The likelihood of depressive episodes in  postpartum  can be twice as high as during  other periods of a woman’s life and they often go undetected . 

Mothers suffering from Postpartum Depression often display hostility ,negligence, lower tolerance and   less responsive to their infants needs.

It negatively impacts the mother with suicide, accounting for approximately 20% of postpartum deaths in mothers.

Extended suicide have also been documented in literature (mother killing the child and attempting death by suicide)

Prevalence of Postpartum Depression

A study was conducted in 2018 on prevalence and incidence of PPD among healthy mothers without prior history of depression including Postpartum Depression and who gave birth to healthy full term babies. In this review 58 articles were included, 37294 women participated in it.

The incidence of Postpartum Depression is  12%

The prevalence of Postpartum Depression is 17 % among healthy mothers without prior history of depression.

Impact of Postpartum Depression

Postpartum depression (PPD)  is a complex condition that can have significant impacts on the health and well-being of new mothers, their infants, and their families. Here are some vital points about the impact of PPD.

For the Mother: PPD can lead to severe mood swings, feelings of inadequacy,anxiety and difficulty bonding with the baby. Maternal health became poor associated with suicidal ideas, attempt and death Mother also have weight loss  and poor quality of life.It increases the risk of future episodes of major depression and can affect a woman’s ability to function daily.

For the Infant : This condition can affect a child’s growth and development. It may also impact the infant’s attachment to the mother and contribute to behavioral, emotional and cognitive  challenges later in life. Mother baby bonding became too poor, the health of infants and children is intimately associated with the health of their mothers.

For the Family:  It also paved the way for family conflict and poor quality of life. PPD can cause emotional distress for everyone close to a new baby. It can also increase the risk of mental health of the baby’s other parent and close relatives. Depressed  women are caught in a vicious circle in which they become depressed,irritable, angry and  family discord. It also affects sexual health and life becomes more difficult to move smoothly with an emotional bond. 

Economic Impact: PPD can increase healthcare costs. It contributes to the mother  Poor quality of life and she is unable to do her work within the family and the professional settings.

Longitudinal studies have shown that PPD can have long-term effects on a woman’s    mental, physical, social and economic health, and may influence her willingness to have more children.It is important to recognize PPD and seek professional help as early as possible.

How does ICD 11 diagnose postpartum depression?

 According to ICD-11 PPD may experience at least five of the following  10 symptoms occurring most of the day during two weeks

At least one symptom should be depressed mood or loss of interest  or pleasure in activities are must for diagnosis.

Affective Cluster: Affective disorders encompass a range of conditions where the primary symptom is a disturbance in mood. In the context of PPD, the mood disturbance is significant enough to impact social and occupational functioning and is directly related to the postpartum period.

1.Depressed mood (sad, irritable)

2.Diminished interest

Cognitive behavioral Cluster:Cognitive behavioral clusters in PPD refers to patterns of negative thoughts, feelings and behaviors that can contribute to and maintain the condition.These cluster may include 

3.Reduced Concentration

4.Low of self-worth and inappropriate guilt

5.Hopelessness

6.Recurring thoughts of death

Neurovegetative cluster: Neurovegetative symptoms are a significant aspect of postpartum depression, affecting the physical functioning and quality of life of new mothers. Symptoms  may include 

7.disturbed sleep  

8.Change in appetite

9.Psychomotor agitation

10. Reduced energy.

PPD is a serious condition that affects approximately 13% of new mothers, often within the 12 weeks after delivery. Itis important for healthcare providers to recognize and address these symptoms as part of a comprehensive approach to the treatment and  prevention of postpartum depression 

How does  DSM V diagnose Postpartum  depression?

Having depression during the postpartum or perinatal  is considered as postpartum depression. Depression must occur the first four weeks of delivery of the child.They experience five or more symptoms at least for three weeks and should have one symptom that is either depressed mood or loss of interest or loss of pleasure.

MAJOR depressive disorder occurring within the first four weeks following delivery.

The individual must be experiencing five or more symptoms, during the same two week period and at least one of the symptoms should be either

1.depressed mood

.2. Loss of interest or pleasure 

3. Significant weight loss

4. A slowing down of thoughts and a reduction of physical movement

5.Fatigue or loss of energy

6. Feelings of worthlessness ,  excessive or inappropriate guilt

7.Diminished ability to think or concentrate or indecisiveness

8. Recurrent thoughts of death, recurrent suicidal ideational attempt

Course specifier  is with peripartum in onset

1. Depressed mood most of the day, nearly every day 
2. Markedly diminished interest or pleasure in all

Baby Blues 

The birth of a baby gives a mom powerful emotions, from excitement and joy to fear and anxiety.

But it can also result in  something you might not expect -depression

Most new moms experience postpartum “ baby blues” after childbirth,which commonly include 

mood swings, crying spells, anxiety and difficulty sleeping. Baby blues usually begins with in the 

first two to three days after delivery and may last for up to two weeks.

The baby blues are common experience for new mothers,affecting about 80% postpartum 

Moms.  It is a mild, transient and self limiting condition that begins shortly after childbirth.

Presents with a variety of symptoms  such as altered mood, mood swings, irritability, dysphoria, insomnia, anxiety, decreased appetite and tearful..

It is not pervasive and lasts for less than two weeks.

If it is more than two weeks one need to consider Postpartum Depression

These feelings typically emerge within a few days of giving birth and can last up to one week to two weeks may include .The reality of baby blues are unknown, it is thought that due to the hormonal imbalance during pregnancy and after baby’s birth. Baby Blues symptoms may include

1.Weepiness or crying: Always tearing up or crying without a clear reason.

 2.Irritability: Feeling irritable and impatient is common during this period.

3.Restlessness:You might feel restless and unable to settle down.

4.Anxiety: Worrying about your baby’s health and safety can be overwhelming

5.Fatigue: Despite exhaustion you may experience insomnia and restlessness.

6.Feeling unattached: Some moms report  feeling unattached or in need of their newborn. 

7.Missing your old Life: Longing for the freedom you had before the baby arrived

But some new moms experience a more severe, long lasting form of depression known as 

postpartum depression , it is also called peripartum depression because it can start during 

pregnancy and continue after childbirth. Rarely, an extreme mood disorder called postpartum 

Psychosis also may develop after childbirth. Postpartum psychosis may lead to life-threatening 

thoughts or behaviors and requires immediate treatment.Postpartum depression is not a character flaw or a weakness.  Sometimes it is simply a complication of giving birth.

Treatment is education about Postpartum Depression for both the patient and spouse

Validation of symptoms ,Reassurance and family support.

The treatment of Baby blues is self limiting such as  educating the mother and family members about the postpartum blues. Validation of symptoms  telling them about t it is very common , self limiting, reassuring, validating the symptoms and asking for family support will do major wonder  the treatment of postpartum blues.

Risk factors of Postpartum depression

Various studies which looked into the risk factors of PPD. one of the studies which was published in 2020 by zia hui and his colleagues. It is a metaanalysis of 48 studies and further there was one more study which was published in 2020 It is also looking for the risk factors of PPD and it is scopint for an umbrella review. It reviewed 21 articles. Here included the combination of both of these studies  meta-analyses. These studies reveals the risk factors of PPD are Prenatal depression,childcare stress,lack of social support,prenatal anxiety,maternity blues, history of depression,family income, women’s occupation,pregnancy and birth complications,neuroticism,negative cognitive attributional style,current abuse or violence, infant temperament, self-esteem,unpleasant or unwanted pregnancy,substance abuse,obesity,sleep disturbance,breastfeeding body image dissatisfaction,preeclampsia, child sexual abuse, HPA axis dysregulation,inflamatory process, genetic vulnerability. 

Associated with various studies the major risk factors are 

• Antenatal depression
• Life stress
• Poor social support
• Prenatal anxiety
• Maternity blues
• Family income
• Marital discord
• Current abuse or domestic violence
• Infant temperament
• Unwanted pregnancy
• Substance abuse
• Sleep disturbance 
• Genetic vulnerability
• Past history of depression.

Postpartum Depression causes

Genetic and epigenetic factors: A history of depression in the family may predispose someone to postpartum depression.

Biochemical factors: Death, diseases ,accidents and illnesses in the family during pregnancy and at the time of delivery can accelerate to postpartum depression.

Neurobiological  changes: PPD appears to impact neurobiological pathways linked to socio-emotional regulation, cognitive and executive function, and physiologic stress response systems, also associated with negative stress and negative health trajectories across the life course.

HPA Axis dysfunction: When cortisol level enhanced Hypothalamus and Pituitary axis  function collapsed.  stress and anxiety in thinking and behavior can contribute to  the production of cortisol led to PPD

Neurohormones: A drop in hormone levels after delivery can contribute to postpartum depression

Circuit level changes : Neural plasticity in pregnancy and the postpartum period links to maternal caregiving and mental health. The female brain during this period may attain dynamic structural and functional changes that take place that accompany fundamental behavioral adaptations. This stimulates the female to progress as an individual with self-directed needs to being responsible for the care of another life.

Postpartum depression, also known as postnatal depression, is a mood disorder that occurs after childbirth. It can affect both mothers and fathers.

Postpartum Depression symptoms    

Postpartum depression is a mood disorder that affects some new mothers after giving birth.It can lead to a range of emotional, behavioral, and cognitive changes.  Postpartum Depression symptoms may include 

Depressed mood or severe mood swings

Excessive crying 

Difficulty in bonding with the baby

Withdrawal from family and friends

Loss of appetite or overeating

Sleep disturbances (insomnia or excessive sleep)        

Additionally, the mom who experiences postpartum depression may feel guilty, worthless,

hopeless and helpless.It is essential to seek professional help if you are experiencing these symptoms. Resources are available   to support you during this challenging time. Remember please take help from a professional, they can guide you in a proper way.

           The birth of a baby gives a mom powerful emotions, from excitement and joy to fear and anxiety.

But it can also result in  something you might not expect -depression

Most new moms experience postpartum “ baby blues” after childbirth,which commonly include 

mood swings, crying spells, anxiety and difficulty sleeping. Baby blues usually begins with in the 

first two to three days after delivery and may last for up to two weeks.

But some new moms experience a more severe, long lasting form of depression known as 

postpartum depression , it is also called peripartum depression because it can start during 

pregnancy and continue after childbirth. Rarely, an extreme mood disorder called postpartum 

Psychosis also may develop after childbirth. Postpartum psychosis may lead to life-threatening 

thoughts or behaviors and requires immediate treatment.

Postpartum depression is not a character flaw or a weakness. Sometimes it is simply a 

complication of giving birth.

Postpartum depression, also known as postnatal depression, is a mood disorder that occurs after childbirth. It can affect both mothers and fathers.

Treatment of postpartum depression

 In the treatment  process, the treatment algorithm played a major role. In the Pyramid mode algorithm in the bottom  postpartum blues, Postpartum depression mild, postpartum moderate, postpartum severe. 

For  postpartum blues and postpartum mild cases psychosocial support helps them to come back to normal rhythm.

To cure postpartum depression at a moderate stage, it is needed both psychosocial support and medications. 

To cure postpartum depression, severe  conditions RTMS/ECT  are more beneficial . along with that medications and psychosocial support are needed to prevent the relapse.

Depression is a common and serious medical illness that negatively affects how you feel, the way you think and how you act. The three important domains of depression are Emotion, Cognition and Behavior.

Depression has three important triad, feelings of sadness, easy fatigability, loss of interest in the pleasurable activities you have once enjoyed. At the same time, Depression is a treatable medical condition.  According to the mental health survey by NIMHANS, 2.7 % of the people suffering from depression. Lifetime prevalence 5% means if a hundred people live for 70 years five people have developed depression.2.7% prevalence means, at any given point of time, 2.7 % of the people are suffering from depression. These may be huge for our Indian population. Unfortunately, the treatment gap is 85% in India. That means only 15 people get treatment out of the hundreds of those who suffer from depression.  If 3.6 Crore people are suffering, approximately 3 Crore people are not on treatment. That means three crore families are suffering due to depression.

WHO launched a global campaign in 2017 called “Depression: let’s talk” to raise awareness and encourage people to seek help. The campaign emphasized the importance of talking about depression as a vital component of recovery.

What are the Challenges in Diagnosis of depression?

There are various challenges to diagnosis of depression. Depression can co-occur with other mental and physical diseases, which may complicate diagnosis and treatment. Stigma and discrimination around cultural sensitivity are also barriers to treating depression. A comprehensive assessment of a patient’s history, context and need is essential. There are no laboratory tests or imaging like M.R.I or C.T. scanning for the diagnosis of depression. The only way to diagnose depression is by doing a Clinical Examination, a mental status examination, an observation and a history- taking process. However, a multidisciplinary and culturally sensitive approach is needed to diagnose and treat depression.

What are the Challenges in treatment for Depression

Depression is  widely undiagnosed and untreated  because of

• Lack of insight and awareness of patients and their family members. Lack of knowledge in mental health, cultural and linguistic differences make some hindrance to treatment.
• Lack of access to treatment: Especially in low- and middle-income countries, there is a lack of trained healthcare professionals, resources and infrastructure.
• Stigma and discrimination: which may prevent people from seeking help or receiving adequate support from their family, friends and community.
• Inadequate mental health settings:  Lack of resources and facilities in developing and underdeveloped countries worsen the condition of affected people.

What Researchers Say about Depression ?

Researchers say that depression is a complex and multifaceted mental disorder that affects millions of people worldwide. Depression is prevalent in medical settings not in psychiatry such as Cardiology, Oncology, Nephrology. Gastroenterology, Gynecology, Endocrinology, Neurology, Neurosurgery etc. In this chronic medical illness depression is highly prevalent and this condition increases mortality and also morbidity. However, if our medical settings are capable of diagnosing depression, the treatment rate and survival rate of patients might be increased.

Importance of Primary care units for diagnosing Depression.

Primary care units are important for diagnosing depression because they are often the first point of contact for people with mental health problems. Depression can be easily diagnosed and treated by primary health physicians in the community. There are various studies across the globe that say that by training the primary care physician we can diagnose and initiate the treatment. But the issue is the person accepting the treatment and continuing the treatment. Depression does not affect only the person and family but the whole society. Depression is the leading cause of mental health- related disease burden globally, affecting an estimated 30 crore (300 million) people worldwide.

What are the burdens behind undiagnosed depression?

Undiagnosed depression may have consequences for individuals, family and society.

• Impaired functioning and productivity

Imagine 30 crore people are in depression that means they are not productive and that causes a huge economic loss across the world.

• Reduced Quality of life and well-being.

People with undiagnosed depression may suffer their daily life with low self-esteem, hopelessness, guilt and worthlessness, agony, anxiety, fatigability, and suicidal thoughts.

• Huge health care loss in manpower  and economy. 

People with undiagnosed depression may visit various doctors for emergency, hospitalization and medication. If these doctors are not capable of diagnosing depression, they may give them various vitamins and injections and over- investigate them. This will cause a huge loss in terms of the manpower involved in treating them and giving them wrong treatment. It also causes economic loss.

• Increased Morbidity and mortality:

 Depression also causes increased mortality and morbidity. A person with a chronic medical condition and depression may stop taking medication or refuse to adhere to the treatment. They may also refuse surgery or attempt suicide. This increases the mortality rate among people with depression. Moreover, studies have shown that depression has the highest morbidity rate worldwide. Among the ten leading causes of disability, depression ranks first. 

 According to a worldwide study in 2000, out of a hundred years lived, 9.4% of them will be with disability due to depression. Imagine if a person is diagnosed of depression, they will spend 9% of their life in depression.

 What are the symptoms of Depression? (Diagnostic criteria)

According to the DSM-5, a person has major depressive disorder if they have Five or more of the following symptoms lasting for two weeks pervasively.

• Depressed mood most of the day, nearly every day
• Loss of interest or pleasure in all activities most of the day.
• Easy fatigability or loss of energy nearly every day  
• Engaging in purposeless movements, such as paring the room, restlessness and so forth. 
• Significant weight loss or gain, change in appetite nearly every day.
• Insomnia or hypersomnia nearly every day
•  Feelings of worthlessness and excessive or inappropriate guilt nearly every day
• Diminished ability to think or concentrate or indecisiveness, nearly every day.
• Recurrent thought of death, recurrent suicidal ideation without a specific plan or a suicide attempt or a specific plan for committing suicide

 The ICD-10 specifies different levels of severity for depressive episodes, based on the number of intensity of symptoms. These are termed as mild, have two or three symptoms and mild functional impairment.

Moderate, have four or more symptoms and moderate functional impairment.

Severe, have most or all symptoms, severe functional impairment with or without psychotic features.

How to differentiate depression from normal sadness?

Sadness is a normal human emotion that lasts for a very short time. It is temporary and usually triggered by something. When the situations change the intensity of hurt fades. In normal sadness you can easily return to a happy mood. A person with sadness talks to many people and responds quickly to the external stimuli.

Depression is a condition that means pervasive sadness. The severity of symptoms can last for more than two weeks, months or even years if left untreated. People with depression often suffer alone and have difficulties in their daily functioning. Depression affects their occupation, social functioning, family life, and biological functions.

Depression is a mental health disorder and can affect thinking, emotions, perceptions and behavior in a pervasive way.

What Causes Depression? 

There are many causes for depression

Genetics is the one of the commonest causes of depression. Twin studies clearly said that there is a 30 % to 40 % chance of genetic vulnerability to depression. First- degree relatives have three to four times the risk of developing depression if their siblings or other family members have suffered from it. In the general population, the risk of developing depression is only 5%. If one of the parents has depression, the risk for their children is four times higher. That is 20%, that means genetics plays an important role.

Environmental factors also account for 60 % of the risk of developing depression. This means that the interplay of Genetics and environment is essential for the development of depression.

Various Biological theories have been developed to explain the causes and mechanism of depression.

•  One of the factors involved in depression is the neural circuit that connects the Amygdala, the hippocampus and the prefrontal cortex.

• Another factor is the hypothalamic-pituitary-adrenal (HPA) axis which is part of the neuro-endocrine system. It causes increased cortisol levels, which contribute to depression.
• Hormonal dysfunctions, such as the development of hypothyroidism, can also lead to depression.
• Brain derived neurotrophic factors, which are important for neuronal survival and plasticity, also ended in depression.
• Finally  Gut- Brain Axis, which is influenced by the microbiota, can affect mood and behavior.  

Recent studies and research have revealed that gut-brain axis dysfunction is one of the important factors for the development of depression. The Gut microbiota communicates with the CNS through neural, endocrine and immune pathways. These microorganisms have direct effect on the neural system through serotonin, GABA, cytokines, tryptophan, butyrate, propionate and acetate.

 Psychosocial factors of depression are prolonged stress, childhood adversity (abuse, maltreatment, bullying), disaster, war, trauma, substance or drug abuse, parental discord, relationship issues, chronic medical illness, certain jobs in the medical field and security forces, poverty etc.

Depression is an exceedingly a complex disorder, with similar cumulative etiologies, including genetic, epigenetic and environmental factors which together lead to the development of the disorder..

What are the health issues (comorbidity) along with Depression?

Comorbidity means having two or more health issues at the same time. Depression is often associated with other mental and physical disorders, which can make it more difficult to treat and manage.

Anxiety disorder also coexisted with depression; it is around 35-40%

Personality disorder also found along with depression; it is around 25-30%

Suicidal attempt or death by suicide is present in depressed person, it is around 10-20%

Chronic medical illnesses are also coexisted with them, it is 60-70%

Obsessive Compulsive Disorder (OCD) which involves unwanted and intrusive thoughts and behaviors. OCD affects about 10%of people with depression. Whenever a person is having depression, it is essential to check various co -morbidity including medical conditions.

Substance use such as alcohol or drug abuse affect about one-third of the people with depression..

Some of the most common physical disorders that co-occur with depression are:

Cardiovascular diseases such as hypertension, coronary artery disease or stroke.

Metabolic disorders such as diabetes, obesity etc. 

Chronic pain such as back pain, arthritis or fibromyalgia

Neurological diseases such as multiple sclerosis, migraine and epilepsy.

What happens if depression is untreated?

 If untreated, the depressed person starts substance abuse or drug use to overcome the difficulties of depression. It badly affects both his physical and mental health.

Disruption in family life, due to depression is very common.  The person cannot go to work, and it affects the family’s smooth running and functioning. Economic, personal and marital issues are developed within the family. It has worsened the condition of the depressed person and the family members. They   do not take responsibility because he always feels tired. Every person in the family is shouting at him and consider him as lazy. They abuse and bully him with words; thus, depression gets worse.

There is also a financial loss, job loss, disability or sometimes he is met with suicide. So, it is essential to be diagnosed and treated for depression as early as possible. 

A person has any chronic medical illnesses along with depression, their treatment is very difficult, morbidity and mortality are high for the patient.

What are the treatment options for depression? 

 Various modalities are available for treatment

• Psychotherapy is suitable in the mild stage of depression. If it is a moderate stage, medication is also essential along with the psychotherapy.
• Psychoeducation is first choice of treatment, educate the family and the patient.
•  Antidepressant Medication: These are drugs manage the levels of certain chemicals in brain such as Serotonin, dopamine and norepinephrine.
• Electro Convulsive Therapy: in severe depression along with suicidal ideation or attempt, it is preferable better for treatment.
• Transcranial magnetic stimulation
•  Vagus nerve stimulation
•  Deep brain stimulation etc.
• Theta-Burst stimulation (TBS)
• Magnetic seizure Therapy (MST)
• Ketamine