A Detailed Biological Approach on Hormonal Imbalance Causing Depression in Critical Periods (Postpartum, Postmenopausal and Perimenopausal Depression) in Adult Women

Motherhood is a critical situation characterized by role conflicts. These conflicts between the roles of mother, worker, and wife are the norm in the postpartum period and may jeopardize a mother's well-being. The purpose of this study was to explore the relationships between postpartum adaptation and depression among new mothers who live in northern Taiwan. A total of 186 first pregnancy mothers were recruited via convenience sampling methods and they completed mailed questionnaires between 1 week and 2 months after giving birth. Structured questionnaires including Demographic Inventory Scale, Postpartum Self-Evaluation Questionnaire, and Edinburgh Postnatal Depression Scale were used. Ninety-four (50.5%) women exhibited depressive symptoms (EPDS > 10) and 73 (39.2%) women needed to consult the doctor (EPDS > 12). The risk factors for postpartum depression symptoms included unplanned birth, low socioeconomic status, and part-time employment. The correlation between women's different aspects of postpartum adaptation and depression ranged was from low to medium. The best predictors of postpartum depression were confidence in their own competence of motherhood tasks, satisfaction with life circumstances, and partner participating in child care. These three subsets explained 44.8% of the total variance. This study shows that healthcare providers who work with primiparas during the first 2 months after giving birth should pay more attention to postpartum depression, keeping in mind associated risk factors. A new mother's confidence in her own abilities as a new mother may be particularly important in determining the likelihood of postpartum depression.

Back to table of contents Previous article Next article Clinical & Research NewsFull AccessBiological Marker May Predict Postpartum DepressionJoan Arehart-TreichelJoan Arehart-TreichelSearch for more papers by this authorPublished Online:20 Mar 2009https://doi.org/10.1176/pn.44.6.0016aSome risk factors for postpartum depression are well documented. They include anxiety, stress, lack of social support, low self-esteem, depression before or during pregnancy, a history of premenstrual syndrome, and a history of oral contraceptive–induced mood changes.A biological marker for postpartum depression may now have been discovered as well. The marker is an elevated level of the hypothalamic hormone corticotropin-releasing hormone (CRH) during the 25th week of pregnancy.The finding was reported in the February Archives of General Psychiatry. The lead investigator was Ilona Yim, Ph.D., an assistant professor of psychology and social behavior at the University of California, Irvine.CRH is known to play an important role in the origin of depression in the non-pregnant state. CRH levels are also known to soar during pregnancy. Yim and her coworkers suspected that a surge of CRH during pregnancy might help set the stage for postpartum depression in some women, so they launched a longitudinal cohort study to test the hypothesis.One hundred pregnant women were recruited into the study. Blood samples were obtained at 15, 19, 25, 31, and 37 weeks of pregnancy from each of the women. The blood samples were screened not just for CRH, but for the pituitary hormone adrenocorticotropic hormone (ACTH), which is regulated by CRH, and for the adrenal cortex hormone cortisol, which is regulated by ACTH. Each woman was assessed for depressive symptoms four times during pregnancy and on average nine weeks after delivery. Out of the 100 women, 16 developed postpartum depression symptoms.After taking prenatal depressive symptoms into consideration, the researchers looked to see whether there was any link between pregnancy levels of CRH, ACTH, or cortisol and the development of postpartum depression symptoms. They found only one link, and that concerned CRH. An elevated level of CRH at 25 weeks of pregnancy was a highly significant predictor of postpartum depression—that is, it predicted postpartum depression with an accuracy of 75 percent and with a misclassification rate of 24 percent.Although Yim and her colleagues had anticipated that CRH might predict postpartum depression, she “was surprised at how robust this finding was,” Yim told Psychiatric News. “I also did not anticipate a timing effect. I would have speculated that overall CRH exposure throughout pregnancy would play a bigger role.”Yim and her group will now attempt to replicate their findings. If they manage to do so, and if other groups manage to do so as well, “it may be considered useful to implement a CRH-postpartum depression screen into standard prenatal care,” they wrote in their study report.“ Because blood draws to screen for gestational diabetes are typically performed at 24 to 28 weeks of gestation, a potential postpartum depression screen could be completed at the same time.”Meanwhile, Yim and her colleagues will attempt to determine why a large surge in CRH around 25 weeks of pregnancy seems to predict postpartum depression. They do know that the placenta starts to churn out large amounts of CRH around this time, supplementing the amount of CRH that is already being made by the hypothalamus. But why many women who develop postpartum depression tend to produce even more CRH at 25 weeks of pregnancy than do women who do not develop postpartum depression is not clear.“This work is an exciting contribution in the area of postpartum depression,” Marlene Freeman, M.D., told Psychiatric News.“ It supports [the notion] that women who suffer from postpartum depression have a biological vulnerability, and that risk may be assessed during pregnancy at a specific point. It would be important to build upon this work to determine how women at risk for postpartum major depressive episodes might be clearly identified for careful monitoring, early treatment, and even prophylaxis.”Freeman is a psychiatrist with a focus on the interface between psychiatry and obstetrics. She is affiliated with the Perinatal and Reproductive Psychiatry Clinical Research Program at Massachusetts General Hospital.The study was funded by the National Institute of Child Health and Human Development.An abstract of “Risk of Postpartum Depressive Symptoms With Elevated Corticotropin-Releasing Hormone in Human Pregnancy” is posted at<http://archpsyc.ama-assn.org/cgi/content/abstract/66/2/162>.▪ ISSUES NewArchived

BackgroundPostpartum depression (PPD) occurs following periods of major hormonal flux and experiments modulating gonadal hormone levels in the humans pharmacologically can lead to the onset of depressive phenotypes(Bloch et al., 2000). Together the data suggest a class of depression driven by hormonal change, here termed ‘hormonal depression’ (Payne, Palmer and Joffe, 2009; Payne, 2019).Previous work out of our laboratories have identified epigenetic variation at the TTC9B and HP1BP3 loci that is prospectively predictive of PPD risk, validated in over 5 cohorts(Guintivano et al., 2014; Osborne et al., 2016; Kaminsky et al., 2020; Lapato et al., 2020; Payne et al., 2020).ObjectivesThe primary objective was to assess the predictive efficacy of epigenetic PPD biomarkers for other hormonally driven depressions including premenstrual dysphoric disorder (PMDD) and post-menopausal depression (PMD). The secondary objective was to assess the influence of antidepressant medications and serum hormones and neuroactive metabolites on biomarker outcomes.MethodsWe applied our published PPD biomarker linear model to DNA methylation generated by targeted pyrosequencing at TTC9B and HP1BP3 in a cohort of N=55 women with and without premenstrual dysphoric disorder (PMDD). The model was evaluated in a convenience sample of publicly available DNA methylation data from N=128 women to predict current depression in post-menopausal women.ResultsIn the PMDD sample, Luteal but not follicular phase samples generated an AUC of 0.71 (95% CI: 0.49-0.93 ) to distinguish N= 10 PMDD cases from N=18 controls and generated an AUC of 0.86 (95% CI: 0.70-0.86). In the PMD sample, the PPD model predicted depression status with an AUC of 0.71 (95% CI: 0.61-0.81) in N=80 women with current depression and N=48 controls. In the PMDD sample, model application to luteal phase samples distinguished between N=5 SSRI responders from N=5 non-responders (AUC= 0.80, 95% CI: 0.50-0.80). HP1BP3 DNA methylation was significantly positively associated with levels of pregnenolone (rho= 0.35, p=0.014), suggesting it may be a marker of progesterone pathway precursor levels. Additionally, follicular phase TTC9B methylation was associated with the change in log(allopregnanolone) levels from follicular to luteal phases (rho= -0.53, p=0.02), suggesting it may be a marker of altered neuroactive steroid metabolism in the progesterone pathway.ConclusionsThis study suggests epigenetic PPD biomarkers can predict other hormonal depressions like PMDD and PMD. Furthermore, they may mark a biology related to variation of gonadal hormones like pregnenolone, the precursor to progesterone, and allopregnanolone, a neuroactive steroid important for modulating mood. Allopregnanolone, a target of recently approved PPD medications like Zuranolone(Althaus et al., 2020; Deligiannidis et al., 2021), can interact with the serotonin system and may be important for antidepressant medication response(Lovick, 2013; Lü scher and Mö hler, 2019). Future work should investigate the interaction of PPD biomarkers with medication response in hormonal depressions.ReferencesAlthaus, A.L. et al. (2020) ‘Preclinical characterization of zuranolone (SAGE-217), a selective neuroactive steroid GABAA receptor positive allosteric modulator’, Neuropharmacology [Preprint]. doi:10.1016/j.neuropharm.2020.108333.Bloch, M. et al. (2000) ‘Effects of gonadal steroids in women with a history of postpartum depression’, American Journal of Psychiatry [Preprint]. doi:10.1176/appi.ajp.157.6.924.Deligiannidis, K.M. et al. (2021) ‘Effect of Zuranolone vs Placebo in Postpartum Depression’, JAMA Psychiatry [Preprint]. doi:10.1001/jamapsychiatry.2021.1559.Guintivano, J. et al. (2014) ‘Antenatal prediction of postpartum depression with blood DNA methylation biomarkers’, Molecular Psychiatry [Preprint]. doi:10.1038/mp.2013.62.Kaminsky, Z.A. et al. (2020) ‘Postpartum depression biomarkers predict exacerbation of OCD symptoms during pregnancy’, Psychiatry Research [Preprint]. doi:10.1016/j.psychres.2020.113332.Lapato, D.M. et al. (2020) ‘Predictive validity of a DNA methylation-based screening panel for postpartum depression’, medRxiv [Preprint].Lovick, T. (2013) ‘SSRIs and the female brain - Potential for utilizing steroid-stimulating properties to treat menstrual cycle-linked dysphorias’, Journal of Psychopharmacology [Preprint]. doi:10.1177/0269881113490327.Lü scher, B. and Mö hler, H. (2019) ‘Brexanolone, a neurosteroid antidepressant, vindicates the gabaergic deficit hypothesis of depression and may foster resilience.’, F1000Research [Preprint]. doi:10.12688/f1000research.18758.1.Osborne, L. et al. (2016) ‘Replication of epigenetic postpartum depression biomarkers and variation with hormone levels’, Neuropsychopharmacology [Preprint]. doi:10.1038/npp.2015.333.Payne, J.L. (2019) ‘Reproductive psychiatry: giving birth to a new subspecialty’, International Review of Psychiatry [Preprint]. doi:10.1080/09540261.2018.1579991.Payne, J.L. et al. (2020) ‘DNA methylation biomarkers prospectively predict both antenatal and postpartum depression’, Psychiatry Research, 285. doi:10.1016/j.psychres.2019.112711.Payne, J.L., Palmer, J.T. and Joffe, H. (2009) ‘A reproductive subtype of depression: Conceptualizing models and moving toward etiology’, Harvard Review of Psychiatry [Preprint]. doi:10.1080/10673220902899706.

Postpartum depression (PPD) and iron deficiency are prevalent challenges for women after childbirth, with substantial impacts on both psychological and physical health. This workshop proposal introduces a biomolecular, psychological, and Complementary and Alternative Medicine (CAM) approach to managing PPD and iron deficiency by integrating phytocannabinoid supplementation, Ayurvedic herbs, and yoga. These interventions target the female Endocannabinoid System (FECS), which plays a vital role in regulating mood, stress, and reproductive health. Recent research highlights the potential of FECS-targeted therapies in managing symptoms of depression and emotional imbalances related to PPD. Postpartum depression is a significant public health problem, affecting approximately 10-20% of postpartum women, and can lead to severe conditions such as suicidal attempts. Deficiencies in trace elements during the postpartum period have been recognized as essential contributors to postpartum depression. Risk factors for postpartum depression include high life pressure, lack of social support, lack of partner support, physical and psychological violence by partners, abuse that has been experienced, and depression that has been experienced during pregnancy. The pathogenic factors of postpartum depression are complicated. Previous clinical studies have illustrated the correlations between the pathogenesis of postpartum depression and altered levels of prenatal hormones, worrying about delivery, and inadequate preparation for childbirth. Another study further confirmed the contribution of limited postpartum health education, insufficient psychological support, and inability to adapt to postpartum roles to the occurrence of postpartum depression in the early postpartum period. Antenatal depression, antenatal anxiety, and previous depressive illness have the most substantial effect size in postpartum depression. Life stress, fear of childbirth, and emergency cesarean delivery have also been identified as risk factors for postpartum depression. Interestingly, women with a history of depression and an IVF-achieved pregnancy experienced substantially less postpartum depression. Regarding delivery factors, studies suggest that emergency cesarean delivery affects post-partum depression in the nulliparous. This seems to confirm that women who express a strong desire to have a natural childbirth during pregnancy but who must undergo cesarean section are more prone to the risk of postpartum depression. Another variable that was directly linked to maternal postpartum depression was infant weight at 4 weeks, which was the total effect on postpartum depression. A previous study has shown that significantly elevated risk factors for postpartum depression include concerns of infant weight gain. The workshop, structured as a one-day, six-hour session, will utilize interactive presentations, small group discussions, and practical demonstrations to explore the biomolecular mechanisms by which the FECS and yoga practices can promote homeostasis and emotional well-being. Phytocannabinoid-based treatments are posited to enhance mood regulation and reduce stress responses in postpartum women suffering from iron deficiency. At the same time, yoga and Ayurvedic practices provide complementary support in managing physical deficiencies and enhancing mental clarity. By combining evidence-based CAM therapies, the workshop aims to empower postpartum women with tools to proactively manage their health through scientifically informed interventions tailored to the unique needs of the postpartum period.

After completing this article, readers should be able to: Postpartum depression (PPD) is a significant public health problem, each year affecting 10% to 20% of new mothers. Many of these women and their children experience short- and long-term adverse consequences. Despite an increasing awareness of the effects of maternal depression on children's health and welfare, it remains unrecognized and poorly understood by women and clinicians alike. Because pediatricians encounter mothers repeatedly during the postpartum year, it is important that they recognize PPD and appropriately educate and refer mothers for evaluation and treatment.PPD describes a heterogeneous group of depressive symptoms and syndromes that occurs during the first year following birth. The American Psychiatric Association Diagnostic and Statistical Manual of Mental Health Disorders-IV (DSM IV) uses the term "postpartum" more specifically to describe symptoms of major depressive disorder, bipolar disorder, or brief psychotic disorder beginning within 4 weeks of delivery. The psychiatric postpartum experiences usually are divided into three categories: "maternal blues," PPD, and postpartum psychosis. The DSM IV does not apply "postpartum" to other psychiatric illnesses. However, anxiety disorders, such as panic, obsessive-compulsive disorder, and phobias, can have an initial onset or exacerbation in the postpartum period.Maternal blues or postpartum mood reactivity is considered a "normal" emotional experience for women in the immediate postpartum period. It is estimated that 50% to 80% of new mothers experience transient symptoms of depressed mood, at times alternating with elated moods, irritability, increased crying spells, and a sense of "unreality" during the first 10 days after birth. These symptoms usually resolve without intervention. On the other end of the spectrum is postpartum psychosis, a rare (1/1,000 live births) and serious event that generally occurs within 2 weeks of delivery and is considered a psychiatric emergency that requires immediate psychiatric intervention. PPD falls in the middle, occurring in 10% to 20% of postpartum women and presenting with a range of mild to severe depressive symptoms.Almost 50% of PPD cases are continuations of depressive episodes that occur during or before pregnancy. The incidence of new-onset cases of depression during the postpartum year is estimated to be 15%. However, new-onset cases occur throughout the year; the peak prevalence is at 10 to 14 weeks after delivery.Little is known or understood about the natural course of PPD. In the general population, the average length of a depressive episode is approximately 5 months. In PPD, the natural course and length of time until remission are unknown. Some studies indicate that postpartum episodes resolve more quickly than episodes in the general population; other studies report episodes of similar duration.Risk factors for developing PPD continue to be studied. Currently, the following have been found to increase a woman's risk: younger maternal age, lower education, single marital status, lower socioeconomic status, personal or family history of a mood disorder, depression during pregnancy, psychosocial stress, lack of social support, and marital discord. Women who have a history of a mood disorder have twice the risk of women in the general population (10% to 40%) of experiencing PPD. Women who have bipolar disorder have the highest risk of developing a postpartum episode, whether psychosis, mania, or depression.The exact pathogenesis of PPD is unknown. It generally is believed that maternal blues is related to the hormonal and physiologic changes that occur after delivery. The role of the dramatic biologic and hormonal fluctuations in the postpartum period is under investigation, with current theories centering on the rapid decrease in progesterone, estradiol, and estriol. Other researchers are exploring the role of the hypothalamic-pituitary-thyroid axis and thyroid dysfunction in PPD. Another biologic theory, related to cyclical hormonal changes, is the kindling model. Because many women who have PPD also experience other reproductive-related mood disorders (premenstrual dysphoric disorder, perimenopausal mood disorders), the kindling model hypothesizes that each reproductive-related psychiatric episode sensitizes the woman to the development or exacerbation of another episode. Psychosocial factors, including culture, social support networks, and economic pressures, also can affect life and role transitions such as motherhood and, hence, are hypothesized to contribute to the development of PPD in some women.It is important to recognize the range of severity and symptomatology that mothers who have PPD can experience. PPD often is differentiated into major and minor depression. Most women (70%) experience minor depression. Symptoms of PPD may include the full range of emotional, cognitive, and neurovegetative symptoms of depression (Table 1). Women who have PPD often experience a cognitive dissonance between being glad they have new infants and not being able to enjoy their children. They may experience anxiety and obsessional thinking that is focused on the welfare of the child and concerns about their parenting ability. Despite what can be severe symptomatology, many women and clinicians do not identify these symptoms as depression.Expert opinions differ as to whether PPD symptoms are unique or "atypical" compared with symptoms of depression in the general population. Some studies indicate that women who have PPD report higher levels of somatic complaints and more irritability, anxiety, fatigue, and depression than women who have depression not related to childbearing. Other studies have found no difference in symptomatology between the two groups.Untreated PPD may result in poor outcomes for the health and welfare of both women and children. There is substantial evidence that maternal depression can have a negative impact on the cognitive, social, and behavioral development of children, including infants and toddlers (Table 2). Although there is no agreed-upon "high-risk age" for exposure to maternal depression, there is evidence that even very young infants exposed to depressed mothers can exhibit withdrawn behavioral styles as early as 3 months of age.The effects of maternal depression can be severe and long-lasting. Infants of depressed mothers may be at increased risk of child abuse and are more likely to exhibit insecure attachment patterns. The behaviors that may be exhibited when attachment is impaired are listed in Table 2. Early attachment patterns are important because they remain stable and influence relationships later in a person's life. School-age children who had postnatally depressed mothers have increased rates of behavioral disturbance. In addition, recent studies have identified that maternal depression may affect the mother's implementation of and follow-through with pediatric preventive practices as well as the use of pediatric health care services. Adult offspring of depressed parents have increased rates of major depression as well as other psychiatric disorders. Finally, it is important to remember that not all children of depressed mothers experience these outcomes; many children cope effectively and develop normally.Many factors contribute to the effects of PPD on infant development. The severity and duration of the condition as well as the stress of life events, maternal age, number of children, economic resources, and emotional support can influence maternal behavior and its subsequent impact on infant development. Furthermore, maternal depression can affect parenting behavior, parenting attitudes, maternal-infant interactions (Table 3), family dynamics, and marital harmony/discord in a variety of ways. An important example of the heterogeneous nature of PPD and its effects are the parenting behaviors exhibited by depressed mothers. Depressed mothers may exhibit normal behavior and affect, be withdrawn and disengaged, be angry and intrusive, or manifest a combination of these behaviors. Infant responses depend on the mother's behavior. Infants of withdrawn mothers are more likely to exhibit fussy and crying behavior; infants of angry mothers avoid looking at or interacting with their mothers. The child's temperament, behavior, and concomitant medical complications also can affect the severity of maternal depression and the mother's ability to cope and parent effectively. The child's biologic and genetic predisposition as well as the age may influence the child's responses to maternal depression.Mothers also may suffer negative repercussions from the PPD experience. They are at higher risk of future depression, not just recurrent PPD. Studies of adolescent mothers find that at 4 months postpartum, depressed adolescent mothers are three times more likely to use alcohol or illicit substances than are nondepressed adolescent mothers. Mothers may have difficulty attaining a healthy maternal role and confidence in their parenting skills. Studies have found that women change their reproductive plans and may choose not to become pregnant again to avoid another postpartum episode.Interpersonal psychotherapy, cognitive behavioral therapy, and antidepressants have been successful in treating PPD. Support groups and psychoeducational material also are essential to decrease the isolation of affected women and to increase their understanding of the disorder and their options for help.Because women who have PPD often do not recognize their symptoms as depression, most do not seek professional care. Almost 50% of women who have clinically significant symptoms of PPD remain undetected by clinicians. Except for the 1-month obstetric postpartum visit, healthy childbearing women do not see a health care practitioner regularly, except pediatricians, during the postpartum year. Thus, pediatricians have a unique opportunity to assess women and to provide early intervention, education, and appropriate referral.Although most pediatricians will not treat mothers, screening mothers for psychosocial issues that may affect children and families is within their scope of practice. Some pediatricians informally screen for maternal depression, but a recent study found this method to be inadequate (Heneghan, et al, 2000). Researchers screened mothers of infants and toddlers for depression with a validated screening tool. At the same time, pediatric clinicians completed questionnaires about the mother that included 10 depressive symptom items. A comparison of results showed that pediatric clinicians did not recognize most mothers who had depressive symptoms regardless of symptom severity.The first step to improving detection is to educate pediatricians about the prevalence, risk factors, and symptoms of PPD. With heightened awareness, pediatricians may be more likely to ask psychosocially oriented questions about the mother and family functioning. Table 4 provides a partial list of questions to help pediatricians begin to talk with mothers about this important, often hidden issue. No studies to date have established an improved rate of PPD detection with the use of these specific questions. Another possibility is to use a validated screening tool. The advantages of a screening tool are that it is quick and easy and has been validated to detect depression at a specific score. Thus, pediatricians may feel more confident talking with mothers about their feelings with this information in hand. Studies in Britain and Sweden indicate that it is feasible for pediatricians to screen mothers for PPD during health supervision visits. Logically, the next questions are: "What screening tool do I use and when?"Only three depression screening tools are designed and validated specifically to detect PPD effectively: The Edinburgh Postnatal Depression Scale (EPDS) (Cox et al, 1987), Postpartum Checklist (Beck, 1995), and the Postpartum Depression Screening Scale (PDSS) (Beck and Gable, 2000). Scales developed to screen for depression in the general population may not detect PPD as well because of the overlap of somatic symptoms (sleep disturbance, fatigability, loss of appetite, somatic preoccupation, loss of libido, body image) with the physical changes in the postpartum period. The EPDS, Postpartum Checklist, and PDSS were designed to minimize the effects of this overlap in the assessment of depression.Screening should not be implemented without attention to follow-through. Because PPD remains undetected by many clinicians, all mothers should be screened, not just those whom pediatricians feel may be at high risk. The number of times and the visit at which mothers should be screened during the postpartum year have not yet been established. However, with the current knowledge of peak prevalence occurring around 3 months, the incidence of new cases throughout the postpartum year, and the significant long-term effects of PPD on mothers and children, it is reasonable to screen mothers at least three times during the year. The 2-, 6-, and 12-month health supervision visits (as well as any time the pediatrician is concerned about the mother) are reasonable time points to use a brief screening tool.Repeated screens may be used to: 1) track changes in symptom severity to determine the need for referral and intervention, 2) identify women at risk as well as affected women, 3) identify women who have suicidal ideation, 4) provide mothers a nonverbal venue to express their emotions, and 5) provide an opening for discussion of other sensitive issues.The practical implementation of using a screening tool in a busy clinical practice is critical. Clinicians must be careful to use the information rather than simply gather the data. It is essential to score the measure consistently and to pay attention to answers that imply high risk (eg, suicidal ideation). Unless there is imminent danger to the mother or infant, the pediatrician's role is limited to providing information about PPD and referring the mother to her primary care clinician, a psychiatrist, a therapist, self-help groups, or Web sites of organizations that may provide education and networking sources. Pediatricians also can help the family by monitoring the impact of the depression on the mother-child interaction, the pediatric preventive practices, and the infant's health and development. Pediatricians already routinely assess preventive practices and infant development. The mother-child interaction may be assessed by a combination of asking questions ("How connected do you feel to your baby?" or "Do you enjoy playing with the baby?") and closely observing the interactions (Table 3).With knowledge of the mother's depression, the pediatrician can provide information and support to the mother as she determines her treatment options. One option is antidepressant treatment. Many mothers who have PPD experience guilt and anxiety when deciding whether to take medications while breastfeeding. Many know the benefits of human milk and wish to breastfeed, but are concerned about their infants' exposure to medication. The pediatrician, in collaboration with the mothers' psychiatrists, can support women in their choices and assist them in weighing the risks and benefits of using specific medications while breastfeeding. The risk-benefit analysis must be highly individualized, taking into account the severity of the maternal illness, the maternal support system, the age and health of the infant, and the potential effects of either nursing or not on the mother's self-esteem. Furthermore, the role of sleep deprivation and the potential for an exacerbation of symptoms due to insomnia associated with breastfeeding must be considered. Insomnia is an especially important consideration for women who have bipolar disorder because it may precipitate mania, depression, or even psychosis.Recent articles review the use of psychotropic medications during breastfeeding (Llewellyn and Stowe, 1998; Chaudron and Jefferson, 2000; Ito, 2000; Burt et al, 2001). These articles provide clinicians with comprehensive reviews, including maternal and infant serum levels, human milk levels, and milk-to-plasma ratios of infants exposed to antidepressants and mood stabilizers through human milk. Table 5 summarizes these reports. The review by Ito suggests that tricyclic antidepressants and sertraline are the antidepressants of choice. However, the article does not address the newer antidepressants or other serotonin reuptake inhibitors except fluoxetine. Among the mood stablizers, carbamazepine and valproate generally are recommended because they are estimated to expose infants to less than 10% of the therapeutic dose standardized by weight. In general, lithium is not recommended during nursing. The American Academy of Pediatrics Committee on Drugs Report (2001) classifies lithium as "associated with significant effects on some nursing infants" and recommends its use with caution in nursing mothers because of the potential for toxicity. However, if a mother requires lithium and chooses to nurse, lithium levels should be monitored closely in the mother's plasma and milk and the infant's plasma. The infant also should be monitored for any signs of lithium toxicity.PPD is a treatable and underrecognized illness that affects 10% to 20% of new mothers and may have significant repercussions for the health and well-being of women and their children. Pediatricians may help mothers to identify, cope with, and seek treatment for PPD by routinely screening new mothers for depression, identifying high-risk maternal attitudes and behaviors, providing referrals to mental health specialists, and assisting with the risk-benefit analysis of medication treatment during breastfeeding. By becoming actively involved, pediatricians can help their pediatric patients.

The genetic architecture of reproductive subtypes of depression in females.

BackgroundPostpartum depression (PPD) is a common mental health condition that can compromise the quality of life and functional capacity of mothers and cause health and developmental problems in children born to affected mothers.ObjectivesWe set out to measure the prevalence of PPD comparing postpartum HIV-1 infected women with pre-pregnancy HIV care experience, newly diagnosed (in latest pregnancy) HIV-1 infected women and HIV negative women, and to identify predictors of major PPD among these women in a peri-urban clinic in South Africa.MethodsWe conducted a cross-sectional survey of 1151 adult (≥18 years) postpartum HIV-1 infected (690) and HIV negative (461) women who delivered up to 30 days before study enrolment, interviewed after their first post-natal visit (3–6 days post- delivery) at Midwife Obstetric Units in Gauteng, South Africa. PPD was categorised into no depression (CES-D 10 total score <5), low to medium depression (CES-D 10 total score ≥5 and <10) and major depressive symptoms (CES-D 10 total score≥10). We used ordered logistic regression to identify predictors of postpartum depression and report adjusted odds ratio (aOR) and 95% confidence intervals (CIs).ResultsOverall 288 (25.0%) women screened positive for postpartum depression, a total of 168 (14.6%) women had low to medium PPD and 120 (10.4%) had major PPD. A higher proportion of HIV negative women experienced PPD, 129/461 (28.0%) among HIV negative vs. 159/690 (23.0%) among HIV-1 infected. Among HIV positive women, there was no meaningful difference in PPD between newly HIV diagnosed and those diagnosed before the most recent pregnancy (aOR 1.3, 95% confidence interval (CI): 0.9–1.8). Predictors of PPD among HIV positive women were living with friends/in a house-share (aOR 0.5 for house-share vs. own home, 95% CI: 0.3–0.9), and attending antenatal care (ANC) for the most recent pregnancy (aOR 0.2 for ANC attendance vs. no ANC attendance, 95% CI: 0.0–0.5). Living with friends/in a house-share was also a predictor of PPD among HIV negative women (aOR 0.4 for house-share vs. own home, 95% CI: 0.2–0.8).Conclusions and recommendationsTargeted symptom screening based on identified risk factors should be considered for postpartum women to increase PPD case-finding and referral to specialised social support services.

Disclosure: Y. Li: None. I.S. Farooqi: None. Y. Xu: None. Postpartum depression is a serious psychiatric disorder that is understudied and underdiagnosed. Postpartum depression, the most common complication of childbirth negatively impacts the mother, with suicide accounting for approximately 20% of postpartum deaths. Further, postpartum depression also has adverse effects on infant behavioral, emotional, and cognitive development. However, the neurobiological mechanisms underlying postpartum depression remain to be comprehensively elucidated. Transient receptor potential channel 5 (TRPC5/Trpc5), an ion channel that conducts calcium inward currents, as a critical regulator of many behaviors. Here, we found that microdeletions on chromosome Xq23 disrupting TRPC5 gene in humans and identified seven rare TRPC5 variants in mothers who exhibited postpartum depression and reduced bonding with their infants. Heterozygous females with TRPC5 deletions had postpartum depression and anxiety after delivery. We then generated a knock-in mouse model of a human severe loss-of-function mutation, K34del (Trpc5K34del). Our study showed that Trpc5K34del/+ heterozygous dams abandoned their pups after delivery. The Trpc5K34del/+ dams also showed inefficient retrieval and increased the time to retrieve pups, which is associated with abnormal pup care. Importantly, Trpc5K34del/+ dams exhibited severe depression-like and anxiety-like behaviors during the postpartum period. Oxytocin (OXT), a polypeptide comprised of 9 amino acids, is primarily synthesized by neurons in the paraventricular nucleus of the hypothalamus (PVH) and the supraoptic nucleus (SON). We found that endogenous Trpc5 protein is abundantly expressed by OXT neurons in PVH but not by SON. Further, the Trpc5K34del/+ dams reduced OXT expression in the PVH but does not affect OXT expression in the SON. Deletion of Trpc5 in OXTPVH neurons recapitulated phenotypes in Trpc5K34del/+ dams, including inefficient retrieval, abnormal pup care, depression-like and anxiety-like behaviors during the postpartum period. We then bilaterally injected AAV-DIO-Trpc5 into the PVH of virgin female Trpc5K34del/+/OXT-Cre mice to result in restoration of Trpc5 only in OXTPVH neurons in these mutant mice. Restoration of Trpc5 in OXTPVH neurons in Trpc5K34del/+/OXT-Cre mutant mice significantly improved pup retrieval behavior and indices of maternal care. After weaning, Trpc5K34del/+/OXT-Cre dams with Trpc5 restoration in OXTPVH neurons showed reduced depression-like and anxiety-like behaviors. Our study indicates that the postpartum depression and impaired maternal behavior of Trpc5 deficient female mice are mediated by impaired function of OXTPVH neurons. This revelation not only offers crucial insights into the pathogenesis of postpartum depression but also provides a foundation for potential therapeutic interventions. Presentation: 6/2/2024

Objectives This study aimed to identify the learning needs that public health nurses (PHNs) wish to meet in addressing postpartum depression among mothers in municipalities Japan.Methods A mail survey was conducted with PHNs working in maternal and child health departments in 1,741 cities, wards, towns, and villages throughout Japan by a representative from each facility using a self-administered, unmarked questionnaire. The questionnaire included 23 items pertaining to sex, age, years of experience as a PHN, previous participation fees, method of participation, and desired future study content regarding postpartum depression. The analysis used Spearman's rank correlation coefficient for the association with each attribute, Mann-Whitney U test for comparisons based on training participation, and Kruskal-Wallis test for comparisons by years of experience. The Bonferroni correction was applied for multiple comparisons.Results In total, 1,741 questionnaires were distributed and 630 were returned (response rate: 36.2%). The participants' mean age was 40.0 ± 9.4 years, with 233 (37.0%) in their 40s. The average number of years of experience as a PHN was 12.7±8.9, with 166 (26.3%) having 1-5 years of experience. Approximately 501 nurses (79.5%) had attended workshops on postpartum depression. Regarding the desire to participate in future training sessions for postpartum depression, 476 (75.6%) responded "Yes." The most common method of payment for participation in past training was "free of charge" (427 respondents, 67.8%), followed by "publicly funded" (242 respondents, 38.4%). Regarding the preferred mode of training, 325 (51.6%) preferred on-demand (video viewing-on-demand) training and 284 (45.1%) preferred real-time online training. Regarding the desired content of training on postpartum depression, the items for which > 60% answered "Yes" were the pathogenesis of postpartum depression, correct use of the Edinburgh Postnatal Depression Scale (EPDS), perspectives on assessing mothers' psychiatric symptoms, and how to deal with suicidal thoughts and feelings.A significant difference was observed in the participation status of training sessions on postpartum depression and learning content regarding the "correct use of the EPDS (P = .004)" and "social resources available in the community (P = .002)."Conclusion Approximately 80% of PHNs have participated in training sessions on postpartum depression and would want to receive further training eventually.Regarding future training methods, PHNs desired learning methods using information and communication technology, and > 60% desired learning content with practical application, such as "perspectives for assessing psychiatric symptoms in mothers," "methods for dealing with suicidal thoughts and feelings," "correct use of EPDS," and "pathophysiology of postpartum depression."

Disclosure: Y. Li: None. I.S. Farooqi: None. Y. Xu: None. Postpartum depression is a serious psychiatric disorder that is understudied and underdiagnosed. Postpartum depression, the most common complication of childbirth negatively impacts the mother, with suicide accounting for approximately 20% of postpartum deaths. Further, postpartum depression also has adverse effects on infant behavioral, emotional, and cognitive development. However, the neurobiological mechanisms underlying postpartum depression remain to be comprehensively elucidated. Transient receptor potential channel 5 (TRPC5/Trpc5), an ion channel that conducts calcium inward currents, as a critical regulator of many behaviors. Here, we found that microdeletions on chromosome Xq23 disrupting TRPC5 gene in humans and identified seven rare TRPC5 variants in mothers who exhibited postpartum depression and reduced bonding with their infants. Heterozygous females with TRPC5 deletions had postpartum depression and anxiety after delivery. We then generated a knock-in mouse model of a human severe loss-of-function mutation, K34del (Trpc5K34del). Our study showed that Trpc5K34del/+ heterozygous dams abandoned their pups after delivery. The Trpc5K34del/+ dams also showed inefficient retrieval and increased the time to retrieve pups, which is associated with abnormal pup care. Importantly, Trpc5K34del/+ dams exhibited severe depression-like and anxiety-like behaviors during the postpartum period. Oxytocin (OXT), a polypeptide comprised of 9 amino acids, is primarily synthesized by neurons in the paraventricular nucleus of the hypothalamus (PVH) and the supraoptic nucleus (SON). We found that endogenous Trpc5 protein is abundantly expressed by OXT neurons in PVH but not by SON. Further, the Trpc5K34del/+ dams reduced OXT expression in the PVH but does not affect OXT expression in the SON. Deletion of Trpc5 in OXTPVH neurons recapitulated phenotypes in Trpc5K34del/+ dams, including inefficient retrieval, abnormal pup care, depression-like and anxiety-like behaviors during the postpartum period. We then bilaterally injected AAV-DIO-Trpc5 into the PVH of virgin female Trpc5K34del/+/OXT-Cre mice to result in restoration of Trpc5 only in OXTPVH neurons in these mutant mice. Restoration of Trpc5 in OXTPVH neurons in Trpc5K34del/+/OXT-Cre mutant mice significantly improved pup retrieval behavior and indices of maternal care. After weaning, Trpc5K34del/+/OXT-Cre dams with Trpc5 restoration in OXTPVH neurons showed reduced depression-like and anxiety-like behaviors. Our study indicates that the postpartum depression and impaired maternal behavior of Trpc5 deficient female mice are mediated by impaired function of OXTPVH neurons. This revelation not only offers crucial insights into the pathogenesis of postpartum depression but also provides a foundation for potential therapeutic interventions. Presentation: 6/2/2024

Postpartum depression is a mood disorder that occurs in some women after childbirth. It is one of the most frequent postpartum complications which usually appears 4-6 weeks after delivery and can persist for up to a year. Consequently, this study looked into the predictors of postpartum depression among nursing mothers in Calabar South Cross River State. A cross-sectional study was conducted among 254 mothers in Calabar South Local Government Area of Cross River State, Nigeria, attending seven primary health centers for infant immunization from four weeks to eleven months postpartum. A standardized questionnaire administered by an interviewer was used to gather the data. Data were analyzed using IBM SPSS 23.0 to generate descriptive and inferential statistics at a p &lt; 0.05 level of significance. The mean score for knowledge was 5.93 ± 2.86. More than half (52.0%) of the respondents had a negative attitude toward postpartum depression, (52.4%) of the respondents had a high perception, and (53.1%) of respondents had high self-esteem. More than half (56.1%) of the respondents had low media influence, (53.1%) of the respondents had social support, and (65.4%) of the respondents had low enabling factors. There was a significant relationship (p= 0.000) between each respondent’s independent variables and level of postpartum depression except for enabling factors. Social support was a predictor of postpartum depression among this study population. It is suggested that family members should be made more aware of the need for supporting nursing mothers so as to improve their mental health by reducing postpartum depression. Keywords: Social Support, Postpartum Depression, Knowledge, Attitude, Media.

Disasters have serious long-term impact on mental health for those exposed. The aim of this study was to identify predictors of postpartum depression among survivors of the 1988 devastating earthquake in Armenia. A nested case-control design was applied to investigate postpartum depression in a large-scale cohort of survivors followed between 1990 and 2012. From an original group of 725 adults who were assessed for psychopathology in 1990, 146 women reported having a delivery after the earthquake and were included in this study. Women with postpartum depression were identified using Edinburgh Postnatal Depression Scale. A logistic regression model was fitted to identify the predictors of postpartum depression. Of the 146 women, 19 (13.0%) had postpartum depression. Five independent predictors of postpartum depression were identified: number of woman's stressful life events (odds ratio (OR)=2.06), her prior history of postpartum depression (OR=16.98), delivering sick/dead neonate (OR=13.65), poor living standards during the post-earthquake decade (OR=5.77), and perceiving oneself reliable in 1990 (OR=0.24). Anxiety in 1990 was marginally significantly related to the outcome (OR=3.75). The rate of postpartum depression in this 22-year cohort was similar to that among the Armenian general population. Earthquake exposure was not related to postpartum depression, indicating that the impact of disaster-related trauma diminishes over time. The identified predictors provided evidence to develop interventions targeting groups of women most prone to postpartum depression under such circumstances.

Are labor pain and birth experience associated with persistent pain and postpartum depression? A prospective cohort study.

Postpartum depression is a common mental health issue that is often unrecognized and undertreated. It is a global public health issue while problematic patterns occur due to postpartum depression can persist across generations, negatively impacting quality of life. This review article addresses major traits of postpartum depression, including brief introduction of postpartum depression, risk factors contributing postpartum depression, current statistics, how it influences families and society. An integrative literature review was done using different electronic databases including PubMed, Google scholar, and Research Gate. The global prevalence of postpartum depression is estimated at 17.22%, though it varies significantly across regions. In Asia, postpartum depression rates range widely, from 0.82% in South Korea to 93% in Japan. Postpartum depression symptoms typically involve significant changes in sleep, eating, and activity patterns. Untreated maternal depression can harm child development and mother-infant bonding, with effects that also impact the partner and family. The greatest risk for postpartum depression is having a history of major depression and experiencing depression during past pregnancies. Research indicates that women’s ability to manage postpartum stress is linked to a combination of biological, social, and environmental factors. These factors differ based on cultural and geographic contexts. To prevent negative effects of postpartum depression on children and family, healthcare professionals and nurse practitioners should be knowledgeable about the signs and symptoms, screening methods, and treatment options. This study aimed to summarize the literature on postpartum depression, highlighting the research findings. Keywords: postpartum depression; risk factors; public health; management

This study was done to develop a prediction model for postpartum depression by verifying the mediation effect of antepartum depression. A hypothesized model was developed based on literature reviews and predictors of postpartum depression by Beck. Data were collected from 186 pregnant women who had a gestation period of more than 32 weeks and were patients at a maternity hospital, two obstetrics and gynecology specialized hospitals, or the outpatient clinic of K medical center. Data were analysed with descriptive statistics, correlation and exploratory factor analysis using the SPSS/WIN 18.0 and AMOS 18.0 programs. The final modified model had good fit indices. Parenting stress, antepartum depression and postpartum family support had statistically significant effects on postpartum depression, and defined 74.7% of total explained variance of postpartum depression. Antepartum depression had significant mediation effects on postpartum depression from stress in pregnancy and self-esteem. The results of this study suggest that it is important to develop nursing interventions including strategies to reduce parenting stress and improve postpartum family support in order to prevent postpartum depression. Especially, it is necessary to detect and treat antepartum depression early to prevent postpartum depression as antepartum depression can affect postpartum depression by mediating antepartum factors.