A cross-cultural form of major depressive disorder can affect a woman that has given birth to a child recently and can have serious health consequences for both the mother and her child.
Post partum depression (PPD) may occur soon after delivery or up to a year later.
Most of the time, it occurs within the first 3 months after delivery.
Studies report prevalence rates among women from 5% to 25%.
Women commonly have mood changes during pregnancy, especially after delivery.
Feelings of anxiety, irritation, tearfulness, and restlessness are common in the week or two after pregnancy.
These feelings are often called "baby blues".
These symptoms almost always go away soon, without the need for treatment.
PPD may occur when the baby blues do not fade away.
RISK FACTORS
- Young age (under 20 years)
- Currently alcohol abuse, taking of illegal substances, or smoking
- Not planned pregnancy or mixed feelings about it
- Depression, bipolar disorder, or an anxiety disorder before the pregnancy, or with a previous pregnancy
- Stressful events during pregnancy or delivery, including personal illness, death or illness of a loved one, a difficult or emergency delivery, premature delivery, or illness or birth defect in the baby
- Have little support from the husband, the family or friends.
SYMPTOMS
The symptoms of PPD are the same as the symptoms of depression that occurs at other times in life.
Along with a sad or depressed mood, the patient may have some of the following symptoms: agitation or irritability, changes in appetite, feelings of worthlessness or guilt, feeling withdrawn or unconnected, lack of pleasure or interest in most or all activities, loss of concentration, loss of energy, problems doing tasks at home or work, negative feelings toward the baby, significant anxiety, thoughts of death or suicide, trouble sleeping.
A mother with PPD may also:
- Be unable to care for herself or her baby
- Be afraid to be alone with her baby
- Have negative feelings toward the baby or even think about harming the baby
- Worry intensely about the baby, or have little interest in the baby
AETIOLOGY
The causes of PPD are not well understood.
According to recent studies, the most likely aetiology is composed by a variety of concomitant different factors, especially of hormonal and socio-psychological derivation.
The most significant and interesting factors are: variation of plasma levels of estrogens, progesterone and prolactin, serotonin availability, postpartum hypothyroidism, sleep deprivation and socio-psychological risk factors (mentioned above).
- ESTROGENS AND PROLACTIN
After delivery, plasma levels of estradiol decrease immediately.
This fact has three main consequences:
- During pregnancy, high levels of estrogens ensure 5-HT receptors synthesis; after the parturition, estradiol plasma levels decrease physiologically, and this event is correlated to reduced effects of serotonin on the central nervous system.
- The estrogens facilitate the expression of TBG, that allows the transport of thyroid hormones in blood.
The decrease of TBG after parturition lowers the delivery of thyroid hormones to tissues: this decrease is not matched with an increase of free T3 or T4 in blood, so the total effect is a decreased action of thyroid hormones.
This is confirmed by the success of replacement hypothyroidism therapy in postmenopausal women, based on somministration of estrogens.
- The estrogens have a positive regulating action on lactotrope cells.
They have a role (with hypotalamic PRF) in the increase of PROLACTIN (PRL) plasma levels at the end of pregnancy.
A study demonstrated that depressed mothers show a more rapid collapse of PRL levels after their child birth than non-depressed women.
This fact is primary in the correlation between hormonal postpartum levels and changes of mood, because PRL acts on the lymbic system.
With oxytocin, it stimulates maternal behaviour, acting on some hypothalamic nuclei as paraventricular nucleus, ventromedial nucleus, medial preoptic nucleus, supraoptic nucleus and others.
This is demonstrated by a study that shows how the number of PRL receptors increases during pregnancy in specific areas of the hypothalamus, probably for the action of estrogens.
These nuclei regulate stress response, anxiety-related behaviour, reproductive behaviour and maternal behaviour.
The onset and maintenance of maternal behaviour is regulated by the medial preoptic area that contains high number of PRL and oxytocin receptors.
In conclusion, if the mother has a PRL breakdown, she doesn't accept to be a mother!
- PROGESTERONE
Progesterone hormone levels oscillate radically during and after pregnancy, which has led to believe that this may be an essential part of the postpartum depression.
A trial observed 156 women experiencing their first pregnancy.
The authors measured the women's progesterone levels at various points during the pregnancy and after birth, and evaluated their emotions based on "the Edinburgh postnatal depression scale, the Stein scale for maternity blues, and the Beck depression rating inventory."
Progesterone levels were measured in the patients by collecting saliva samples daily in the weeks before delivery, and for the following 40 days.
The women were also asked to complete a daily questionnaire to gauge mood after birth for 10 days, and after 40 days they were seen by a psychiatrist to assess depression.
Blood samples were also drawn at four separate points during the trial.
In all women, progesterone production builds slowly during pregnancy, when it is chiefly produced by the placenta.
By the time of birth, progesterone levels are several hundred times above normal.
After birth and the shedding of the placenta, progesterone levels drop abruptly and severely.
The report determined that the women most likely to undergo from the maternal blues were those with the most acute swings in progesterone levels, the highest levels of progesterone during pregnancy, the steepest drop in levels after birth, and continued lower progesterone levels postpartum.
The results of this study have led some to believe that progesterone therapy may be a viable option for the treatment of postpartum depression.
- SEROTONIN AND MELATONIN
To proliferate and grow up, the fetus needs tryptophan.
Where does it take it? From the mother.
She gives her Trp to her child; the remaining Trp is used in cell proliferation, so the nervous system can't build up serotonin (5-HT) from this aminoacid.
Serotonin deficiency produces depression.
Moreover, Trp deficiency brings to decreased melatonin synthesis: this brings to insomnia and sleeping troubles in women after pregnancy.
- POSTPARTUM HYPOTHYROIDISM
Postpartum hypothyroidism is a pshysiological consequence of lack of TSH after delivery.
In fact, during pregnancy the human chorionic gonadotropin (hCG) mimics TSH action on thyroid cells (hCG and TSH have an identical subunit, alpha, that activates adenylate cyclase) and TSH levels decrease.
After delivery, hCG levels fall down, but TSH is rapidly brought back to normal levels.
This involves a transient physiological hypothyroidism before normal levels are re-established.
This situation can get worse if the mother suffers of tyroiditis: in pregnancy hCG hides thyroid breackdown but, when its effects end, TSH stimulation of thyroid is not adequate and we have hypothyroidism.
Cells poorly breath, CNS is less active, it suffers increasingly and the woman is tired and depressed!
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CONCLUSIONS
PPD is a complex desease, due to several causes.
It occurs when environmental or social factors add up to pshysiological hormonal changes after pregnancy; these variations can be more meaningful when they are more drastic and rapid.
The therapy normally contemplates psychological help, with family and doctors' supporting, according to somministration of antidepressants.
Recently, support therapy of estrogens and progesterone has shown a hopeful success.
Following studies about postpartum depression aetiology will allow more specific therapies.
