What s New in Postpartum Depression: A 2016 Review Kathleen Kendall-Tackett, PhD, IBCLC, FAPA
Nothing to Disclose
PMADs (Postpartum Mood and Anxiety Disorders) Anxiety Perinatal Depression Depression PTSD OCD
Review of Current Studies Incidence Adult Adversities Depression and preterm birth Birth Interventions Depression and Breastfeeding Cessation Breastfeeding protects maternal mental health
Privilege 10% to 15% of New Mothers 40% to 60%
Adult Adversities Immigrant Intimate Partner Violence Depression Disaster Survivors Lower Income Ethnic Minority
True Incidence of Depression
31% had depression in the first 4 years Risk factors: young maternal age, stressful life events, adversity, IPV, and low income Woolhouse et al., 2015, Brit J Ob Gyn, 122, 312-321 1,507 Australian mothers, longitudinal study, 3 mos to 4 years
86,957 UK mothers and fathers, pregnancy to age 12 Depression is common in parents High risk the first year By age 12, 39% mothers and 21% of fathers have been depressed Dave et al. 2010 Arch Ped Adolescent, 164(11), 1038-1044
In the past 2 weeks, 34% depressed mood 36% anhedonia Listening to Mothers II, Nat l representative US sample, N=1,573 Declercq et al. 2008. New mothers speak out. New York: Childbirth Connection.
Centers for Disease Control and Prevention, 2015. Mental health among women of reproductive age. CDC study found depression less likely to be diagnosed and treated: young women, African Americans, Hispanics, and other non-white women
Korea 49% (Lee & Hwang, 2015) 41% Pregnancy, 61% 4 weeks postpartum (Park et al., 2015) Vietnam 16%-20% (Murray et al., 2015) Lee & Hwang, 2015. Taiwanese J Ob Gyn, 54, 355-363; Murray et al., 2015, BMC Preg Childbirth, 234; Park et al., 2015. Asian Nurs Res, 9, 219-225
Han Chinese 18% (N=5391; Yang et al., 2015) India 23% (Patel et al., 2002) Pakistan v Malawi 27% Pakistan, 3% Malawi (Zafar et al., 2015) Patel et al., 2002. Am J Psychi, 159, 43-47; Yang et al., 2015. J Affect Dis, 183, 339-346; Zafar et al., 2015. PLoS One, 10
Mothers in Turkey 14% (Danaci et al. 2002) 14% at 6 weeks (Kirpinar et al., 2010) 15% (Turkcapar et al., 2015) Danaci et al., 2002. Soc Psychiatry Psychiatric Epidem, 37, 125-129; Kirpinar et al., 2010, J Clin Nurs, 19, 422-431; Turkcapar et al., 2015, BMC Preg Childbirth
24 studies, 13,749 women 20% of immigrants had PPD, twice that of native-born population (Falah-Hassani et al., 2015) 8 studies of immigrant, asylum-seeking women, Canada Up to 42% (Collins et al., 2011) Collins et al., 2011. Arch Wom Mental Health, 14, 3-11; Falah-Hassani et al., J Psychiat Res, 70, 67-82
15% reported IPV More common in poorest pregnant women 5,162 pregnant women, Montreal Combo of immigrant status and IPV increased risk of PPD by 7 times For native-born women, IPV increased risk 4.78 times Miszkurka et al., 2012, Arch Wom Ment Health, 15, 387-396
Review 67 articles VAW during pregnancy increased risk of PMADs 3 times Antenatal depression increased the risk of IPV 3 to 5 times Howard et al., 2013. PLoS Med, 10(5)
44% met criteria for depression Latina women: 118 no IPV, 92 IPV Assessed during pregnancy, and 3, 7, and 13 months postpartum IPV better predictor of postpartum depression than depression in pregnancy Valentine et al. 2011. Arch Women s Ment Health, 14, 135-143
Review of 43 studies of child abuse and partner violence Child abuse + partner violence=more severe depression Lifetime depression Depression during pregnancy Postpartum depression Alvarez-Segura et al. 2014, Arch Women s Ment Health, 17, 343-357
317 new mothers after Sichuan earthquake 20% PTSD symptoms, 10% full criteria 29% PPD at 8 months, not higher than general population Qu et al., 2012. Arch Wom Ment Health, 15, 49-55
14% v 1% had PTSD 32% v 12% depression Pregnant women in NOLA with high v low exposure to Hurricane Katrina Xiong et al., 2010. Am J Disas Med, 5, 181-187
Depression, PTSD, and Preterm Birth
Major Causes of Newborn Deaths 25% 17% 35% Save the Children, 2013, State of the World s Mothers 23% Preterm birth Asphyxia Infection Other
Dayan et al. 2006, Psychosom Med, 68, 938-946 681 French pregnant women, 20-28 weeks gestation 4% for nondepressed women 9.7% for depressed women
Rate of Preterm Birth 16,334 deliveries at VA Hospital 2000-2012 7.4% no PTSD 8% previous PTSD 9.2% current PTSD Shaw et al. 2014, Obstet Gynecol, 124(6), 1111-1119
2,654 women in U.S. Yonkers et al. 2014, JAMA Psychiatry, 71(8), 897-904 PTSD and major depression increased the risk of preterm birth by 4 times
Following September 11, women with Arabic last names were twice as likely to have a low birthweight baby Not true for the prior year Pregnant women in CA Lauderdale, 2006. Demography, 43,185-201
Inflammation underlying mechanism for depression
IL-1β IL-6 TNF-α
IL-6 and TNF-α high in stressed and depressed mothers IL-6 and TNF-α ripen the cervix Coussons-Read et al. 2005, Psychosom Med, 67, 625-631
Smuts et al. 2003, Obstet Gyn, 101, 469-479 291 low-income moms DHA-enriched eggs increased gestation length by 6 days (+ 2.3 days)
No difference in PPD at 6 weeks or 6 months Child cognitive or language development at 18 months more women in the DHA group were induced or had cesareans because they were post-dates 2,399 pregnant women from Australia, 800 mg DHA, 100 EPA, or vegetable oil placebo from 21 weeks gestation to birth Makrides et al. 2010, JAMA, 304, 1675-1683
Women with moderate-to-high stress and high social support had less than half the rate of preterm birth Retrospective case-control study, 1,027 preterm births, 1,282 full-term births, mothers from LA Ghosh et al, 2010, Arch Women s Ment Health, 13, 327-338
Study of 116 women in Finland with depression ACEs associated with low social support High social support associated with low CRP Runsten 2013 Nordic J Psychiatry: Apr 30
Birth Interventions
5,332 mothers in the UK More breastfeeding problems at 3 months following forceps-assisted and unplanned cesarean births Rowlands & Redshaw 2012, Rowlands & Redshaw, 2012 BMC Preg Childbirth, 12, 128
Epidurals had small effect on early breastfeeding but no effect on neonatal outcomes 317 with epidurals 617 no epidurals Gizzo et al. 2012, Breastfeeding Med, 7, 262-268
Cesareans (vs. vaginal) at <32 weeks associated with lower milk volume at Day 4 and less exclusive breastfeeding at NICU discharge Murase et al., 2014, J Hum Lact, 30(4), 425-435
1,280 mothers and infants from Hong Kong Induction of labor Opioid pain medications Emergency cesarean Any Exclusive Bai et al., 2013, J Midwif Wom Health, 58(1), 25-32
Epidurals associated with partial breastfeeding and breastfeeding difficulties in the first week postpartum Women who had epidurals twice as likely to stop breastfeeding by 24 weeks Prospective study of 1280 Australian women, 1 to 24 weeks postpartum Torvaldsen et al., 2006, Int Breastfeed J, 1:24
Survey of Mothers Sleep and Fatigue Survey 6,410 mothers of infants 0-12 months, 59 countries
Feeding Method by Delivery Type 90 80 70 60 50 40 30 20 10 0 83 15 Vaginal 71 69 70 69 26 2 3 Asst. Vaginal 24 7 27 28 Unplanned Planned Emergency Breastfeeding Mixed Formula-Feeding 2 4 Kendall-Tackett et al. 2015, Clin Lact, 6(3), 87-96
Epidural by Feeding Method Epidural No Epidural 80 70 60 50 40 30 20 10 0 65 68 58 42 35 32 Breastfeed Mixed Formula Kendall-Tackett et al. 2015, Clin Lact, 6(3), 87-96
Other Pain Medications by Feeding Method 80 76 Pain Meds No Pain Meds 70 65 60 60 50 40 40 35 30 24 20 10 0 Breastfeed Mixed Formula-Feed Kendall-Tackett et al. 2015, Clin Lact, 6(3), 87-96
Epidurals 214 mothers from China 15 depressed with epidural 37 depressed without epidural Ding et al., 2014, Anesthes Analges, 119, 383-392
185 women in Finland PPD No Epidural PPD Epidural At one week postpartum No difference at 4 months Hiltunen et al. 2004, Acta Obstet Gynecol Scand, 83, 257-261
Following elective cesarean 25%-28% depression Kuo et al., 2014, PLoS ONE, 9, e86653 30%-37% anxiety
Ease of Labor by PPD 1.2 1 0.8 0.6 0.4 0.2 0 Very easy Moderate Very difficult Kendall-Tackett et al. 2015, Clin Lact, 6(3), 87-96
1.05 Perceived Labor Pain by PPD 1 0.95 0.9 0.85 0.8 0.75 Low pain Moderate pain High pain Kendall-Tackett et al. 2015, Clin Lact, 6(3), 87-96
Impact of Epidural on PPD 1 0.95 0.9 0.85 0.8 0.75 Yes No Kendall-Tackett et al. 2015, Clin Lact, 6(3), 87-96
Significantly related to depressive symptoms Epidurals Postpartum hemorrhage Postpartum surgery Even after controlling for All other birth interventions Primip v multip Number of hours in labor Income Education History of depression History of sexual assault Current anxiety Current anger/irritability
Depression by Birth Type 1.1 1.05 1 0.95 0.9 0.85 0.8 0.75 Kendall-Tackett et al. 2015, Clin Lact, 6(3), 87-96
Postpartum Depression 160 patients, 24-36 weeks gestation Preferred vaginal birth Houston et al. 2015, Am J Obstet Gynecol, 212, e1-7
Depression is a direct threat to breastfeeding
PPD Weaning Low Support Mathews et al. 2014, J Hum Lact 30(4): 480-487
Anxiety at 3 months reduced odds of exclusive breastfeeding by 11% at 6 months d Adedinsewo et al. 2014, J Hum Lact, 30(1), 102-109
Complex pregnancy was associated with >30% lower odds of exclusive breastfeeding Supportive hospital practices increased odds of any or exclusive breastfeeding by 2 to 4 times 2400 births in U.S. Kozhimannil et al. 2014. PLoS One, 9(8), e104820
ALSPAC sample, Avon UK, 14,541 pregnancies PPD Intended to breastfeed and did Intended to breastfeed and did not PPD Borra et al, 2014, Matern Child Health J, DOI 10.1007/s10995-014-1591-z
More depression if mothers had not intended to breastfeed but did Borra et al, 2014, Matern Child Health J, DOI 10.1007/s10995-014-1591-z
Breastfeeding protects maternal mood
Well-being Affiliation Bonding Depression & anxiety Alienation Hostility & strife Oxytocin Stress
1.5 Mothers Depression N=6,410 1 0.5 Breastfeeding Mixed Formula Kendall-Tackett et al., 2011, Clin Lact, 2(2), 22-26
30 Minutes to Fall Asleep 25 N=6,410 20 15 10 19.61 22.36 27.05 5 0 Breastfed Mixed Formula Kendall-Tackett et al., 2011, Clin Lact, 2(2), 22-26
6.7 6.6 Hours Mothers Sleep 6.61 N=6,410 6.5 6.4 6.3 6.41 6.3 6.2 Breastfeeding Mixed Formula Kendall-Tackett et al., 2011, Clin Lact, 2(2), 22-26
What About Sexual Assault Survivors?
N=6,410, 994 sexual assault survivors 1.2 1 0.8 0.6 0.4 0.2 0 Current Depression 1.11 0.853 No Sexual Assault Sexual Assault Kendall-Tackett et al., 2013, Breastfeed Med, 8(1), 16-22
Percentage who are Breastfeeding 80 78.6 78.9 N=6,410, 994 sexual assault survivors 70 No Sexual Assault Sexual Assault Kendall-Tackett et al., 2013, Breastfeed Med, 8(1), 16-22
6.7 6.6 6.5 Hours Mothers Sleep 6.63 6.52 6.44 6.4 6.3 6.2 6.1 6.16 Breastfeeding Mixed/Formula 6 No assault Sexual assault Kendall-Tackett et al., 2013, Breastfeed Med, 8(1), 16-22
28 Minutes to Get to Sleep 27.01 26 24 22 22.07 23.87 Breastfeeding Mixed-/Formula 20 18.73 18 No assault Sexual assault Kendall-Tackett et al., 2013, Breastfeed Med, 8(1), 16-22
1.3 Depression 1.25 1.2 1.1 1 0.9 0.8 0.7 1.03 0.8 No Assault 1.07 Sexual Assault Breastfeeding Mixed/Formula Kendall-Tackett et al., 2013, Breastfeed Med, 8(1), 16-22
1.75 1.7 1.65 1.6 1.55 1.5 1.45 1.4 1.35 Angry or Irritable 1.69 1.53 1.49 1.51 No Assault Sexual Assault Breastfeeding Mixed/Formula Kendall-Tackett et al., 2013, Breastfeed Med, 8(1), 16-22
Conclusions Depression in new mothers is substantially more common than 10% to 15%
The effects of depression are severe and potentially lethal. They are too serious to ignore
Depression is a direct threat to breastfeeding
Birth interventions can have a negative impact on both breastfeeding and depression
There are many treatments that can help
Many mental health professionals are still not on board with breastfeeding
Empowered clinicians Empowered mothers
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