Postpartum Depression: Signs, Symptoms, and Solutions

JENNIFER HAHN -HOLBROOK, PHD

DIRECTOR OF THE LATCH LAB

DEPARTMENT OF PSYCHOLOGY

HEALTH SCIENCES RESEARCH INSTITUTE

UNIVERSITY OF CALIFORNIA, MERCED

OverviewDepression in Parents

Consequences for Children and Families if Unaddressed

Signs that Someone is Depressed

What Causes Depression in Parents?

What Can be Done About It?

Visions of New Parenthood

The Postpartum Transition

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Postpartum Depression

• ().

In the US, approximately 13% of women will

experience depressive symptoms within the first 3 months postpartum (O’Hara &

Swain, 1996)

20% of women will experience depressive

symptoms within the first year postpartum

(Gaynes et al., 2005).

13

Postpartum Depression Around the Globe?

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Hahn-Holbrook, Taylor-Cornwell & Anaya (2018) Frontiers in Psychiatry

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Maternal Mental Health Report Card

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Good! Bad!

USA

Chile

Hahn-Holbrook, Taylor-Cornwell & Anaya (2018) Frontiers in Psychiatry

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Variability in Depression Profiles

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Key Symptoms

• Having trouble enjoying things that you once enjoyed

• Overwhelming sadness

• Guilt, shame & anxiety that are disproportionate to the situation

• Thoughts of death or harming oneself

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Why focus on depression in pregnancy and postpartum?

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Developmental deficits in children (Grace, Evindar, Stewart, 2003)

Disrupt parenting behaviors

(Field, 2010; Paulson, Dauber & Leiferman, 2006)

Raises risk for subsequent depressive episodes

(Cooper & Murray, 1995)

Associated with Marital Discord(Zellowitz & Milet, 1996)

Consequences of Maternal Depression

22

Breastfeeding RecommendationsThe American Academy of Pediatrics recommends exclusive breastfeeding for the first 6 months of life, with continued breastfeeding and complementary foods at least until the child’s first birthday

Breastfeeding Benefits

DepressionLess

Breastfeeding?

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Study Design

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Participants: 205 mothers, >18, English-speaking, non-smoking, singleton

pregnancy, absence of medical condition that deregulates neuroendocrine

function, 70% White,15% Latina, 10% Asian

Measures: CES-D in pregnancy, EPDS postpartum; breastfeeding

frequency, breastfeeding vs. breast-pumping

Analyses: Growth Curve Multilevel Modeling

Covariates: Maternal age, income, work outside the home, martial status,

Latina ethnicity, preterm birth, social support

Birth

5x Pregnancy 3 mos 6 mos 1 yr 2 yrs

Hahn-Holbrook, Haselton, Dunkel Schetter, & Glynn (2013) Archives of Women’s Mental Health

Prenatal Depression Predicted Less Likelihood of Breastfeeding at 3 months

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

3 months 6 months 12 months 24 months

Pro

po

rtio

n o

f W

om

en

Bre

astf

ee

din

g

No Prenatal Depression

Prenatal Depression

P < .05*

27Hahn-Holbrook, Haselton, Dunkel Schetter, & Glynn (2013) Archives of Women’s Mental Health

Prenatal depression predicted less

breastfeeding at 3 months postpartum

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Major Risk Factors

• History of Depression

• Stress (chronic stress or major life events)

• Infant health problems

• Poor social support

• Hormonal profiles in pregnancy

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Previous Research onPostpartum Depression

Yim, Tanner, Guardino, Hahn-Holbrook & Dunkel Schetter(2014) Annual Reviews of Clinical Psychology. 32

11 StudiesIncluded both biological and

psychosocial variables

1 StudyIntegrates biological

and psychological predictors

200 StudiesPublished since 2000

Predictors of Postpartum Depression

Poor Social Support (see Beck, 2001; O’Hara, 2009, for

reviews)

Deregulation of the Stress Hormones in Pregnancy

(see Bloch, Daly, & Rubinow, 2003; Hillerer, Neumann, & Slattery, 2012; Zonana & Gorman, for reviews)

Hormonal Withdrawal?

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Yim et al. (2009) Higher pCRH in Pregnancy predicts Postpartum depression

Yim et al., (2009) Archives of General Psychiatry

Does Social Support Provide

a Buffer?

Study Design• Participants: 210 women were recruited from an urban hospital in

Southern California

• Eligibility criteria: > 17 yrs, English or Spanish speaking, < 20 weeks gestation

• Depression: Beck Depression Inventory

• pCRH: Assayed with RIA

• Statistical Methods: Multilevel Modeling

• Covariates: Age, income, education, ethnicity, medical risk, and parity

19 wks 29 wks 37 wks 8 wks

pCRH, Perceived Partner& Family Support

Measured in pregnancy

Postpartum Depression

Birth

Higher pCRH in Pregnancy Predicted Postpartum Depression

0

20

40

60

80

100

120

19 weeks 29 weeks 37 weeks

Low DepressiveSymptoms

High DepressiveSymptoms

** P < .01

** P < .01900

800

700

300

200

20

Overall Interaction: (F(1, 3) = 3.73, p < .05)

pC

RH

(pg

/ml)

Hahn-Holbrook, Dunkel Schetter, Arora & Hobel (2014). Clinical Psychological Science

Prenatal Family Support was Protective Against Increases in pCRH

0

30

60

90

120

150

180

19 weeks 29 weeks 37 weeks

Low Family Support

High Family Support

*** P < .001

** P < .01900

850

800

300

200

20

Overall Interaction: F(1,3) = 4.20, p < .01

pC

RH

(pg

/ml)

Hahn-Holbrook et al. (2014). Clinical Psychological Science

Mediation Model

Path A:b= -9.84***

Path B:b = -.03*

Hahn-Holbrook et al. (2014) Clinical Psychological Science

Today200,000 years

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• vz

Last 100 years200,000 years

41v

Multigenerational Families because “it takes a village”

Nuclear Families

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Dramatic Changes in Many Aspects of Motherhood Predict Postpartum Depression

Less Family Support

Formula Feeding

Omega 3 poor diets

Vitamin D Deficiency

Sedentary Lifestyles

Hahn-Holbrook & Haselton (2014) Current Directions in Psychological Science.

Breastfeeding in Prehistory

• Formula-feeding was not possible for our ancestors

• Species typical age of weaning is estimated to be around 2.5 years (Stuart-Macadam, 1995)

– Isotopes unique to breast milk in skeletal remains (Clayton, Sealy, &

Pfeiffer, 2006).

– Surveys of traditional societies

– Comparisons of adult/weaning weight in other primates

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BreastfeedingDepression Protection?

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Breastfeeding frequency at 3 months Predicts Depressive Symptoms

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0

5

10

15

20

25

3 months 6 months 1 yr 2 yrs

% w

ith

Dep

ress

ive

Sy

mp

tom

s

Low BreastfeedingFrequency at 3months

High BreastfeedingFrequency at 3months

p p < 0.05NS p <p < 0.05

Hahn-Holbrook, Haselton, Dunkel Schetter, & Glynn (2013) Archives of Women’s Mental Health

Breastfeeding frequency at 3 months Predicts Depressive Symptoms

46

0

5

10

15

20

25

3 months 6 months 1 yr 2 yrs

% w

ith

Dep

ress

ive

Sy

mp

tom

s

Low BreastfeedingFrequency at 3months

High BreastfeedingFrequency at 3months

p p < 0.05NS

p <p < 0.05

Hahn-Holbrook, Haselton, Dunkel Schetter, & Glynn (2013) Archives of Women’s Mental Health

Mode of Breast Milk Expression

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Lower Rates of Depression

1 & 2 years

after Birth

Hahn-Holbrook, Haselton, Dunkel Schetter, & Glynn (2013) Archives of Women’s Mental Health

Bidirectional Relationship

BreastfeedingDepression

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Potential Mediators

• Direct Pathways – Less stress (Mezzacappa, 2004)

– Breastfeeding hormones?– Maternal programming? (Glynn, 2010)

– Maternal bonding– Maternal physical health (see Bernier, Plu-Bureau, Bossard, Ayzac, &

Thalabard, 2000; Rea, 2004, Stuebe & Rich-Edwards, 2009, for reviews)

• Indirect Infant-Mediated Pathways – Breastfeeding improves infant health (see Kramer et al., 2008;

Kramer et al., 2001, for reviews)

– “Easier” infant temperaments? (Jones, McFall, & Diego, 2004)

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Hypothalamus

Suck

ling

Stim

ulu

s

Decreased estradiol & progesterone

Acute hormonal responses to breastfeeding session

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orm

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Time course of circulating levels of oxytocin and prolactin from a breastfeeding bout

Oxytocin

Prolactin

feeding bout

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Experimental Study

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Participants: 40 mixed feeding mothers

Measures: Negative affect, PANAS

Analyses: Repeated measures ANCOVA

Covariates: Infant age

Random Assignment

Mixed Feeding Moms

Bottle-FeedBreastfeed

Experimental test of the acute effects of breastfeeding on maternal mood

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Baseline

• Negative affect

Breastfeeding vs.

Bottle-feeding

• Negative affect

Infant Play Session

• Negative affect

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AH-HA! It’s Biological!

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Nature & Nurture/Genes & Environment

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“plasticity alleles”

• Those genes that are predicted to cause either

increased or decreased sensitivity of an individual to

their environment (Belsky, 2009)

• Do certain allelic differences in DNA predispose

some women to be more sensitive to social factors in

their environment?

Oxytocin: The Love Hormone?

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Oxytocin Receptor Gene

• 7 transmembrane domains

belonging to the family of

G protein coupled receptors

(Carson et al., 2013)

• Encoded by OXTR gene on

chromosome 3p25 in

humans (Saphire-Bernstein

et al., 2011).

• Activates

phosphatidylinositol-

calcium second messenger

system

rs53576

• Silent change in the third intron of the OXTR gene

• AA/AG vs GG

• GG genotypes are more empathetic, feel less lonely,

employ more sensitive parenting techniques compared

to AA/AG genotypes (Saphire-Bernstein et al., 2009)

Methods

• Participants: 224 mothers

• Locations of data collection: Orange County, mainly at farmer’s markets, mommy & me classes, and baby boutiques

• Procedure :

• Saliva samples collected in OraGene 5mL tubes from DNA Genotek

• Sequenced by the Roswell Park Cancer Institute in Buffalo, NY

• Survey testing measures such as Perceived Stress Scale (PSS), Edinburgh Postpartum Depression Scale (EPDS), and social support measures

Are you socially sensitive?

B = -.37, p = .003 B = -.06, p = .79

It’s Not Just Moms

• 1 in 10 Dads will Experience Depression during

Their Partners Pregnancy

• Hormones Change in Dads Too!

• Predictors of Depression in Dads

• Partner who is depressed

• Hormonal changes

• Sleep disturbances

• Stress

It’s Not Just Postpartum

• Major depression is very common

• Times of heightened risk:

• Adolescence

• Transition to parenthood

• Major life changes

• Pregnancy & postpartum

• Menopause

• Parents report more stress than non-parents, especially at the beginning

• Women with more children are more likely to be depressed than women with fewer children

INTERIM SUMMARY

• Postpartum depression is bad for mom, baby and family.

• Loads of factors contribute to postpartum depression risk.

• Biological, social and psychological factors can collide to create a ‘perfect storm’ for some women.

• What can we do about it?

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Screen for Postpartum Depression

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Free & Reliable Tools are Available

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Best Treatments

• Cognitive Behavioral Therapy

• Anti-depressant Medications

• Enhancing Social Connections

• Reducing Stress

• Exercise

• Improving Sleep

• Nutrition

• PREVENTION

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What Can you Do?

• If you work directly with children and parents…

– You are a key member of the Support Network

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What Can you Do?

• Be their confidante.

• Parents need your reassurance.

• They need to feel that you like their children and care about them.

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What to do if you think someone is struggling?

• Ask how they are doing/Check in

• Listen and provide support in response to their fears and anxiety

• Delicately destigmatize depression

• If they say they are struggling, reassure them that they are not alone and help is available if they need it

• Know the resources in your community

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UC Merced Affiliated Families

• Most have good medical coverage for low-cost psychological assessments and treatments

• Most family general practitioners are aware of postpartum depression and can refer mothers to a psychologist or even prescribe anti-depressant medications

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Medi-Cal Families• Figure 4

• Mental health care is an essential service covered by all health plans in the USA

• Primary health Drs. can refer people to mental health care

• People can contact their health plan to find providers in their area

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Empowering Families

• Give families realistic expectations of new parenthood

• Don’t forget about dad, grandma or other key caregivers

• Destigmatize mental illness

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