Treating Postpartum Depression

Women with postpartum depression have intense feelings of sadness, anxiety, or despair that can interfere with their ability to do their daily tasks.  It can occur up to one year after having a baby, but it most commonly starts about one to three weeks after childbirth.  The term “postpartum depression” commonly includes major and minor depression, which differ in severity and prognosis, and have a combined incidence of 12% in healthy women, who gave birth to full-term infants.[1]  Risk factors for postpartum depression include a history of postpartum major depression with a previous pregnancy, antenatal depressive symptoms (relative risk [RR] = 5.6), a history of major depressive disorder (RR = 4.5), poor social support (RR = 2.6), major life events or stressors during pregnancy (RR = 2.5), and a family history of postpartum major depression (RR = 2.4).[2][3]  Treatment options include lifestyle changes, counseling, dietary supplementation, and pharmaceuticals.

Lifestyle

Encourage mothers to be open about their feelings and reach out.  Help them get in touch with people who can help with childcare, household chores and errands. They can consider hiring a postpartum doula, if such services are available locally.  Encourage finding a social support network to help her find time for herself, so she can rest.  Eliminate the stigma of postpartum depression and baby blues.

Advice to give to mothers:

  • Find time every day to do something for yourself, even if it’s only 15 minutes a day. Try reading, exercising (walking is great for your health and is easy to do), taking a bath or meditating.
  • Exercise for 30 minutes a day may help to alleviate symptoms.
  • Keep a diary. Every day, write down your emotions and feelings. This is a way to let out your thoughts and frustrations. Talking with supportive friends is another way to express your feelings.
  • Even if you can only get one thing done on any given day, remember that this is a step in the right direction. There may be days when you can’t get anything done, but try not to get angry with yourself when this happens.
  • It’s okay to feel overwhelmed. Childbirth brings many changes, and parenting is challenging. When you’re not feeling like yourself, these changes can seem like too much to cope with. Most mothers can relate to what you’re going through.
  • You’re not expected to be a “supermom.” Be honest about how much you can do, and ask other people to help you when you need it.
  • Engage in supportive reading, movies, music, and uplifting entertainment with others.
  • Tell family and friends to be on the lookout for symptoms of depression in you, such as becoming reclusive or excessively emotional. Ask them to call and visit with you and support you if you need extra help.

Counseling

Maintain a list of local counselors who specialize in working with postpartum women.  Mothers with depression should establish a relationship with a counselor she can see regularly.  Many times, depression will improve dramatically with counseling alone.[4]  Counselors who are willing to allow mothers to bring their children along are especially helpful, as finding childcare is often a barrier to seeking professional help.

If a mother is in crisis, contact one of the resources below for immediate support:

Keep a list on hand of local crisis support options

Postpartum Doulas

Unlike therapists or psychiatrists, doulas do not treat postpartum depression. However, they will help by attending to the mother’s home environment to support her emotionally. They relieve some of the pressure on the mother by helping with household chores and baby care, allowing her to move into her expanded responsibilities gradually.  By “mothering the mother,” doulas make sure that the mother feels nurtured and cared for, as well as making sure she is eating well and getting enough sleep.

Families can go to DONA International to find a postpartum doula locally.

Nutrition

Pregnancy and lactation both increase the demands on the body for nutrients and caloric intake.  Proper nutrition and dietary supplementation will help to support mood and energy levels during the postpartum period.  Provide ideas for healthy nutrition and consider keeping a list of quick, nutritious recipes on hand.  Mothers should try to avoid junk food, and focus on eating meals, preferably with others who are positive and supportive.  They should avoid skipping meals or indulging in comfort eating.  Advise women to keep healthy and easy-to-prepare food handy, as she may not have much time for lengthy cooking.  Women should focus on plenty of fruits, vegetables, whole grains and olive oil for cooking. They should decrease intake of salt, caffeine, and high-fructose corn syrup.

Note: Please refer to the Passport to Whole Health, Chapter 15 on Dietary Supplements for more information about how to determine whether or not a specific supplement is appropriate for a given individual. Supplements are not regulated with the same degree of oversight as medications, and it is important that clinicians keep this in mind. Products vary greatly in terms of accuracy of labeling, presence of adulterants, and the legitimacy of claims made by the manufacturer

Omega-3 fatty acids

Despite increased demand for omega-3 fatty acids during pregnancy, dietary intake by perinatal women in the United States has been noted as deficient. Dietary intake during pregnancy further diminished after the U.S. Food and Drug Administration issuances of mercury advisories regarding fish intake during pregnancy.  In a large Danish prospective cohort study of more than 54,000 women, participants who were in the lowest quartile of self-reported fish intake during pregnancy were at increased risk of being treated for depression with an antidepressant up to one year postnatally.[5]. Dietary supplementation with omega-3 fats prenatally may decrease the risk of developing postpartum depression, as well as reduce some depressive symptoms in the postpartum period.[6]

Omega-3 fatty acid supplements have been well tolerated by perinatal women and appear free of significant levels of mercury or other contaminants.  The overall data on their use is mixed, which is thought to mainly be due to the varying dosages used in the studies done thus far.[7]  Fish oil may be helpful for the woman struggling with postpartum depression and should be dosed as 1,000 mg daily of DHA+EPA.  Formulas that are higher in EPA may have more beneficial effects for mood.

Vitamin B

Women may find that their intake of vegetables high in B vitamins may be decreased during the postpartum time, as they adjust to balancing the needs of the baby with time to prepare fresh food.  Some studies report an association of low folate levels and an increased risk of depression.[8][9][10]  Low blood folate has also been associated with a poorer response to treatment with antidepressants[11] and higher folate levels at baseline appear associated with a better response to treatment.[12]  There have not been conclusive studies published that looked specifically at folate or other B vitamins in the treatment of postpartum depression.  Consider recommending to women who are postpartum to continue their prenatal vitamin or take a B-100 complex with about 1 mg (or 1,000 mcg) of folic acid, or folate.

Vitamin D

Studies suggest a link between low serum vitamin D levels and an increased risk of postpartum depression.[13][14]  Correction of vitamin D deficiency may play a significant role in the recovery from postpartum depression.[15]  Mothers struggling with depression should have their 25-OH vitamin D level tested.  Many women find that they need at least 2,000-3,000 IUs of cholecalciferol, which is vitamin D3 (a form that is very readily absorbed) throughout the winter months.  Additionally, they can try and get 10-15 minutes of direct sunlight to the face and arms every day of the week.  In the summer months, less oral vitamin D may be needed, depending on the latitude where the mother lives.

Risk factors for vitamin D deficiency include living far away from the equator, spending time indoors, dark skin pigment, and obesity.

Sunlight and Movement

Exercise and fresh air can be very therapeutic to mothers, who often find themselves spending a lot of time indoors, tending to their baby’s needs.  Sunlight for 15-30 minutes a day (being careful not to burn) is important.  This may mean going for a walk, sitting outside, going to a park, or whatever works best for her.  Movement is one of the most important, low-cost, and effective treatments for depression.  The available research on physical activity and yoga as interventions for perinatal depression is encouraging with regard to feasibility, acceptability, patient safety, and preliminary efficacy.[16]

Encourage mothers to try to get the equivalent of 30 minutes of brisk walking in daily, once cleared by their physician or midwife.  Other options are riding a bike, running, dancing, swimming, joining a health club or whatever she enjoys.  Many communities offer postpartum yoga classes, where women can bring their babies.  The YMCA is often a low-cost option that provides free daycare.

Social Support

Social connection is necessary during the postpartum time.  Encourage mothers to ask for help and connect with family, friends, and supportive people through recreation, classes, religious groups, etc.

Postpartum Support International (PSI), a world-wide organization founded in 1987, exists to provide support, reliable information, resources, and education for distress in pregnancy and postpartum. PSI coordinators help women, families, and providers to find support and make connections. Women can connect with a local volunteer who can put her in touch with appropriate postpartum resources depending on her needs.

Resources

  • Postpartum Support International (PSI)
  • The Mother-to-Mother Postpartum Depression Support Book: Real Stories from Women Who Lived Through It and Recovered, Sandra Poulin (2006)
  • Natural Health After Birth: The Complete Guide to Postpartum Wellness, Aviva Jill Romm (2002)

Author(s)

“Treating Postpartum Depression” was written by Jill Mallory, MD (2014, updated 2020).

This Whole Health tool was made possible through a collaborative effort between the University of Wisconsin Integrative Health Program, VA Office of Patient Centered Care and Cultural Transformation, and Pacific Institute for Research and Evaluation.

References

  1. Shorey S, Chee CYI, Ng ED, Chan YH, Tam WWS, Chong YS. Prevalence and incidence of postpartum depression among healthy mothers: a systematic review and meta-analysis. J Psychiatr Res. 2018;104:235-248.
  2. Milgrom J, Gemmill AW, Bilszta JL, et al. Antenatal risk factors for postnatal depression: a large prospective study. J Affect Disord. 2008;108(1-2):147-157.
  3. Robertson E, Grace S, Wallington T, Stewart DE. Antenatal risk factors for postpartum depression: a synthesis of recent literature. Gen Hosp Psychiatry. 2004;26(4):289-295.
  4. Hadfield H, Wittkowski A. Women’s experiences of seeking and receiving psychological and psychosocial interventions for postpartum depression: a systematic review and thematic synthesis of the qualitative literature. J Midwifery Womens Health. 2017;62(6):723-736.
  5. Strom M, Mortensen EL, Halldorsson TI, Thorsdottir I, Olsen SF. Fish and long-chain n-3 polyunsaturated fatty acid intakes during pregnancy and risk of postpartum depression: a prospective study based on a large national birth cohort. Am J Clin Nutr. 2009;90(1):149-155.
  6. Hsu MC, Tung CY, Chen HE. Omega-3 polyunsaturated fatty acid supplementation in prevention and treatment of maternal depression: Putative mechanism and recommendation. J Affect Disord. 2018;238:47-61.
  7. Miller BJ, Murray L, Beckmann MM, Kent T, Macfarlane B. Dietary supplements for preventing postnatal depression. Cochrane Database Syst Rev. 2013(10):Cd009104.
  8. Kendrick T, Dunn N, Robinson S, et al. A longitudinal study of blood folate levels and depressive symptoms among young women in the Southampton Women’s Survey. J Epidemiol Community Health. 2008;62(11):966-972.
  9. Watanabe H, Ishida S, Konno Y, et al. Impact of dietary folate intake on depressive symptoms in young women of reproductive age. J Midwifery Womens Health. 2012;57(1):43-48.
  10. Nguyen PH, Grajeda R, Melgar P, et al. Micronutrient supplementation may reduce symptoms of depression in Guatemalan women. Arch Latinoam Nutr. 2009;59(3):278-286.
  11. Papakostas GI, Petersen T, Mischoulon D, et al. Serum folate, vitamin B12, and homocysteine in major depressive disorder, Part 1: predictors of clinical response in fluoxetine-resistant depression. J Clin Psychiatry. 2004;65(8):1090-1095.
  12. Alpert M, Silva RR, Pouget ER. Prediction of treatment response in geriatric depression from baseline folate level: interaction with an SSRI or a tricyclic antidepressant. J Clin Psychopharmacol. 2003;23(3):309-313.
  13. Robinson M, Whitehouse AJ, Newnham JP, et al. Low maternal serum vitamin D during pregnancy and the risk for postpartum depression symptoms. Arch Womens Ment Health. 2014;17(3):213-219.
  14. Gur EB, Gokduman A, Turan GA, et al. Mid-pregnancy vitamin D levels and postpartum depression. Eur J Obstet Gynecol Reprod Biol. 2014;179:110-116.
  15. Amini S, Jafarirad S, Amani R. Postpartum depression and vitamin D: A systematic review. Crit Rev Food Sci Nutr. 2019;59(9):1514-1520.
  16. Eustis EH, Ernst S, Sutton K, Battle CL. Innovations in the treatment of perinatal depression: the role of yoga and physical activity interventions during pregnancy and postpartum. Curr Psychiatry Rep. 2019;21(12):133.

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