evaluate the relationship between antenatal depression(APD) and postpartum depression(PPD) and predictors of postpartum depression among an obstetric population in South-western Nigeria.Methods: This was a prospective longitudinal cohort study involving272 pregnant women recruited between 34 and 36 weeks of pregnancy and followed up to till 6 weeks after delivery. Edinburgh Postnatal Depression Scale (EPDS) questionnaires were administered to collect data. Data were analysed with SPSS version 23.A p-value < 0.05 was taken as statistically significant.Results: The prevalences of antepartum and postpartum depression were 6.3%, (95% CI 3.4%-9.2%) and 8.8% (95% CI 5.4%-12.1%) respectively. The Spearman correlation coefficient for antepartum EPDS and postpartum EPDS scores was 0.52, p < 0.001.The predictors of postpartum depression were antepartum depression (adjusted OR 10.6, 95% CI 8.33-48.60, p < 0.001), puerperal sepsis (adjusted OR 4.33, 95% CI 3.89-8.69, p = 0.03), domestic violence (adjusted OR 3.40, 95% CI 1.94-15.67, p = 0.01) and age group 25-34 years (adjusted OR 0.11, 95% CI 0.02-0.75, p = 0.02), and household income $1671-$3330 (adjusted OR 0.10, 95% CI 0.02-0.56, p = 0.01).Conclusion: There was a positive association between the antenatal EPDS and postnatal EPDS scores. Screening for maternal depression should be considered in prenatal period. Further studies are necessary to explore the novel finding of predictive role of puerperal sepsis in PPD.

Maternity blues: a risk factor for anhedonia, anxiety, and depression components of Edinburgh Postnatal Depression Scale

Background: Women undergo adaptive physical and psychological changes during pregnancy, which make them vulnerable to psychological disorders.Methods: This study used a prospective observational design and included concurrent validation analysis of the 16-item Maternity Blues Scale (MBS) Dutch version to determine the direction and magnitude on the Edinburgh Postnatal Depression Scale (EPDS) symptoms, including three factors, anhedonia, anxiety, and depression in 320 puerperae early after childbirth.Results: We found a statistically significant correlation between MBS and EPDS global scores (0.22, p < .001). Moreover, Negative affect was significantly correlated with the EPDS global score (0.23, p < .001), anhedonia (0.12, p < .05), and anxiety (0.25, p < .001); Positive affect with the EPDS global score (0.14, p < .05) and depression (0.13, p < .05); and Depression subscale with EPDS global score (0.15, p < .05), anhedonia (0.12, p < .05), and anxiety (0.12, p < .05), and depression (0.12, p < .05). In addition, the subgroup of women (n = 33, 10.3%) with EPDS > 12 presented significantly higher global MBS score (2.51 ± 0.38 versus 2.26 ± 0.38, p = .01), with negative affect (2.88 ± 0.67 versus 2.62 ± 0.38, p=.04), positive affect (2.52 ± 0.69 versus 2.32 ± 0.38, p = .04), and depression (2.09 ± 0.75 versus 1.82 ± 0.36, p = .02).Conclusion: These findings together suggest that women with higher maternity blues scores may represent a distinct subgroup at increased risk of depression.

Economic and Health Predictors of National Postpartum Depression Prevalence: A Systematic Review, Meta-analysis, and Meta-Regression of 291 Studies from 56 Countries

BACKGROUND

Postpartum depression (PPD) poses a major global public health challenge. PPD is the most common complication associated with childbirth and exerts harmful effects on children. Although hundreds of PPD studies have been published, we lack accurate global or national PPD prevalence estimates and have no clear account of why PPD appears to vary so dramatically between nations. Accordingly, we conducted a meta-analysis to estimate the global and national prevalence of PPD and a meta-regression to identify economic, health, social, or policy factors associated with national PPD prevalence.

METHODS

We conducted a systematic review of all papers reporting PPD prevalence using the Edinburgh Postnatal Depression Scale. PPD prevalence and methods were extracted from each study. Random effects meta-analysis was used to estimate global and national PPD prevalence. To test for country level predictors, we drew on data from UNICEF, WHO, and the World Bank. Random effects meta-regression was used to test national predictors of PPD prevalence.

FINDINGS

291 studies of 296284 women from 56 countries were identified. The global pooled prevalence of PPD was 17.7% (95% confidence interval: 16.6-18.8%), with significant heterogeneity across nations (Q = 16,823, p = 0.000, I2 = 98%), ranging from 3% (2-5%) in Singapore to 38% (35-41%) in Chile. Nations with significantly higher rates of income inequality (R2 = 41%), maternal mortality (R2 = 19%), infant mortality (R2 = 16%), or women of childbearing age working ≥40 h a week (R2 = 31%) have higher rates of PPD. Together, these factors explain 73% of the national variation in PPD prevalence.

INTERPRETATION

The global prevalence of PPD is greater than previously thought and varies dramatically by nation. Disparities in wealth inequality and maternal-child-health factors explain much of the national variation in PPD prevalence.

Immediate postpartum mood assessment and postpartum depressive symptoms

BACKGROUND

Negative affect (NA) and positive affect (PA) in the early postpartum period have been associated with postpartum depressive symptoms, but the exact relationship is not well understood. This study aimed to determine if NA and PA in the immediate postpartum period predicted postpartum depressive symptoms over and above well-established predictors (previous trauma, history of depression).

METHODS

Participants were prospectively recruited from a Mother-Baby Unit at a large Midwestern academic medical center in the United States from April 2011 to April 2014. Participants (N=526) completed the Daily Experiences Questionnaire (DEQ), a self-report measure which assessed NA and PA, within three days post-delivery. Participants then reported their depressive symptoms at two weeks (n=364) and twelve weeks postpartum (n=271).

RESULTS

Hierarchical regression analyses indicated that low PA and high NA after birth significantly predicted depressive symptoms early (at 2 weeks) and later (at 12 weeks) in the postpartum period, over and above previous traumatic experiences and history of depression.

LIMITATIONS

The sample was relatively homogenous, and data were from self-report instruments.

CONCLUSIONS

The current study found NA and PA in the days immediately after birth predicted depressive symptoms at multiple time points in the postpartum period. Because the perinatal period places women at a higher risk for depressive symptomatology, prevention and early intervention are critical. Measuring affect in hospitals immediately after birth may provide a more normalized set of items that is predictive of later depression, which will allow physicians to identify those at highest risk for developing depressive symptoms.

Opinion of women on emergency obstetric care provided in public facilities in Lagos, Nigeria: A qualitative study

Limited attention has been given to opinions of women receiving emergency obstetric care (EmOC) in developing countries. We organized focus groups with 39 women who received this care from Lagos public facilities. Availability of competent personnel and equipment were two positive opinions highlighted. Contrarily, women expressed concerns regarding the seeming unresponsiveness of the service to nonmedical aspects of care, associated stress of service utilization, and high treatment costs. There is a need to leverage the positive perception of women regarding the available technical resources while improving institutional care components like administrative processes, basic amenities, and costs toward increasing utilization and preventing complications.

Maternity “Blues”: Prevalence and Risk Factors

Objectives: estimate the prevalence and track the risk factors associated with, Maternity blues (MB).

Methods: a transversal study was performed with 113 women, on the tenth day of puerperium. The following instruments were used: Pitt Scale (1968), Stein (1980), Inventory for stressful life events by Holmes & Rahe (1967), and a questionnaire with sociodemographic and obstetric data.

Results: the prevalence of MB was 32.7% according to the Stein scale. In the univariated analysis, civil status and tobacco use were associated with MB. Legally married women and nonsmokers showed a risk approximately 4 times lower of experiencing the problem.

Conclusions: MB was very prevalent in this sample. Obstetricians must be aware of this condition which may be associated with postpartum depression.

Maternity blues as a predictor of DSM-IV depression and anxiety disorders in the first three months postpartum

BACKGROUND

Maternity blues have been described as a relevant risk factor for postpartum depression. Information regarding the influence of maternity blues on the onset and course of clinical postpartum anxiety disorders is scarce. The goal of this study was to determine whether maternity blues significantly predict postpartum depression and anxiety disorders in the first 3 months after delivery in a German sample. Demographic, psychiatric, and obstetric correlates of maternity blues were also investigated.

METHODS

Maternity blues were assessed 2 weeks after delivery in a community sample of 853 women using a telephone interview and the Patient Health Questionnaire-Depression. Depression and anxiety disorders were diagnosed according to DSM-IV criteria over the first 3 months following delivery. A two-stage screening procedure was applied. In a first stage, the Patient Health Questionnaire-Depression, the Edinburgh Depression Scale, and two anxiety-screening instruments were employed. In the case of clinically relevant scores, the Structured Clinical Interview for DSM-IV was administered in a second stage.

RESULTS

The estimated prevalence rate of maternity blues among German women was 55.2%. We found a significant association between maternity blues and postpartum depression (odds ratio: 3.8) and between maternity blues and anxiety disorders (odds ratio=3.9).

LIMITATIONS

Based on our predominantly middle class low-risk sample, maternity blues prevalence may be underestimated. Retrospective assessment of maternity blues 2 weeks postpartum might lead to biased results.

CONCLUSIONS

Women with maternity blues should be carefully observed in the first weeks postpartum with the aim of identifying those at risk of developing postpartum depression/anxiety disorders and providing treatment at an early stage of the disorder.

Effect of peer support on prevention of postnatal depression among high risk women: multisite randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of telephone based peer support in the prevention of postnatal depression.

DESIGN

Multisite randomised controlled trial.

SETTING

Seven health regions across Ontario, Canada.

PARTICIPANTS

701 women in the first two weeks postpartum identified as high risk for postnatal depression with the Edinburgh postnatal depression scale and randomised with an internet based randomisation service.

INTERVENTION

Proactive individualised telephone based peer (mother to mother) support, initiated within 48-72 hours of randomisation, provided by a volunteer recruited from the community who had previously experienced and recovered from self reported postnatal depression and attended a four hour training session.

MAIN OUTCOME MEASURES

Edinburgh postnatal depression scale, structured clinical interview-depression, state-trait anxiety inventory, UCLA loneliness scale, and use of health services.

RESULTS

After web based screening of 21 470 women, 701 (72%) eligible mothers were recruited. A blinded research nurse followed up more than 85% by telephone, including 613 at 12 weeks and 600 at 24 weeks postpartum. At 12 weeks, 14% (40/297) of women in the intervention group and 25% (78/315) in the control group had an Edinburgh postnatal depression scale score >12 (chi(2)=12.5, P<0.001; number need to treat 8.8, 95% confidence interval 5.9 to 19.6; relative risk reduction 0.46, 95% confidence interval 0.24 to 0.62). There was a positive trend in favour of the intervention group for maternal anxiety but not loneliness or use of health services. For ethical reasons, participants identified with clinical depression at 12 weeks were referred for treatment, resulting in no differences between groups at 24 weeks. Of the 221 women in the intervention group who received and evaluated their experience of peer support, over 80% were satisfied and would recommend this support to a friend.

CONCLUSION

Telephone based peer support can be effective in preventing postnatal depression among women at high risk.

TRIAL REGISTRATION

ISRCTN 68337727.

What does Chilean research tell us about postpartum depression (PPD)?

BACKGROUND

In Chile, a country with a so called emerging market-economy, where rapid social and life style changes are taking place, women and the more socially disadvantaged are more at risk of becoming depressed.

METHODS

Results of several studies are summarized in the context of a review of the literature.

RESULTS

A third of Chilean women have depressive and/or anxiety symptoms during midpregnancy, while prevalence figures both in the early and the late postpartum period increase up to 50% in most studies. If strict operational criteria describing well defined depressive disorders are used postnatally, differences in prevalence and incidence figures arise depending on socioeconomic status. Whereas incidence rates for postpartum depression (around 9%) are very similar to those found in the northern hemisphere and do not appear to vary across different socioeconomic levels, higher prevalence rates are found among women from lower socioeconomic status.

LIMITATIONS

The studies focused on current diagnostic entities and did not consider different clusters or dimensions.

CONCLUSION

A shared biological etiology may be triggered by the physiology of childbirth and account for similarities in incidence across different socioeconomic levels. In turn, we hypothesize that the higher prevalence of postpartum depression (PPD) in Chilean women from lower socioeconomic status is the result of pre-existing depression and is not caused by more new cases of the illness.

Some early indicators for depressive symptoms and bonding 2 months postpartum--a study of new mothers and fathers

The aim was to investigate associations between blues, bonding, perception of the child's temperament and depressive symptoms two months postpartum in both parents. Questionnaires to be filled out during the first week were; Blues Questionnaires day 1-5, Postpartum Bonding Questionnaire (PBQ) and Edinburgh Postpartum Depressive Scale (EPDS) and at two months; questions about breastfeeding, EPDS, PBQ and the Infant Characteristic Questionnaire (ICQ). In all, 106 couples returned all questionnaires on both occasions. Although there were differences in parents' rated levels of blues, depressive symptoms and postpartum bonding, we found many similarities in the ratings. Blues, bonding and depressive symptoms in the other partner were significantly related to EPDS in both parents. Thus, we found a risk for couple morbidity. The similarities between the parents' responses could be interpreted in terms of a broader human way of reacting to childbirth, while the differences e.g. their understanding of the child could refer to different gender roles.

A study of Welsh mothers' experiences of postnatal depression

OBJECTIVE

to examine the experiences of Welsh mothers diagnosed with postnatal depression and to question whether postnatal depression is socially determined.

DESIGN

qualitative interviews using a semi-structured questionnaire to clarify mothers' thoughts and feelings within the postnatal period.

SETTING

a semi-rural part of south-west Wales, previously dominated by the mining industry.

PARTICIPANTS

ten mothers with one or more children participated in the study. Most of the mothers were from lower socio-economic groups. They were selected from 30 women diagnosed with postnatal depression.

FINDINGS

mothers had little knowledge of the effects of postnatal depression before becoming pregnant, and were initially reluctant to confide or share their feelings. Economic pressures determined a second income and necessitated mothers returning to work. This left them with little quality time for their babies and family. The prime support networks, which in previous generations were grandmothers, were absent, and mothers relied on social services and voluntary support groups.

IMPLICATIONS FOR PRACTICE

a greater understanding of the emotional and social effects of childbirth may help mothers to avoid feelings of isolation and the inability to cope. Discussing the issues of socio-emotional strain during pregnancy may help the mother to recognise the symptoms that identify postnatal depression, legitimise the condition and begin the recovery process.

Relationships among infant sleep patterns, maternal fatigue, and development of depressive symptomatology

BACKGROUND

Postpartum depression is a serious condition for women after childbirth. Although its etiology is unclear, one potentially important predictive variable that has received little attention is maternal sleep deprivation. The objective of this study was to examine relationships among infant sleep patterns, maternal fatigue, and the development of postpartum depression in women with no major depressive symptomatology at 1 week postpartum.

METHODS

As part of a population-based postpartum depression study, 505 women who had an Edinburgh Postnatal Depression Scale (EPDS) score < 13 at 1 week postpartum completed questionnaires at 4 and 8 weeks postpartum.

RESULTS

Mothers exhibiting major depressive symptomatology (EPDS > 12) at 4 and 8 weeks were significantly more likely to report that their baby cried often, be woken up 3 times or more between 10 pm and 6 am, have received less than 6 hours of sleep in a 24-hour period over the past week, indicate that their baby did not sleep well, and think that their baby's sleep pattern did not allow them to get a reasonable amount of sleep. Consistent with these findings, mothers with an EPDS score > 12 were significantly more likely to respond that they often felt tired.

CONCLUSIONS

These results suggest that infant sleep patterns and maternal fatigue are strongly associated with a new onset of depressive symptoms in the postpartum period, and provide support for the development of postpartum depression preventive interventions designed to reduce sleep deprivation in the early weeks postpartum.

Review of screening instruments for postpartum depression

This paper presents a review and discussion of eight self-report measures used to assess for depressive symptoms in the postpartum period. Because postpartum depression is a significant mental health problem, there is a need for reliable and valid screening instruments. Published psychometric data (e.g., reliability, sensitivity, specificity, positive predictive value, concurrent validity) of each self-report instrument are presented and critiqued. Results suggest that the Edinburgh Postnatal Depression Scale is the most extensively studied measure with postpartum women with moderate psychometric soundness. This review illustrates the need for more research in this area. Issues involved in the selection of measures are considered. Implications for clinical practice, research, culture and language are discussed.

Identifying women at-risk for postpartum depression in the immediate postpartum period

OBJECTIVE

To develop a multifactorial predictive model of depressive symptomatology in the first week postpartum in order to assist in targeted screening procedures.

METHOD

As part of a longitudinal study, a population-based sample of 594 mothers in a health region near Vancouver, British Columbia completed a mailed questionnaire at 1-week postpartum that included diverse risk factors from the following domains: sociodemographic, biological, pregnancy-related, life stressors, social support, obstetric and adjustment to motherhood. Following univariate analysis, sequential regression analysis was completed to develop a multifactorial predictive model.

RESULTS

In the multivariate model, the factors predictive of depressive symptomatology at 1-week postpartum included immigration within the last 5 years, history of depression independent of childbirth, diagnosis of pregnancy-induced hypertension, vulnerable personality style, stressful life events, lack of perceived support, lack of readiness for hospital discharge and dissatisfaction with infant feeding method.

CONCLUSION

The findings suggest that several risk factors for depressive symptomatology in the immediate postpartum period are consistent with previously identified factors but other factors such as recent immigrant status, feeling unready for hospital discharge, dissatisfaction with their infant feeding method, and pregnancy-induced hypertension should also be examined.

Postnatal blues: a risk factor for postnatal depression

Postnatal blues have been regarded as brief, benign and without clinical significance. However, several studies have proposed a link between blues and subsequent depression but have methodological problems. We report a prospective, controlled study of postpartum women with severe blues which uses systematically devised and validated instruments for that purpose which tests the hypothesis that severe blues increases the risk of depression in the six months following childbirth. 206 first-time mothers were recruited in late pregnancy. Blues status was defined using the Blues Questionnaire and those with severe blues and their controls who had no blues (matched for age, marital status and social class) were followed for 6 months with postal Edinburgh Postnatal Depression Scale. RDC diagnoses were made following SADS-L interview at the end of the protocol. Backwards stepwise Cox regression analysis found severe blues and past history of depression to be independent predictors each raising the risk by almost 3 times. Depression in those with severe blues onset sooner after delivery and lasted longer. The difference was largely accounted for by major depression. Severe postpartum blues are identified as an independent risk factor for subsequent postpartum depression. Screening and intervention programs could be devised.

Étude de l’EPDS (Échelle postnatale d’Edinburgh) chez 859 mères : dépistage des mères à risque de développer une dépression du post-partum

The postpartum is a high-risk period for the occurrence of anxious and depressive episodes. Indeed, during the first few days after delivery, mothers can present postpartum blues symptomatology: fatigue, anxiety, disordered sleeping and a changing mood. Postpartum depression is characterised by a changing mood, anxiety, irritability, depression, panic and obsessional phenomena. It occurs in approximately 10 to 20% mothers. The exact prevalence depending on the criteria used for detection. The first symptoms usually appear between the fourth and sixth week postpartum. However, postpartum depression can start from the moment of birth, or may result from depression evolving continuously since pregnancy. We can add that the intensity of postpartum blues is a risk factor that can perturb maternal development. So it is important for health professionals to dispose of predictive tools. This study is a validation of the French version of the EPDS. The aims of the study were to evaluate the postpartum depression predictive value at 3 days postpartum and to determine a cut-off score for major depression. Subjects participating in this study were met in 3 obstetrical clinics in, or in the vicinity of, Toulouse. Mothers with psychological problems, under treatment for psychological problems or mothers whose babies present serious health problems were excluded from the study. The EPDS was presented to 859 mothers (mean age=30.3; SD=4.5) met at one of the clinics at 3 days postpartum (period 1). They had an EPDS mean score of 6.4 (SD=4.6); 258 (30%) mothers had an EPDS score 9. 82.6% of these mothers experienced a natural childbirth and 17.3% a caesarean section; 51.5% gave birth to their first child, 36.2% to their second child and 12.3% to their third or more. All subjects were given a second EPDS with written instructions to complete the scale during the period 4 to 6 weeks postpartum and return it for analysis (period 2). Between the 4 to 6 weeks postpartum period, 722 mothers replied again to the EPDS. 131 mothers had an EPDS score 11 (mean age=30.3; SD=4.8). They had an EPDS mean score of 13.6 (SD=3.3). Mothers with probable depression were interviewed and assessed, using the Mini (Mini Neuropsychiatric Interview, Lecrubier et al. 1997), the SIGH-D (Structured Interview Guide for the Hamilton Depression Scale) and the BDI (Beck Depression Inventory) in order to diagnose a major depressive episode. They had a HDRS mean score of 13.7 (SD=5.1) and a BDI mean score of 13.6 (SD=5). At 3 days postpartum, we observed that 258 mothers (30%) had an EPDS scores 9 and 164 mothers (19%) had an EPDS scores 11. Between 4 and 6 weeks postpartum, we observed 18.1% of postpartum depression (EPDS 11) and 16.8% (EPDS 12) of major postpartum depression. The analysis of the sensitivity and the specificity at 3 days postpartum provides a cut-off score of 9 (Sensibility: 0.88) (Specificity: 0.50) as predictive of postpartum depression, for this cut-off score, the type I error is low (5.8%) but the type II error is more higher (18.9%). The analysis of the sensitivity and the specificity between 4 and 6 weeks postpartum provides a cut-off score of 12 (Sensibility: 0.91) (Sensibility: 0.74) for the detection of major postpartum depression. Factor analysis shows at 3 days postpartum that the internal structure of the scale is composed of two subscales. The first factor F1 "anxiety" accounts 28% of the variance and the second factor F2 "depression" accounts 20% of the variance. Between 4 and 6 weeks postpartum, factor analysis suggests an unidimensional model in the evaluation of postpartum depression which is better than a two factor model. This factor accounts 40% of the variance. The scale has a good predictive value, and we can observe a significant correlation with the EPDS periods 1 and 2 (r=0.56; p<0.05). This result shows that the depressive mothers mood intensity predicts a future depressive risk. Furthermore, correlations between EPDS and BDI (r=0.68; p<0.05) and EPDS and HDRS (r=0.67; p<0.05) show a good convergent validity. The reliability study confirms the good internal consistency of the EPDS, at 3 days postpartum and in the postpartum depression -symptomatology evaluation (Cronbach's Alpha>0.80). In conclusion, this scale demonstrates good validity and is fast and easy use in obstetrical services, allowing early detection of women who risk to develop postpartum depression and, in the first week of postpartum, of mothers who suffer from a major postpartum depression. The use of the EPDS for an early screening of the risk of postnatal depression which is essential considering the consequences that postnatal depression can have on the development of the infant, on the quality of the relationship within the couple and on other social relationships. Mothers at risk for postnatal depression should be controlled and surveyed by the health professionals in obstetrical clinics.

Does pain relief during delivery decrease the risk of postnatal depression?

BACKGROUND

To test the hypothesis that sufficient pain relief during delivery decreases the risk of postnatal depression.

METHODS

As part of a prospective follow-up study of the risk factors for postnatal depression and its impact on the mother-infant interaction and child development, 185 parturients filled in the Edinburgh Postnatal Depression Scale (EPDS), first during the first postpartum week and again (n = 162) 4 months later. The incidence and the risk of high EPDS scores was calculated according to the mode of delivery and the mode of pain relief during vaginal delivery, also after adjusting for the length of labor.

RESULTS

Mothers who received epidural/paracervical blockade during their delivery spent less time in the delivery room than mothers in the nitrous oxide/acupuncture group (p = 0.033) or mothers with no pain relief (p = 0.026) and had shorter length of labor than mothers without pain relief (p = 0.04). The adjusted risk of depressive scores at the first postnatal week was decreased in the epidural/paracervical group when compared with no analgesia group (OR: 0.25, 95% CI: 0.09-0.72). This difference was not shown at 4 months postpartum. Elective or emergency cesarean section did not increase the risk of high EPDS scores at the first week or at 4 months postpartum.

CONCLUSION

The mode of pain relief during vaginal delivery seems to be associated with the incidence of postpartum depression, especially immediately after delivery.

Seasonal variation in postnatal depression

BACKGROUND

We evaluated the occurrence of postnatal depression in general and during different seasons as part of a larger longitudinal mother-child follow-up study.

METHOD

One hundred and eighty-five mothers, from the maternity wards of University Hospital of Oulu, Finland, completed a self-rating depression scale, the Edinburgh Postnatal Depression Scale (EPDS) twice: first at hospital 2-7 days after delivery and the second time at home 4 months after the delivery. Different psychosocial variables were mapped out to avoid any confounding factors. The year was divided in two separate ways: first, three different time periods were selected by the amount of sunlight: dark (October-January), intermediate (February, March, August, September) and light (April-July), and second, the year was divided by seasons. The results were analysed by the chi(2)-test for multinomials.

RESULTS

Sixteen percent (16.2) of mothers were scored as being depressed using 13 as a cut-off point immediately after the infant was born. Thirteen percent (13.0) were depressed measured 4 months postpartum. There was more mild depression in the autumn (ratio observed/expected 1,62; 95% confidence interval 1.05-2.19) immediately after delivery, using 10 as a cut-off, and less depression in the spring (0.27; 0.00-0.62) measured at home later, using 13 as a cut-off. When using classification by the amount of light there was more depression during the dark time (1.58; 1.05-2.11) immediately postpartum.

LIMITATIONS

The group sizes and the amount of sample sizes collected within each month are quite small.

CONCLUSIONS

It should be borne in mind that seasonal changes and alterations in the amount of light might influence the occurrence of postnatal depression.

Seafood consumption, the DHA content of mothers' milk and prevalence rates of postpartum depression: a cross-national, ecological analysis

BACKGROUND

Mothers selectively transfer docosahexaenoic acid (DHA) to their fetuses to support optimal neurological development during pregnancy. Without sufficient dietary intake, mothers become depleted of DHA and may increase their risk of suffering major depressive symptoms in the postpartum period. We postulated that the DHA content of mothers' milk and seafood consumption would both predict prevalence rates of postpartum depression across countries.

METHODS

Published prevalence data for postpartum depression were included that used the Edinburgh Postpartum Depression Scale (n=14532 subjects in 41 studies). These data were compared to the DHA, eicosapentaenoic acid (EPA) and arachidonic acid (AA) content in mothers' milk and to seafood consumption rates in published reports from 23 countries.

RESULTS

Higher concentrations of DHA in mothers' milk (r=-0.84, p<0.0001, n=16 countries) and greater seafood consumption (r=-0.81, p<0.0001, n=22 countries) both predicted lower prevalence rates of postpartum depression in simple and logarithmic models, respectively. The AA and EPA content of mothers' milk were unrelated to postpartum depression prevalence.

LIMITATIONS

These findings do not prove that higher omega-3 status cause lower prevalence rates of postpartum depression. Data on potentially confounding factors were not uniformly available for all countries.

CONCLUSIONS

Both lower DHA content in mothers' milk and lower seafood consumption were associated with higher rates of postpartum depression. These results do not appear to be an artifact of cross-national differences in well-established risk factors for postpartum depression. Interventional studies are needed to determine if omega-3 fatty acids can reduce major postpartum depressive symptoms.

Prevalence of depressive symptoms in late pregnancy and postpartum

BACKGROUND

Postnatal depression refers to a non-psychotic depressive episode that begins in or extends into the postpartum period. The aims of this study were to examine the prevalence of depressive symptoms in a pregnant and later postnatal population, to determine the natural course of these symptoms and whether there is an association between antenatal and postnatal depressive symptomatology.

METHODS

A longitudinal study with a total population of 1,558 consecutively registered pregnant women in the southeast region of Sweden. Presence of depressive symptoms was measured with the Edinburgh Postnatal Depression Scale on four occasions namely in gestational week 35-36, in the maternity ward, 6-8 weeks and 6 months postpartum.

RESULTS

The prevalence of depressive symptoms during late pregnancy was 17%; in the maternity ward 18%; 6-8 weeks postnatally 13%; and 6 months postnatally, 13%. A correlation between antenatal and postnatal depressive symptoms was found (r=0.50, p<0.0001).

CONCLUSION

Detection of women at risk for developing postnatal depressive symptoms can be done during late pregnancy. Antenatal care clinics constitute a natural and useful environment for recognition of women with depressive symptoms.

Postpartum mood and anxiety disorders: a guide for the nonpsychiatric clinician with an aside on thyroid associations with postpartum mood

This article summarizes the considerable progress that has been made in recent years in our understanding of the risks of pregnancy-associated mood and anxiety disorders, effective somatic and nonsomatic treatments for those disorders, and the risks and benefits of psychotropic medications during pregnancy and breast-feeding. Ten to 15% of women develop syndromal depressions within the first 2 to 3 months postpartum, making this the most common serious medical complication of the puerperium. Prior history of depressive disorders, lack of social support, and stressful life events all increase the risk of postpartum depression. Psychotic mood disorders (commonly called postpartum psychosis) occur after approximately 1 to 2 deliveries per 1000. To ensure safety, women who develop postpartum psychotic symptoms should be hospitalized. History of bipolar illness increases the risk of postpartum psychosis to as much as 25%. Prior episodes of postpartum psychosis further increase the risk to 50%-75%. The risk of first onset or exacerbation of panic disorder or obsessive-compulsive disorder appears to increase during pregnancy and the puerperium. Postpartum mood and anxiety disorders are highly responsive to psychotherapy and in more serious cases, to medication. Fortunately, several classes of psychotropic medications, especially tricyclic and selective serotonin reuptake inhibitor antidepressants, appear to be reasonable safe during pregnancy and breast-feeding. Electroconvulsive therapy is the most effective treatment for very severe postpartum mood disorders, including postpartum psychosis. Preliminary results are also presented that suggest that lower range total and free thyroxine concentrations during late pregnancy are related to postpartum depressive symptoms.

Early postnatal depressive mood: associations with obstetric and psychosocial factors

The central purpose of this investigation was to detect incidence and influencing factors on early postnatal depressive mood in a large hospital sample. By means of an interview we acquired information on sociodemographic data, physical and psychiatric anamnesis, and obstetric and psychologic variables. The Edinburgh Postnatal Depression Scale (EPDS) served to determine the depressive mood of our patients. The interview was carried out on 1250 women at two postnatal wards 5 days after delivery. According to the results of the German validation of the EPDS, where a cutoff of 9/10 indicates at least mild depressive disorder, the whole sample was divided into group A (EPDS score < or = 9; n = 996, 79.7%) and group B (EPDS score > or = 10; n = 254, 20.3%). Early postnatal depressive mood, as assessed by the EPDS, appeared with 20% of all women taking part in our investigation on the fifth postnatal day. Subjective measurements such as high childbirth burden, elevated trait anxiety, low life satisfaction and lower social class, and low birth weight of the infant seem to be of predominant relevance for early postnatal depressive mood.

Prospective study of postpartum depression in an Israeli cohort: prevalence, incidence and demographic risk factors

This study aimed to assess the prevalence and incidence of postpartum depression (PPD) and to identify risk factors in a community cohort of Israeli-born, as well as new and veteran immigrant women. A random sample of 288 registrants at a community clinic was assessed for depressive symptoms at 26 weeks' pregnancy using the Beck Depression Inventory (BDI) and at 6 weeks postpartum using the Edinburgh Postnatal Depression Scale (EPDS). Information regarding risk factors was gathered through interviews and medical record abstracting. The prevalence of PPD was 22.6%. Two-thirds of the women had scored 'depressed' during pregnancy, and one-third (6.9%) were new incident cases. Immigrant status was the only significant demographic predictor of PPD identified by either univariate or multivariate analysis, with Russian new immigrants having over twice the risk for PPD as Israeli-born subjects. The rate of PPD in this Israeli cohort was comparable to that found in other countries. The finding that immigrant status was the most potent demographic predictor may support the role of stressful life events in the etiology of PPD. The use of the EPDS for PPD screening was found acceptable and feasible in the primary health setting.