New Findings Say Postpartum Depression Can Start During Pregnancy

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Feb 29, 2016

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In January, a US panel redefined what we know as postpartum depression. The New York Times reported the doctors’ findings that “many cases of what has been called postpartum depression actually start during pregnancy.”

Dr. Ashlesha Bagadia, a Bangalore psychiatrist who specializes in perinatal care explains.

“Previously it was believed that pregnancy was a protective period for women and the post-natal period was the most vulnerable time,” she says. “It appears that for many women, depression/anxiety begins during pregnancy itself and they are no longer protected by the ‘happy hormones.'”

Perhaps surprisingly, pre-existing mental health conditions aren’t factors in early onset.

“For women with the pre-existing severe mental illnesses like bipolar disorder and schizophrenia, the post-natal period still remains the most vulnerable time,” Dr. Bagadia says.

So what does this new knowledge change for Indian women? Unfortunately, not much. India still has no regulated screening process and, in most places, diagnosis and treatment are done in an ad hoc manner relative to the patient’s awareness and understanding and the obstetrician’s awareness, understanding and willingness to refer to mental health services. The onus is on the individual woman, her spouse or family to notice a changed mental state and seek help.

However, the panel’s findings do change when women should pay particular attention to their mental state and when it’s best to seek a screening, says Dr. Bagadia. During pregnancy, the first and third trimesters are the best times to screen for PPD; after pregnancy, at the four- to six-week mark.

But, Dr. Bagadia notes, while some cases of PPD start during pregnancy, some do start after delivery. So while it’s important to screen during pregnancy, if a woman is cleared of PPD in the first or third trimester, that doesn’t mean she won’t develop it later on.

And while screenings are important, they are also imperfect. Where postpartum depression screenings do occur in India, most doctors use a self-reported questionnaire known as the EPDS, which widely used in the US and other Western countries to diagnose the condition.

“The trouble with using EPDS in the Indian context is that it presumes a basic knowledge of words like anxiety and depression, which is very scant in a majority of Indian women, more so in the lower socioeconomic [strata of] women,” Dr. Bagadia says.

Its style of symptom-based questioning is also difficult for Indian women to follow, she says, because Indian women are more likely to minimise their symptoms and focus on identifying stressors. For example, it’s the difference between withdrawing from friends and family – a symptom of PPD – and lacking support or help in caring for the baby.

“My assessment usually starts off by understanding the woman’s background, current stressors, if any, and then I move on to symptoms,” says Dr. Bagadia, who is part of a task force working with the NIMHANS perinatal psychiatry department and obstetric department at Rangadore Hospital in Bangalore to develop a more Indian-appropriate PPD screening strategy.

“We’re in the process of piloting a more basic screening tool which picks up external stressors to identify women who may be at risk of developing depression or have underlying depression, and then get a mental health professional to rule out that possibility,” she explains.

Some of these stressors, or risk factors, include: marital conflict, domestic violence, lack of support for care of the baby, previous history of depression or a ‘breakdown,’ family history of depression, a unplanned or unwanted pregnancy, a complicated pregnancy with multiple medical issues, health problems in the baby, previous history of pregnancy loss, or in India, sadly, the birth of a baby girl. Dr. Anjali Chhabria, a Mumbai psychiatrist, also notes that extreme life changes after delivery — like a move, change of job, or death of a loved one – assisted conception, like IVF, a family history of PPD, and multiple births can also be stressors/risk factors.

Dr. Bagadia and the task force have no timeline for introducing the new screening tool broadly, but that’s because their focus is on quality, not quickness, she says.

“We are hoping to roll out the screening questionnaire in all hospitals over time, but first we have to make sure we, the obstetricians, ask the right questions and do not scare off patients,” she says.

Even with an India-specific screening in place, there are still obstacles to getting women with PPD the care they need. Diagnosis and treatment involve consulting a psychiatrist, something many women, families and even referring doctors are loath to do.

“From my experience, stigma and isolation of the mother in the aftermath of pregnancy is a particularly severe problem within the middle income group of society compared to the lower income groups,” says Dr. Ajay Vijayakrishnan, a consultant psychiatrist in Kozhikode.

But the alternative – leaving postpartum depression ignored and untreated – means the condition can last as long as three years, says Dr. Chhabria.

“The duration of this disorder can last long if it goes untreated and can get worse with time,” she says.

However, prompt diagnosis and treatment – usually antidepressant medication and/or counselling – can turn things around much more quickly for the woman, her child, and her family.

“Child rearing with happiness brings about positive results not only in the lives of the new mothers but also the newborn children who are yet to experience the world,” says Dr. Chhabria.


Postpartum depression differs from the ‘baby blues’ in that its symptoms don’t just come and go, but gradually worsen and are experienced over longer periods of time.

SYMPTOMS OF POSTPARTUM DEPRESSION

Moderate symptoms (during or after pregnancy)

  • Disturbed sleep (unrelated to posture, or need to go to the bathroom, etc) and/or inability returning to sleep due to worries
  • Unusual irritability or shortness of temper
  • Panic attacks or increased fearfulness
  • Avoidance of routine activities
  • Low mood
  • Inability to enjoy usual pleasures

Severe symptoms (during or after pregnancy)

  • Inability to feel excitement or interest in the pregnancy
  • Loss of appetite and loss of weight (without any medical cause)
  • Withdrawal from friends and family members
  • Feelings of failure, low self-esteem or guilt
  • Suicidal thoughts or plans

(post-partum only)

  • Frequent negative thoughts
  • Vicious cycle of guilt that follows negative thoughts
  • Anger toward the baby or persistent difficulty bonding with the baby
  • Thoughts of harming the baby

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Written By Deepa Padmanaban

Deepa is a freelance journalist who writes about health, wellness, science, environment, people and culture. She has published in The Hindu, Mint, The Caravan, Open magazine, India Spend, and international publications such as Quartz, Christian Science Monitor and others. In her previous avatar, she was a biologist at The Indian Institute of Science (Bangalore) and Harvard University. You can follow her work at deepapadmanaban.com or on Twitter @deepa_padma

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