Postpartum depression

Postpartum Depression
Classification and external resources
ICD-10	F53.0
ICD-9	648.4
DiseasesDB	10921
MedlinePlus	007215
eMedicine	med/3408

Postpartum depression (PPD), also called postnatal depression, is a form of clinical depression which can affect women, and less frequently men, typically after childbirth. Studies report prevalence rates among women from 5% to 25%, but methodological differences among the studies make the actual prevalence rate unclear. Among men, in particular new fathers, the incidence of postpartum depression has been estimated to be between 1.2% and 25.5%.^[1] Postpartum depression occurs in women after they have carried a child, usually in the first few months, and may last up to several months or even a year.^[2] Symptoms include sadness, fatigue, changes in sleeping and eating patterns, reduced libido, crying episodes, anxiety, and irritability. Although a number of risk factors have been identified, the causes of PPD are not well understood. Many women recover with a treatment consisting of a support group or counseling.^[3][4]

The Edinburgh Postnatal Depression Scale, a standardized self-reported questionnaire, may be used to identify women who have postpartum depression.^[5]

Postpartum Exhaustion (PPE)

PPE is caused by sleep deprivation coupled with hormonal changes in a woman's body shortly after giving birth. It may be mild or severe. Most cases are noted in women who have babies with severe colic or other underlying causes that result in abnormal sleep schedules. PPE is not the same as postpartum depression, but can be classified as a postpartum depression even though exhaustion is usually only caused from extreme fatigue. Medical treatment is minimal. PPE can last from 1 to 20 days and responds with adequate amounts of sleep.^{[citation needed]}

PPD and the "baby blues"

Baby or maternity blues are a mild and transitory moodiness suffered by up to 80% of postnatal women^{[citation needed]} (and in some cases fathers). Symptoms typically last from a few hours to several days, and include tearfulness, irritability, hypochondriasis, sleeplessness, impairment of concentration, feelings of isolation and headache. The maternity blues are not the same thing as postpartum depression, nor are they a precursor to postpartum depression or postnatal psychosis.^{[citation needed]}

Symptoms

Symptoms of PPD can occur anytime in the first year postpartum^[6] and include, but are not limited to, the following:

• Sadness^[6]
• Hopelessness^[6]
• Low self-esteem^[6]
• Guilt^[6]
• A feeling of being overwhelmed
• Sleep and eating disturbances^[6]
• Inability to be comforted^[6]
• Exhaustion^[6]
• Emptiness^[6]
• Anhedonia^[6]
• Social withdrawal^[6]
• Low or no energy^[6]
• Becoming easily frustrated^[6]
• Feeling inadequate in taking care of the baby^[6]
• Impaired speech and writing
• Spells of anger towards others
• Increased anxiety or panic attacks
• Decreased sex drive – see Sex after pregnancy

One method of detecting Postnatal Depression (PND) is the use of Edinburgh Postnatal Depression Scale. If the new mother scores more than 13, she is likely to develop PND.^[7]

Risk factors

While the causes of PPD are not understood, a number of factors have been identified as predictors of PPD (the effect size is given in parentheses, where larger values indicate larger effects):

• Formula feeding rather than breast-feeding (2.04)^[8]
• A history of depression (1.87)^[8] (.38 to.39) Beck (2001)
• Cigarette smoking (1.58)^[8]
• Low self esteem (.45 to. 47) Beck (2001)
• Childcare stress (.45 to .46) Beck (2001)
• Prenatal depression during pregnancy (.44 to .45) Beck (2001)
• Prenatal anxiety (.41 to .45) Beck (2001)
• Life stress (.38 to .40) Beck (2001)
• Low social support (.36 to .41) Beck (2001)
• Poor marital relationship (.39) Beck (2001)
• Infant temperament problems/colic (.33 to .34) Beck (2001)
• Maternity blues (.25 to .31) Beck (2001)
• Single Marital Status (.21 to .25) Beck (2001)
• Low socioeconomic status (.19 to .22) Beck (2001)
• Unplanned/unwanted pregnancy (.14 to .17) Beck (2001)

Of these, three factors - formula feeding, a history of depression, and cigarette smoking - have been shown to be additive effects.^[8]

These factors are known to correlate with PPD. "Correlation" in this case means that, for example, high levels of prenatal depression are associated with high levels of postnatal depression, and low levels of prenatal depression are associated with low levels of postnatal depression. But this does not mean the prenatal depression causes postnatal depression—they might both be caused by some third factor. In contrast, some factors, such as lack of social support, almost certainly cause postpartum depression. (The causal role of lack of social support in PPD is strongly suggested by several studies, including O'Hara 1985, Field et al. 1985; and Gotlib et al. 1991.) Anthropologists Kruckman and Stern tested the idea cross culturally, and their pioneering study determined six ways in which postpartum rituals, including the use of the postpartum ritual, la cuarentena, in Chicago Latina mothers, to protect or cushion the expression of mood disorders.^[9]

In addition to Beck’s meta-analysis cited above, other academic studies have shown a correlation between a mother’s race, social class and/or sexual orientation and postpartum depression. In 2006 Segre et al., conducted a study "on the extent to which race/ethnicity is a risk factor" for PPD.^[10] Studying 26,877 postpartum women they found that 15.7% were depressed. Of the women suffering from PPD, 25.2% were African American, 22.9% were American Indian/Native Alaskan, 15.5% were Caucasian, 15.3% were Hispanic, and 11.5% were Asian/Pacific Islander. Even when "important social factors such as age, income, education, marital status, and baby’s health were controlled, African American women still emerged with significantly increased risk for…PPD".^[10]

Segre et al., also found a correlation between a mother’s social class and PPD. Not surprisingly, women with fewer resources indicate a higher level of postpartum depression and stress than those with more financial resources. Rates of PPD decreased as income increased as follows:^[10] Women with fewer resources are also more likely to have an unintended or unwanted pregnancy, further increasing risk of PPD. Beck (2001) concurs with this, stating that these women are at risk for PPD because they may experience stressors such as financial difficulties. Single mothers of low income may have fewer resources that they have access to while transitioning into motherhood.

Income	PPD rate
<$10,000	24.3%
$10,000-$19,000	20.0%
$20,000-$29,000	18.8%
$30,000-$39,000	15.3%
$40,000-$49,000	13.7%
$50,000+	10.8%

Likewise, a study conducted by Howell et al. in 2006 confirms Segre’s findings that women who are not Caucasian and in lower socioeconomic categories have more symptoms of PPD.^[11]

In a 2007 study conducted by Ross et al., lesbian and bisexual mothers were tested for PPD and then compared with a heterosexual sample. Ross et al. found that "lesbian and bisexual biological mothers had significantly higher Edinburgh Postnatal Depression Scale (EPDS) scores than the…sample of heterosexual women."^[12] The Ross study suggests that PPD may be more common among lesbian and bisexual mothers. From a study conducted in 2005 by Ross, the higher rates of PPD in lesbian/bisexual mothers than heterosexual mothers may be due to less "social support, particularly from their families of origin and…additional stress due to homophobic discrimination" in society.^[13]

Causes

The etiology of PPD is not well understood. It is sometimes assumed that postpartum depression is caused by a lack of vitamins.^[14] Other studies tend to show that more likely causes are the significant changes in a woman's hormones during pregnancy.^[15] Yet other studies have suggested there is no known correlation between hormones and postpartum mood disorders,^[16] and hormonal treatment has not helped postpartum depression victims. Further, fathers, who are not undergoing profound hormonal changes, suffer PPD at relatively high rates (e.g., Goodman 2004). Finally, all mothers experience these hormonal changes, yet only about 10–15% suffer PPD. This does not mean, however, that hormones do not play a role in PPD.^[17] For example, in women with a history of PPD, a hormone treatment simulating pregnancy and parturition caused these women to suffer mood symptoms. The same treatment, however, did not cause mood symptoms in women with no history of PPD. One interpretation of these results is that there is a subgroup of women who are vulnerable to hormone changes during pregnancy. Another interpretation is that simulating a pregnancy will trigger PPD in women who are vulnerable to PPD for any of the reasons indicated by Beck's meta-analysis (summarized above).

Profound lifestyle changes brought about by caring for the infant are also frequently claimed to cause PPD, but, again, there is little evidence for this hypothesis. Mothers who have had several previous children without suffering PPD can nonetheless suffer it with their latest child (Nielsen Forman et al. 2000). Plus, most women experience profound lifestyle changes with their first pregnancy, yet most do not suffer PPD.

Sometimes a pre-existing mental illness can be brought to the forefront through PPD^{[citation needed]}. It is widely found in women whose families have a history of mental illnesses and disorders such as bipolar disorder, schizophrenia and autism, and above-average rates of drug addiction and alcoholism.^{[citation needed]}

In 2009, researchers at the University of California, Irvine, reported that the levels of placental corticotropin-releasing hormone (CRH) during the 25th week of pregnancy may help predict a woman's chances of developing postpartum depression.^[18]

Evolutionary psychological hypothesis

Research suggests that PPD is a functional component of human reproductive decision-making, research supports the notion that PPD declined mothers investment in their offspring (Hagen 1999). Human infants require an extraordinary degree of care. Lack of support and insufficient investment from fathers and/or other family member will increase the costs borne by mothers, whereas infant health problems will reduce the evolutionary benefits to be gained (Hagen 1999). If ancestral mothers did not receive enough support from fathers or other family members, they may not have been able to afford raising the new infant without harming any existing children, or damaging their own health (nursing depletes mothers' nutritional stores, placing the health of poorly nourished women in jeopardy).

For mothers suffering inadequate social support or other costly and stressful circumstances, negative emotions directed towards a new infant could serve an important evolved function by causing the mother to reduce her investment in an unaffordable infant, thereby reducing her costs. Numerous studies support the correlation between postpartum depression and lack of social support or other childcare stressors (Beck 2001; Hagen 1999).

Kruckman, using observations from anthropological field work, suggests that supportive rituals and knowledge, if projected to the mother in a meaningful and sincere fashion, can affect the hypothalamus, pituitary and adrenal function and the production of endocrine signal molecules, and reduce the expression of anxiety or panic in postpartum women.^[19][20]

Mothers with postpartum depression can unconsciously exhibit fewer positive emotions and more negative emotions toward their children, are less responsive and less sensitive to infant cues, less emotionally available, have a less successful maternal role attainment, and have infants that are less securely attached; and in more extreme cases, some women may have thoughts of harming their children (Beck 1995, 1996b; Cohn et al. 1990, 1991; Field et al. 1985; Fowles 1996; Hoffman and Drotar 1991; Jennings et al. 1999; Murray 1991; Murray and Cooper 1996). In other words, most mothers with PPD are suffering some kind of cost, like inadequate social support, and consequently are mothering less.

In this view, mothers with PPD do not have a mental illness, but instead cannot afford to take care of the new infant without more social support, more resources, etc. Treatment should therefore focus on helping mothers get what they need. (See Hagen 1999 and Hagen and Barrett, n.d.)

Effects on the parent-infant relationship

Postpartum depression may lead mothers to be inconsistent with childcare. Women diagnosed with postpartum depression often focus more on the negative events of childcare, resulting in poor coping strategies (Murray).

There are four groups of coping methods, each divided into a different style of coping subgroups. Avoidance coping is one of the most common strategies used (Murray). It consists of denial and behavioral disengagement subgroups (for example, an avoidant mother might not respond to her baby crying). This strategy however, does not resolve any problems and ends up negatively impacting the mother’s mood, similarly of the other coping strategies used (Honey).

Four coping strategies:

• Avoidance coping: denial, behavioral disengagement
• Problem-focused coping: active coping, planning, positive reframing
• Support seeking coping: emotional support, instrumental support
• Venting coping: venting, self-blame

Security

Mothers who resort to avoidance coping and so don’t respond to their infants' needs may make the infant feel insecure. According to Edhborg’s article on long-term impacts^{[citation needed]}, insecurity can lead to infant stress and infant avoidance, where the infant may become so subdued that it will not interact with the mother or any other adult. This is a concern because months two through six in an infant’s life are very important; it is in these months that the infant develops some interaction and cognitive skills. Parent-infant interaction is most essential during this time because it builds the connection not only with the mother, but others as well. It is also the time of most risk for the child because of a possible increased onset of depression in the mother (Long-term). The lack of interaction can lead to difficulties in parent-infant communication and result in poorer infant performance (Murray). Multiple factors must be considered when evaluating the capacity of a seriously depressed mother to provide a safe-enough caregiving environment that can support the healthy development of her baby and her relationship with that baby ^[21] Such factors, including maternal attachment history, present social supports, insight, and ability to accept help are often best considered by an indisciplinary professional treatment team that includes infant mental health specialists or other mental health practitioners with experience in working with children and families.

Attachment study

A study by Edhborg on mother-child attachment looked at 45 randomly selected mother-child pairs. These pairs were chosen using the Edinburgh Postnatal Depression Scale^[22] (EPDS) form, measuring postpartum depression in the community. 326 women returned the form and of the 326, 24 scoring above twelve were recruited and 21 women scoring less than nine were recruited. A score above twelve is considered "potentially depressed" and a score of less than nine is considered to have no form of depression. The 45 mother-child pairs were videotaped, in their homes, for five minutes in three different situations. Mother and child were first put in a room with a standard set of toys, to represent a control play. In the second situation, mother and child were allowed to play freely in an average toy room. In the third situation, the mother was asked to leave the room as if she had to check on something, like she would regularly do in their home environment, and then return.

Senior Psychologists then scored the interaction between mother and child. The first two taped situations were scored on a five point scale; 1 (being the area of most concern) to 5 (being an area of strength). In the third situation, the attachment behavior was put into three groups based on how the child reacted to the mother's return.

Three classified groups:

• Secure and joyful attachment: consists of child greeting mother with joy and being comforted by her presence.
• Secure attachment but restricted in expressed enjoyment and pleasure: consists of the child acknowledging the mother, but showing less joy than would normally be expected.
• Insecure attachment: consists of child showing signs of avoidance and resistance. In the form of resistance the child would go to the mother, but then pull away and often repeat this action.

Analysis showed only one difference between the groups. In the free play situation, children of mothers with high EPDS scores showed less interest in playing with their mothers and exploring on their own, than the children of mothers with low EPDS scores. The mothers too only showed one difference. Those with a high EDPS score showed little maternal emotional availability to the child. Following the results, Edhborg performed a cluster analysis, keeping interest on the different interaction styles. Some children did show signs of depression, but when comparing the children it was found that there is no significance with the EPDS scores and the interaction styles. The study did find, however, that children of high EPDS scorers were less involved in the free play situation than the children of low EPDS scorers, showing that children of high EPDS are more likely to be insecure. When performing the structured task from the first situation it showed that the mothers with high EPDS were “aware of their unavailability for the child in the early postpartum period and thus tried harder… to help their children succeed in the task” (Edhborg). This overreaction proves that too much interaction can cause a negative mood in the child and a continuing difficulty in mother-child communication. Attachment issues have been shown to be a problem in older children, also. As a result of being exposed to the depression symptoms, as an infant, older children may have impaired cognitive and socio-emotional developments. The lack of attachment can also cause troubles in the interaction with others and personal independence (Long-term). Children with these issues have a higher risk of being diagnosed with depression later in life as well (Honey). John Bowlby's attachment theory explains how infants learn about their environment while keeping their caregiver close. Bowlby explains his theories with the principles of variety, heredity, and natural selection. Children need balance between the outside world and the love and support of their parents. Bowlby concentrates on a child's instinct and human nature, in opposition of Locke who believes that a newborn has no instinct to direct him or her. (Chasse, J.)

Prevention

Early identification and intervention improves long term prognoses for most women. Some success with preemptive treatment has been found as well. A major part of prevention is being informed about the risk factors, and the medical community can play a key role in identifying and treating postpartum depression. Women should be screened by their physician to determine their risk for acquiring postpartum depression. Also, proper exercise and nutrition appears to play a role in preventing postpartum, and general, depression.

In the US, the American College of Obstetricians and Gynecologists recommends that the first prenatal visit include screening for depression, stress, support, and whether the pregnancy was planned. ^[23] However providers do not consistently provide screening and appropriate follow-up.^[23]

Currently, Alberta is the only province in Canada with universal PPD screening which has been in place since 2003. The PPD screening is carried out by Public Health nurses in conjunction with the baby's immunization schedule.

Nutrition

Pregnant, nursing and postpartum women are strongly encouraged to seek the medical advice of their obstetrician, primary care physician, registered dietitian, or midwife regarding optimal nutrition during pregnancy and after birth.

The following nutritional information may be beneficial in achieving a well-balanced diet during and after pregnancy, but studies are needed to confirm their role in preventing postpartum depression.

Omega-3 fatty acids: Some experts believe that postpartum depression can be attributed to depletion of omega 3 fatty acids from the mother's brain to support development of the brain of the fetus or breast fed infant. This can be prevented by ensuring that sufficient omega 3 fatty acids are provided in the mother's diet.^[24] Good natural sources of omega 3 fatty acids include edible linseed oil, certain fish, grass fed rather than grain fed meat, and eggs from chickens fed on flax seed or other feed high in omega 3 fats. Omega 3 fatty acids can also be purchased in capsule form as a dietary supplement.

Protein can be found in a wide variety of foods. Some examples follow: 3 ounces of most meat products contain 25 grams of protein, 3 large eggs have approximately 19 grams, and 3 ounces of Swiss cheese have about 15 grams.

Hydration: One of the most important roles in any diet (especially for pregnant and nursing mothers) is that of hydration. Physicians may recommend that pregnant women consume ten 8-ounce glasses of water every day. Mothers who are nursing are strongly urged to drink a tall glass of water, milk or juice before sitting down to breastfeed their child. Women should consult with their physicians about caffeine and alcohol consumption postpartum.

Vitamins: A pregnant and postpartum woman should speak with her physician for information about, and a recommendation for, a daily prenatal/postnatal vitamin supplement.

B Vitamins Some limited research has indicated that the intake of B vitamins, specifically riboflavin, can help reduce the chance of post partum depression.^[25] B vitamins are water soluble and must be replenished each day.

Appetite: If a woman finds herself with a loss of appetite or other eating disturbance, she should consult her physician. This may be a sign of postpartum depression and therefore should be discussed with a doctor.^[6]

Treatment

Numerous scientific studies and scholarly journal articles support the notion that postpartum depression is treatable using a variety of methods. If the cause of PPD can be identified, as described above under “social risk factors,” treatment should be aimed at mitigating the root cause of the problem, including increased partner support, additional help with childcare, cognitive therapy, etc.

Women need to be taken seriously when symptoms occur. This is a twofold practice: First, the postpartum woman will want to trust her intuition about how she is feeling and believe that her symptoms are real enough to tell her significant other, a close friend, and/or her medical practitioner; erring on the side of caution will go a long way in the treatment of PPD.^[6] Second, the people in whom she confides must take her symptoms seriously as well, aiding her with treatment and support. Partners, friends and physicians may notice changes in a postpartum mother that she may not. Knowing that PPD is treatable with a variety of methods can make persistence in seeking treatment easier.

Various treatment options include:

• Medical evaluation to rule out physiological problems
• Cognitive behavioral therapy (a form of psychotherapy)
• Possible medication
• Support groups
• Home visits/Home visitors
• Healthy diet
• Consistent/healthy sleep patterns

An experienced medical professional will work with a postpartum mother to develop a treatment plan that is right for her. This plan may include any combination of the above options, and might include some discussion or feedback from/with a partner. If a woman suffering from PPD does not feel she is being taken seriously or is being recommended a treatment plan she does not feel comfortable with, she will want to seek a second opinion.^[6]

A 1997 study conducted by Appleby et al., confirms that postpartum depressed mothers’ symptoms promptly improved at similar rates when treated with cognitive behavioral therapy or the antidepressant fluoxetine. “A group of 61 depressed mothers completed a 12-week treatment program with or without the antidepressant plus one session versus six sessions of counseling.” Improvement followed after “one to four weeks of either treatment.”^[26] The findings of Appleby et al.’s study conclusively showed that combining counseling with drug therapy did not add to the improvement of just drug therapy or just counseling.^[26] This suggests that counseling is equally as effective a treatment for PPD as medication, and that “the choice of treatment [psychotherapy vs. medication] may…be made by the women themselves”.^[26] Other forms of therapy (like group therapy and home visitors) are also effective treatments for PPD.^[6]

A woman will want to discuss the various treatment options available with her physician and, if considering drug therapy, should speak about which medications are safe to take while breastfeeding.

Treatment for PPD can reduce the length of suffering and its severity. Untreated, the Baby Blues may go away on its own (and does in most cases). PPD may or may not go away without treatment. Speaking to a health care provider as soon as symptoms occur is the safest way to ensure prompt treatment and return to normal life.

According to The National Institutes of Mental Health, studies show that the childbearing years are when a woman is most likely to experience depression in her lifetime. Approximately 15% of all women will experience postpartum depression following the birth of a child. (Chasse, J). When the mental health of the mother is compromised, it affects the entire family. (Postpartum Support International).

Psychosis

Main article: Postpartum psychosis

Postpartum psychosis is a separate mental illness, which involves a complete break with reality. Although sometimes confused with or erroneously referred to as postpartum depression, postpartum psychosis is a very different disorder. It is less common than PPD, and it involves the onset of psychotic symptoms that may include thought disturbances, delusions, hallucinations and/or disorganized speech or behavior.

Treatment for Postnatal Psychosis is essential; it will not go away without medical attention.^[6]

See also

• Psychiatric disorders of childbirth

References

1. ^ Paulson JF. http://www.psychiatrictimes.com/display-old/article/10168/1519072 [Focusing on depression in expectant and new fathers: prenatal and postpartum depression not limited to mothers.] Psychiatry Times. 2010;27(2).
2. ^ Canadian Mental Health Association > Post Partum Depression Retrieved on June 13, 2010
3. ^ Kinnaman, Gary & Jacobs, Richard. Seeing in the Dark. Michigan: Baker Publing Group, 2006.
4. ^ Agency for Health Care Research and Quality: Perinatal Depression: Prevalence, Screening Accuracy, and Screening Outcomes [1].
5. ^ Cox J.L., Holden J.M., Sagovsky R. (1987). "Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale". Br J Psychotherapy 150: 782–6. 
6. ^ ^{a b c d e f g h i j k l m n o p q r s} The Boston Women's Health Book Collective: Our Bodies Ourselves, pages 489–491, New York: Touchstone Book, 2005
7. ^ Edinburgh Postnatal Depression Scale
8. ^ ^{a b c d} Sarah J. Breese McCoy (April 2006). "Risk Factors for Postpartum Depression: A Retrospective Investigation at 4-Weeks Postnatal and a Review of the Literature". The Journal of the American Osteopathic Association (JAOA) 106 (4): 193–8. PMID 16627773. http://www.jaoa.org/cgi/content/full/106/4/193. Retrieved 2008-07-04. 
9. ^ Stern, G., Kruckman, L. "Multi-Disciplinary Perspectives on Postpartum Depression: An Anthropological Critique," Social Science and Medicine, Vol. 17, 15, pages 1027-1041, 1983.
10. ^ ^{a b c} Segre, Lisa S, Mary E. Losch, Michael W. O’Hara. Race/Ethnicity and Perinatal Depressed Mood. Journal of Reproductive and Infant Psychology. Vol 24 No 2: 99–106
11. ^ Howell, Elizabeth A, Pablo Mora, Howard Leventhal. Correlates of Early Postpartum Depressive Symptoms. Maternal and Child Health Journal. Vol 10 No 2: 149–157
12. ^ Ross, Lori E, L Steele, C Goldfinger, and C Strike. Perinatal Depressive Symptomatology Among Lesbian and Bisexual Women. Archives of Women’s Mental Health. Vol 10 No 2: 53–59
13. ^ Ross, Lori E. Perinatal Mental Health in Lesbian Mothers: A Review of Potential Risk and Protective Factors. Women & Health. Vol 41 Issue 3: 113–128
14. ^ John L. Beard, et. al.; J. Nutr. 135: 267–272, 2005.
15. ^ Soares CN, Zitek B. Reproductive hormone sensitivity and risk for depression across the female life cycle: a continuum of vulnerability? J Psychiatry Neurosci. 2008 Jul;33(4):331-43.
16. ^ Miller, Laura J. Postpartum Depression, JAMA 2002:28(6):762-765; see also Harris 1994; O'Hara 1995.
17. ^ Block et al. (2000).
18. ^ Rich-Edwards JW, Mohllajee AP, Kleinman K et al. (May 2008). "Elevated Midpregnancy Corticotropin-Releasing Hormone Is Associated with Prenatal, But Not Postpartum, Maternal Depression". J. Clin. Endocrinol. Metab. 93 (5): 1946–51. doi:10.1210/jc.2007-2535. PMC 2386278. PMID 18303075. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2386278. 
19. ^ Kruckman, L. “Rituals as Prevention: The Case of Postpartum Depression,” In The Nature and Function of Rituals, Ruth-Inge Heinze, Greenwood Publishing, 1999.
20. ^ Kruckman, L. “A Renewed Call for a Biocultural Understanding of Postpartum Depression Etiology,” paper presented at the Max Planck Institute International Symposium, “Postpartum Dysphoria & Depression: Anthropological, Ethnopsychiatric & Evolutionary Dimensions” Reimers Stiftung, Bad Homburg, Germany, 2000.
21. ^ Almeida A, Merminod G, Schechter DS (2009). "Mothers with severe psychiatric illness and their newborns: a hospital-based model of perinatal consultation". Journal of ZERO-TO-THREE: National Center for Infants, Toddlers, and Families 29 (5): 40–46. 
22. ^ Edinburgh Postnatal Depression Scale
23. ^ ^{a b} "Providers miss opportunities to prevent depression in and discuss birth control with women with unplanned pregnancies". Research Activities (Agency for Healthcare Research and Quality) (372): 15. August 2011. http://www.ahrq.gov/research/aug11/0811RA18.htm. 
24. ^ "Pregnant/Nursing Women Need Proper Fat Intake to Combat Depression". obgyn.net. 2001-10-25. http://www.obgyn.net/newsrx/womens_health-Women's_Health-20011101-19.asp. Retrieved 2008-07-04. 
25. ^ The Osaka Maternal and Child Health Study
26. ^ ^{a b c} Appleby, Louis, Rachel Warner, Brian Faragher, and Anna Whitton. "A Controlled Study of Fluoxetine and Cognitive-Behavioural Counseling in the Treatment of Postnatal Depression". British Medical Journal: 932–937. 314.n7085. 

Further reading

• Beck C.T. (1995). "The effects of postnatal depression on maternal-infant interaction: a meta-analysis". Nursing Research 44 (5): 298–304. PMID 7567486. 
• Beck C.T. (1996a). "A meta-analysis of predictions of postpartam depression". Nursing Research 45 (5): 297–303. doi:10.1097/00006199-199609000-00008. PMID 8831657. 
• Beck C.T. (1996b). "A meta-analysis of the relationship between postpartum depression and infant temperament". Nursing Research 45 (4): 225–230. doi:10.1097/00006199-199607000-00006. PMID 8700656. 
• Beck C.T. (2001). "Predictors of Postnatal Depression: An Update". Nursing Research 50 (5): 275–285. doi:10.1097/00006199-200109000-00004. PMID 11570712. 
• Canadian Pediatric Society. "Depression in Pregnant Women and Mothers: How Children are Affected." October 2004. Accessed 22 November 2005 at
• Cohn J.F., Campbell S.B., Matias R., Hopkins J. (1990). "Face-to-face interactions of postpartum depressed and nondepressed mother-infant pairs at 2 months". Developmental Psychology 26: 15–23. doi:10.1037/0012-1649.26.1.15. 
• Cohn J.F., Campbell S.B., Ross S. (1991). "Infant response in the still-face paradigm at 6 months predicts avoidant and secure attachment at 12 months. Special Issue: Attachment and developmental psychopathology". Development and Psychopathology 3 (4): 367–376. doi:10.1017/S0954579400007574. 
• Edhborg Maigun; Lundh, Wendela; Seimyr, Louise; Widstrom, Ann-Marie (2001). "The long-term impact of postnatal depressed mood on mothers + child interaction: a preliminary study". Journal of Reproductive and Infant Psychology 19: 61–71. doi:10.1080/02646830123255. 
• Edhborg Maigun; Friberg, Malin; Lundh, Wendela; Widström, Ann-Marie (2005). "'Struggling with Life': Narratives from women with signs of postpartum depression". Scandinavian Journal of Public Health 33 (4): 261–267. doi:10.1080/14034940510005725. PMID 16087488. 
• Field T., Sandburg S., Garcia R., Vega-Lahr N., Goldstein S., Guy L. (1985). "Pregnancy problems, postpartum depression, and early mother-infant interactions". Developmental Psychology 21 (6): 1152–1156. doi:10.1037/0012-1649.21.6.1152. 
• Fowles E.R. (1996). "Relationships among prenatal maternal attachment, presence of postnatal depressive symptoms, and maternal role attainment". Journal of the Society of Pediatric Nurses 1 (2): 75–82. doi:10.1111/j.1744-6155.1996.tb00004.x. PMID 8933479. 
• Gotlib I.H., Whiffen V.E., Wallace P.M., Mount J.H. (1991). "Prospective investigation of postpartum depression: factors involved in onset and recovery". Journal of Abnormal Psychology 100 (2): 122–132. doi:10.1037/0021-843X.100.2.122. PMID 2040762. 
• Goodman J.H. (2004). "Paternal postpartum depression, its relationship to maternal postpartum depression, and implications for family health". Journal of Advanced Nursing 45 (1): 26–35. doi:10.1046/j.1365-2648.2003.02857.x. PMID 14675298. 
• Harris B (1994). "Biological and hormonal aspects of postpartum depressed mood: working towards strategies for prophylaxis and treatment. Special Issue: Depression". British Journal of Psychiatry 164: 288–292. 
• Hagen E., Barrett H. C. (2007). "Perinatal sadness among Shuar women: Support for an evolutionary theory of psychic pain" (PDF). Medical Anthropology Quarterly 21 (1): 22–40. doi:10.1525/maq.2007.21.1.22. PMID 17405696. http://www.sscnet.ucla.edu/anthro/faculty/barrett/Hagen-Barrett-2007.pdf. 
• Hagen E. (1999). "The functions of postpartum depression" (PDF). Evolution and Human Behavior 20: 325-359. http://cogprints.org/1720/3/ppd_for_cogprints.pdf. 
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External links

Psychiatry portal

• MedlinePlus Overview postnataldepression
• Postpartum depressive illness at GPnotebook
• The functions of postnatal depression
• Postnatal Depression, from the National Woman's Health Information Center
• Mother's Voice UK Charity supporting women and families affected by maternal depression/anxiety/psychosis
• Acacia Family Support UK charity supporting women and families affected by post natal depression
• Perinatal Pro – expert postpartum depression and perinatal mood disorder information
• Postpartum Depression, Postpartum Support International, an exhaustive resource for locating information and postpartum support groups worldwide
• Postnatal Depression, information from the mental health charity The Royal College of Psychiatrists
• NHS Choices Health A-Z: Postnatal depression
• NHS Choices Pregnancy Care Planner: The baby blues and postnatal depression
• NHS Choices Live Well: Postnatal depression
• PND -PMH Training Training in Postnatal Depression &Perinatal Mental Health Issues.
• Postpartum Depression Awareness Resources and Help.