Beyond the Blues

The joy of motherhood can be an exciting and blissful experience. But what if, instead of happiness and joy, the new mom is experiencing weepiness and irritation, and is crying all the time, but does not understand why? What if, instead of excitement at seeing her baby, she has negative feelings and worries that she may hurt her baby? And what if, instead of bliss, she entertains thoughts of suicide? Add to that the shame, confusion, and fear of believing that she alone is having this experience? This is a reality for roughly 13% of women who give birth.^[1] Postpartum mood disorders fall into three main categories: postpartum blues (“baby blues”), postpartum depression (PPD), and postpartum psychosis.

Postpartum Blues

While “baby blues” are often very common after pregnancy, including symptoms like crying, low mood, sleep disturbances, changes to appetite, and anxiety, the nature of this concern is usually temporary and transient. The ability of the mother to care for her child and function effectively is not limited or affected adversely. It is estimated that 30–75% and even up to 85% of women experience the blues at some point, but they are short-lived.^[2]

Postpartum Depression

While the anxiety, weepiness, and sleepiness of the baby blues often pass, postpartum depression symptoms should not be ignored. The main difference between these two presentations is the severity of symptoms experienced by the new mom. When there appears to be a frank concern that the mother is experiencing an inability to care for her newborn because of negligence, suicidal thoughts, or behavioural changes that indicate harm to the baby or herself, and they are longer-lasting, then the mother is experiencing postpartum depression (PPD).^[2] Other common symptoms include feelings of worthlessness, guilt, lassitude, loss of pleasure, prolonged sleep, and changes in appetite and weight. These symptoms increase in intensity and become more long-standing and consistent; however, screening should be done to confirm clinical suspicions. This type of depression can often present within the first three months of giving birth, but any such symptoms that develop within the first year are also considered as part of this presentation.

Postpartum Psychosis

On the other end of the spectrum, postpartum psychosis presents very severely and rapidly. Within two weeks psychoses, delusions, and hallucinations become apparent, and mood can fluctuate quite wildly and quickly.^[2] The mother is confused, disoriented, and extremely anxious. These symptoms make it challenging for the new mother to understand the experience, and can be very difficult overall. The consequences to the health and wellbeing of both mom and child can be drastic, especially if left unattended. Development and behavioural changes may surface later on for the child.

Screening

To assess whether a woman in fact is experiencing PPD, an Edinburgh Postnatal Depression Scale (EPDS) screening is often administered. It should be noted that even before this screen is performed, it is common that members of the woman’s family will already have noticed changes in her mood and behaviour. This self-report provides an even better indication of pathology than conventional scales that assess for depression (e.g. Beck depression inventory). The screen contains 10 items that the woman needs to answer in a quiet environment to assess her risk. However, the drawback of this assessment is its inability to determine severity. Therefore, clinical assessment and judgement are very important as well. A score of more than 10 at specific time intervals can indicate the presence of PPD.

Why Does This Happen?

It is not fully understood why postpartum depression develops. However, some common risk factors include hormonal changes, inflammatory processes within the body, poor social support systems, stressful life events, a personal or familial predisposition, or a personal or family history of depression or anxiety, with the strongest indicators being previous history of depression during pregnancy, poor relationship with spouse or partner, low social support, and stressful life events or experiences.

Hormonal Influences

During pregnancy, progesterone levels remain high to support the growing fetus. Estrogen levels are fairly constant. During labour, the body produces oxytocin to stimulate labour, and prolactin levels increase for the newborn to be able to breastfeed. Oxytocin also assists in bonding for the mother and newborn.^[3] Testosterone levels tend not to influence pregnancy and labour too much; however, it was found in one study that high testosterone levels were measured in women who also were experiencing PPD.^[4] The levels tended to remain high even at one day postpartum for these women, indicating an influence by this hormone in the PPD.

Thyroid function is also very important in pregnancy. Low thyroid levels can increase the risk of depression and mood disturbances.^[5] High TSH levels (low thyroid hormone levels) were found in women who experienced PPD, indicating that it is important to address any concerns with the thyroid especially during pregnancy.^[5]

Inflammatory Changes

There exists very little data about the role of high inflammation levels on the risk of postpartum depression. However, one way to assess inflammation is by looking at homocysteine levels in the body. Vitamin cofactors like B1, B6, B9, and B12 are very important for the healthy maintenance of pregnancy as well as the development of the nervous system and organs of the fetus. When homocysteine levels rise, levels of these vitamin cofactors decrease, and this can affect the mood. In one study, it was found that within the first six weeks postpartum, homocysteine levels in the blood were high, indicating higher levels of inflammation in the body. Also, serotonin levels tended to be lower within the first week postpartum, and were associated with lower moods overall for the mothers studied,^[6] which may help to explain the difficulty experienced by the new mothers who have PPD.

New areas of research are looking into the effect of stressful early-life events of the mother and her tendency towards PPD later on in her life. Stressful events can stimulate a cascade of inflammatory molecules that essentially make the mother more prone to developing depression during or after pregnancy later in her life.^[7] It will potentially shed light on what pathways are commonly affected by women who tend to experience PPD.

Support Systems

Support is a necessary component for any woman going through pregnancy. While close family and friend support is important, intimate relationships and the support they offer far outweigh the effect on the new mom. The effect of a supportive partner helps the new mother to feel balanced and positively affects her mood and hormones.^[2] However, when there is disharmony in intimate relationships and even violence and abuse, the risk of postpartum depression can increase significantly.

Personal or Family History

Previous history of depression can increase the risk of postpartum depression as well. When a woman has experienced depression (postpartum or general) before, she has a higher likelihood of experiencing it with subsequent pregnancies.^[2] Moreover, when a family member—often the mother or father—has a history of depression or anxiety, this may also increase the new mother’s risk of PPD.

Management

Naturopathic approaches to any concern are holistic and individual. They encompass multiple aspects of health including the physical, mental, and emotional states. The following are very general considerations that have shown benefit for some women experiencing PPD.

Nutritional Supplementation

Omega-3s—Pregnant women are encouraged to eat one or two servings of oily fish (e.g. salmon and sardines), which contain the essential fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Other sources of omega-3s include flax seed and chia seeds. Eating fish does not necessarily prevent the onset of PPD, as there are numerous factors at play, but higher levels tend to support a healthy nervous system and body overall.^[8] They can also help with inflammatory changes that affect mood regulation.

SAMe—S-Adenosylmethionine is made naturally in the body when there is enough folic acid and B12 in the body. B12 is often found in animal protein, and folic acid supports healthy central energy’s system development. SAMe protects against oxidation, inflammation, and depression, which are all important in supporting a woman experiencing PPD.^[8]

Folic Acid—Folate helps convert homocysteine to methionine. Women with PPD often exhibit low levels of folate, which further increases risk.^[8] It is very important in supporting healthy development of the brain, spinal cord, and nerves of the newborn.

Botanicals

St. John’s Wort—Its active constituent, hyperforin, shows good benefit for depressive symptoms in general, but also for women experiencing PPD.^[8]

Moreover, studies done with an infusion of lavender resulted in immediate improved sleep, decreased depressive effects, as well as less fatigue.^[9]

Chamomile tea was also seen to have benefit on sleep quality for the new mothers.^[10]

Lifestyle

Exercise—Gentle exercise, such as yoga, has shown better benefit for women with PPD than unsupervised social support sessions. Women who did yoga for 20 minutes weekly experienced lower levels of depression and anxiety.^[11] Cortisol levels also decreased overall. In addition, expressive writing done by the new mother decreased the symptoms of depression and distress postpartum.^[12]

In traditional Chinese medicine, PPD can be considered as an imbalance of yin and yang, and therefore corresponding treatment (food, acupuncture, and TCM herbs) are used to address the concern accordingly and individually. Overall, self-care for the new mother and support from those in the home generally provide a balancing effect for the mother to reduce the intensity and severity of her concern.

Discussion

There are multiple contributors as to why any woman can experience postpartum depression. Through naturopathic medicine, the aim is to address the individual in a holistic manner and understand the reasons for the presentation. It is important to consult with your naturopathic doctor and health-care team to address concerns accordingly. For women experiencing PPD, general considerations include gaining healthy support systems, acknowledging the discomfort and challenge she is experiencing, and encouraging different aspects of self-care like gentle exercise, good sleep hygiene, and wholesome nutrition, in addition to individual concerns she may have.