Beyond Baby Blues: Unpacking Postpartum Depression
Jack Matter
Illustrations by Laurel Obermueller
Note: This article sometimes uses female-gendered language to refer to pregnant and postpartum people. This choice was made because cited literature on the subject frequently focuses on only female-identifying patients. The journal wishes to recognize that pregnancy is independent of gender identity.
“The storm hit right away. I was plagued with irrational thoughts and crippling guilt. I was afraid to show my new baby any affection in front of my toddler for fear that she would think I didn’t love her anymore. I was so depressed that I could not take care of the children” [1]. This is just one of thousands of stories of the turmoil that can take over a mother’s life in the weeks directly after giving birth. This period, known as the postpartum period, lasts anywhere from four weeks to six months and is rife with hormonal fluctuations and waves of strong emotions that last until the body has returned to its pre-pregnancy state [2, 3, 4, 5]. For new mothers, the experience of giving birth can bring profound feelings of joy and attachment. But what happens when this is not the case? Sometimes, the emotional fluctuations associated with the postpartum period can manifest as sadness in a phenomenon typically called the ‘baby blues’ [6, 7, 8]. When this melancholy extends beyond minor mood changes, mothers may be suffering from a specific type of depression known as postpartum depression (PPD) [9].
What is Postpartum Depression?
What makes postpartum depression different from other depressive disorders, such as major depressive disorder (MDD), is the specific term ‘postpartum’ [10]. MDD is a very common psychiatric disorder characterized by a persistent depressed mood [11,12]. While MDD can appear at any point in a person’s life, PPD applies to a major depressive disorder that emerges after a mother gives birth. Psychiatric screening tools like diagnostic manuals are able to detect and diagnose major depressive episodes in the postpartum period as well as differentiate depressive disorders like PPD and MDD from other disorders [10]. Although they are two distinct disorders, PPD and MDD episodes both commonly manifest as persistent feelings of sadness, anxiety, fatigue, and even thoughts of self-harm and suicide [13, 14]. PPD can also involve thoughts of infanticide, or harming one’s own child [15].
Depressive symptoms make caring for a newborn, an already difficult undertaking, significantly more difficult for new mothers. Suicidal ideation and thoughts of infanticide can be overwhelming and can severely impact the well-being of both the parent and the child [16]. Moreover, PPD negatively affects not only a mother and child’s life expectancy but also the growth and psychological development of the child during the postpartum period [17]. Infants with depressed mothers, for example, have a higher chance of being underweight during the first year of their lives, as a depressed parent may struggle to care for themselves and their child [18]. Evidently, PPD can have devastating effects on the entire family, not necessarily just on the parent experiencing the disorder [18].
For a disorder that can have such devastating effects on afflicted individuals and their families, PPD affects a surprisingly significant percentage of new mothers around the world. PPD occurs in around one out of every eight women globally, with some local variations in prevalence due to social stigma, lack of awareness, and medical racism [19, 20]. It is imperative to be mindful of overlapping determinants of health when discussing the risk factors of PPD since several biological and social factors are believed to be responsible for the development of the disorder. In particular, complications during pregnancy, birth, or the postpartum period — including hormonal changes, difficulties with breastfeeding, and whether an infant was born preterm — can increase the likelihood of developing PPD [21]. Additionally, there are correlations between a mother’s degree of bodily autonomy during the birthing experience and the occurrence of PPD [22]. Traumatic birth experiences — such as emergency C-sections or being put under general anesthesia during or after giving birth — can contribute to the development of postpartum disorders [23]. One mother experiencing PPD describes her feelings after she was put under anesthesia by doctors due to birthing complications: “I can barely remember what exactly happened the first twenty-four hours of my child’s life. Now I constantly fear that me and her missed our connection, or she felt connected to someone more than me who held her when she was first born” [1]. With that being said, the list of possible causes of PPD remains incomplete and some people have developed the disorder without any known or apparent risk factors.
Moreover, PPD is both clinically and experimentally understudied and underdiagnosed [24]. Historically, the research surrounding PPD has failed to accurately represent a broad spectrum of people who experience the disorder or convey how racial factors can affect the individual experiences of mothers with PPD. More recently, scientific literature has begun to address the effects of structural racism on pregnant people [25]. Stereotypes and prejudices surrounding race, ethnicity, and culture can form insurmountable barriers to the timely diagnosis and treatment of mothers of color experiencing PPD [26]. In addition to general stigmas that exist within these communities, there are several intersecting factors that affect PPD treatment and diagnosis. These factors can heighten feelings of isolation and a reluctance to seek help for the disorder [25]. Mothers of color are less likely to receive a diagnosis of PPD and are more likely to experience treatment delays than white mothers [27, 28]. Societal prejudices and stereotypes contribute to the risk of developing psychiatric disorders due to the compounded effects of life stressors and decreased quality of care [26, 27, 28].
The Neurological Nature of Postpartum Depression
PPD cannot be researched in standard ways because of the complex ethics of studying pregnant and postpartum people; thus, many aspects of PPD remain a mystery [29]. What we do know about the disorder comes from the use of low-risk functional magnetic resonance imaging (fMRI). When a person receives an fMRI scan, magnets and radio waves are used to generate an intricate map of their brain activity by measuring blood flow and electrical transmission [30, 31]. These fMRI-generated images indicate that there are both chemical and structural differences in the brains of mothers with PPD when compared to mothers without PPD [32].
One chemical factor implicated in the development of PPD is the chemical messenger glutamate, one of the brain’s primary excitatory chemical messengers. Glutamate has long been known to play an important role in learning, mood regulation, and memory [33, 34]. It is helpful to imagine glutamate as a traffic light for the brain; just as a green light allows cars to move through an intersection, glutamate acts as a ‘go’ signal that prompts cells in the brain to communicate with one another [33]. Moreover, abnormalities in the neurological systems that glutamate is involved in have been linked to depressive disorders [35]. That being said, the specific mechanisms behind these abnormalities are not entirely understood, and their role in PPD warrants further research [36]. One major hypothesis is that the dysregulation of glutamate signaling in PPD relates to changes in the levels of female reproductive hormones [37, 38]. Glutamate levels in the brain increase during pregnancy to support the growth of the fetus, especially during the second and third trimesters [39, 40].
After childbirth, there is a massive, sudden drop in reproductive hormones accompanied by an imbalance of glutamate and other chemical messengers in specific brain regions [41]. For example, in the medial prefrontal cortex (MPFC), a brain region that regulates emotions and memory, levels of glutamate are found to be significantly higher for individuals with PPD [42, 43, 44, 45]. In contrast, decreased levels of glutamate have been found in the dorsolateral prefrontal cortex (DLPFC), which is thought to be involved in learning, planning, and auditory processing [46, 47]. In the MPFC and DLPFC, abnormal levels of glutamate can cause disruptions to the flow of traffic in the brain, since both too much and too little glutamate can negatively affect learning, memory and mood regulation [33, 48]. These discoveries show us that there is a theoretically optimal level of glutamate transmission in the MPFC and DLPFC [32, 33]. However, this ideal level is unknown because people rarely get MRI scans when they are not presenting with a disorder, as they can be costly and time-consuming [49]. This — combined with a lack of data on individual differences and glutamate concentrations throughout the brain — has made it hard to determine a healthy baseline level of glutamate signaling.
The brain is thrown into even further disarray by the disruption of signaling highways that lead to other parts of the brain. In particular, the cingulate cortex, amygdala, and MPFC — several connected brain regions — share these highways, often ‘speaking’ to each other to modulate our moods and actions [24, 50, 51]. The cingulate cortex and the amygdala are heavily involved in behavioral responses, emotions, and memory [52, 53]. The amygdala is also linked to mood and depressive disorders [54]. Disruptions in communication between the cingulate cortex, amygdala, and MPFC regions can potentially impact the emotional state of people with PPD, diminishing mothers’ ability to recognize and respond to their child’s emotional cues [51, 55]. Appropriate emotional response from mothers to cues from their children are vital in developing the attachment between mother and child [56]. For example, a major sensory cue that has been linked to maternal depression is sound. Brain scans of mothers with and without depression revealed that non-depressed mothers had increased neural responses to their infant’s cries when compared to depressed mothers [57]. This could mean that the brains of non-depressed mothers are more responsive to their infant’s cries than those of depressed mothers, suggesting that depression in mothers affects their ability to respond appropriately to their child’s needs. The very same networks that are involved in PPD’s symptoms are also involved in a parent’s response to cues from their child, emphasizing how neurological causes aside from glutamate imbalances may play a role in the development of PPD [57].
Treating Postpartum Depression Holistically
Early diagnosis and intervention are crucial for the successful management of PPD [13]. After diagnosis, interventions include both the use of pharmaceuticals and non-pharmaceutical treatments [13]. So far, all of the drug-based therapies that are used to treat PPD have been adapted from depressive disorder treatments, so no specific drugs have been approved for PPD [58]. This means that the application of these therapies to PPD comes with its own set of complications. Selective serotonin reuptake inhibitors (SSRIs) are a class of antidepressant medications that have been in use for almost 40 years [59, 60]. They are an effective treatment for major depressive disorders and a strong first line of defense against PPD [59, 60]. Still, these traditionally prescribed antidepressants present certain risks [61, 62, 63]. The use of SSRIs during pregnancy has sometimes been linked to physiological problems in newborns, such as low birth weight and increased risk of respiratory distress [61, 62, 63]. However, some trials resulted in few complications and have found SSRIs to be effective in mitigating symptoms of PPD. The lack of systematic clinical trials studying the efficacy of SSRIs in fighting PPD highlights the conflicting nature of our current knowledge regarding antidepressant use during and after pregnancy [64]. Therefore, antidepressants like SSRIs must be further explored before their efficacy in PPD treatment can be confirmed [65]. The question of whether to start or continue taking antidepressants during pregnancy is a challenging one that forces many pregnant people and their doctors to weigh the potentially enormous costs of the drugs against their benefits [66].
Often used in conjunction with medications, nonpharmacological treatments for PPD include psychotherapy, parenting classes, dietary supplements, and physical exercise [13]. One particular type of psychotherapy called cognitive behavioral therapy (CBT) is frequently used to treat PPD [67]. CBT is a form of talk therapy that endeavors to change negative thinking patterns in patients [68]. Another noteworthy postpartum care strategy that can be used in conjunction with CBT is skin-to-skin contact between mother and child [69]. While it may seem like a simple concept, skin-to-skin contact outside of breastfeeding is rarely encouraged despite its numerous physiological and emotional benefits for both mother and child [70]. The main kind of skin-to-skin contact involves a parent holding their baby against their bare chest in an upright position, similar to how a kangaroo holds its baby in its pouch; as a result, this is called kangaroo care [71]. Kangaroo care is easy to do and has numerous benefits for both mother and child, such as pain relief, sleep quality improvements, and even improved heart rate and breathing rate [72]. Thus, it has been found to be effective in preventing and regulating symptoms of PPD and is particularly useful in combination with other modes of treatment like CBT [13, 73].
Postpartum Depression’s Struggle for Recognition
Postpartum neurological conditions have a complicated history in the psychiatric field [74, 75]. For more than 150 years, the usefulness of a distinction between postpartum depression from other depressive disorders has been highly contested [74, 75, 76]. 'Postpartum' as a modifier for depression diagnoses is only a recent addition to psychiatric diagnostic tools [10]. Additionally, current American diagnostic guidelines only recognize pregnancy-related depression up to four weeks after birth [77]. However, we know from previous research that the postpartum period lasts anywhere from four weeks to six months, which is inconsistent with diagnostic criteria [2]. In addition to this lengthy debate, various forms of mass media may have inaccurately represented the realities or science of PPD [78, 79]. The media is a major source of health information for most people and can shape people’s beliefs about health, sickness, and body image [80, 81, 82]. Even in people without PPD, the period after birth is associated with decreased self-esteem, which may put pregnant people in a vulnerable state where they are more likely to be impacted by media portrayals of pregnancy and PPD [83]. This impact is even further complicated when mass media and psychiatrists do not agree on something as basic as the definition of PPD [76]. Some popular online media outlets, like news sites, conflate PPD with other postpartum disorders, painting a confusing picture for readers and revealing the continued lack of a consensus on the details of PPD [79]. Very few prominent mass media sites have presented the disorder in a scientifically accurate and non-sensationalized way [78].
Apart from diagnostic complications and inaccurate media representation, there are other barriers to the diagnosis and treatment of PPD. The popular mythology of the ‘supermom’ puts forth the idea that mothers are independent, all-encompassing providers, which can contribute to social isolation when PPD prevents them from properly caring for or bonding with their baby [84, 85]. This message has been reinforced by PPD treatment guidelines and self-help books alike, which both frequently insist that motherhood should bring happiness and that intervention is necessary if it does not [86]. Mothers have expressed feelings of failure and exasperation when their reality does not align with the expectations that society has placed upon them [1, 87]. Mothers may even develop an aversion to seeking treatment, a phenomenon called self-stigma [88, 89]. As a result, mothers may be more reluctant to accept help and delay seeking treatment for months or even years [90, 91].
The misrepresentation of PPD is a result of the disconnect that exists between the severity of the disorder and the way in which it is medically treated. PPD is complex and multifaceted in its symptoms, risk factors, and treatment plans [13]. While the exact causes of PPD are not fully understood, some biological mechanisms potentially contribute to the disorder [29]. One crucial area of study that has emerged from PPD research is the role of glutamate imbalance and structural connectivity differences in regulating a person’s emotions and memory [35, 43]. This abnormality in glutamate signaling can disrupt the flow of communication between brain regions, impacting emotional states, memory, and mood regulation, as well as affecting the attachment between mothers and their children [24]. Discoveries like this have advanced our understanding of the brain and its unique inner workings within the postpartum period. As a result, we have a better grasp of PPD and what makes it scientifically distinct from other depressive disorders [92]. Social factors play a critical role in risk factors for PPD, since those with socioeconomic disadvantages and marginalized identities are more likely to face disparities in diagnosis and treatment. When it comes to improving the well-being of those affected by PPD, there are two main areas to focus on. One is promoting general awareness of postpartum depression and improving the accessibility of treatment options like skin-to-skin contact. The other is breaking down barriers that prevent members of marginalized groups from receiving the same level of care as other people with PPD. This way, every family affected by the disorder has the support they need to thrive.
If you or someone you know is experiencing symptoms similar to those described in this article, know that you are not alone. Help is available at the following resources:
Mental health crisis line (US):
988
HRSA maternal mental health line (US):
1-833-943-5746 (1-833-9-HELP4MOMS)
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