Postpartum Depression (PPD) is the most common complication of childbearing, and impacts one in seven women globally. These estimates are likely low given that researchers have found that over 80% of women experiencing perinatal (time immediately before and after birth) mood symptoms do not report their symptoms to their doctors. This intersection of high rates of occurrence and low rates of medical help seeking point to a major breakdown in maternal care with damaging outcomes - risks associated with untreated perinatal disorders include suicide, poor nutrition, loss of interpersonal and financial resources, and negative outcomes for newborns. 

As someone in recovery from PPD (following each of my two completed pregnancies), it feels important to share parts of my personal experience here. Hearing real stories from people who went through PPD was an important part of my own healing. Let’s take a closer look at perinatal depression to examine signs and symptoms, risk factors, systemic issues, and treatment options.

Signs and Symptoms
The first few months after having a baby are intense to say the least. Everything from our bodies to our sleep, to our moods are in flux as a function of hormonal and neurological shifts, all while adjusting to keeping a new tiny human alive. Many women experience noticeable mood dips, changes in appetite, and difficulty concentrating during the first two weeks postpartum, which are commonly known as “baby blues.”

After two weeks, the body has largely regulated estrogen and progesterone levels and as a result, mood tends to stabilize. For many women, symptoms persist and evolve into PPD, which may include the following: 

• Depressed mood
• Lack of pleasure or decreased interest in activities that used to bring pleasure
• Lethargy 
• Brain fog
• Extreme guilt (generally focused on being a bad mother)
• Suicidal thoughts or recurrent thoughts of death
• Intense fear of harming their child

For the first three months after my first son was born, I assumed being a mother was just naturally incredibly hard and to some degree, joyless. How much fun could it possibly be to have a newborn when I was getting three hours of sleep at a stretch, and spent most days in spit-up covered sweatpants? One day a friend came to visit, and I felt a surge of panic. I could not be around another adult human, I could not let her see how much I hated being a mother, my whole body reacted with a giant “NO.” I ran upstairs with my baby, and rocked for what seemed like hours, thinking of how unfit I was for this role, and how much better off my son would be if I just left. A little voice (thankfully) said, “something’s not right here.”

Possible Mechanisms
Hormones impact our emotions and thought processes as well as our bodies. Estrogen and progesterone, the primary hormones that facilitate pregnancy, seem to have an indirect effect on mood: when these hormone levels crash post-pregnancy, mood symptoms can ensue. One study found that supplementing at-risk women with estrogen postpartum led to a resolution of depressive symptoms. Since estrogen affects so many neural pathways, there are still questions as to how estrogen affects mood. 

Neurotransmitters that are directly linked to mood regulation during the perinatal period are serotonin and norepinephrine. Women with PPD have been found to have less serotonin (a neurotransmitter that helps us regulate mood) in their blood streams and brains. Norepinephrine is one of the body’s ways of turning off a stress response, and appears to be elevated in women with PPD. Researchers reverse-engineered this finding to hypothesize that women who are more likely to develop postpartum depression may have a higher stress response during pregnancy - more epinephrine (stress hormone) would result in more norepinephrine to curb the stress response. 

Awareness of the chemical and physiological aspects of perinatal mood disorders isn’t just an intellectual exercise. Many disorders that affect predominantly female-identified folks are understudied and undertreated due to a long history of our ailments being considered a consequence of our general inferiority. The word “hysteria” is derived from the Greek word for “uterus” - meaning female biology has been linked to pathology from a very early stage. When we name physical processes that lead to disorders impacting women, we facilitate a long overdue process of destigmatizing women’s health concerns.   

Risk Factors
Postpartum Depression is a medical disorder, but like all physical and psychological conditions, our predisposition, treatment, and recovery is impacted by factors beyond the body and mind. We might think of individual factors such as genetics as being a light switch, while external factors such as financial and emotional support, birth trauma, and childcare stress flip the switch of PPD on. 

Some of the biggest risk factors include:

• A personal or family history of Major Depressive Disorder - nearly 30% of women who develop PPD had depression prior to pregnancy. A family history of depression increases the risk for PPD two fold.
• Experiencing a stressful life event during or shortly after pregnancy. 
• Low levels of social support.
• Child-care stress, such as lack of paid parental leave.
• Having a disability (physical or psychiatric) prior to pregnancy. It’s important to note that the disability itself is not likely the predisposing factor. Disabilities are generally under-supported and under-accommodated across cultures, which causes heightened stress and reduced access to resources.

I was first diagnosed with depression in my mid-twenties, and had several episodes that were effectively managed with therapy, medication, exercise, social support, and meditation. When I got pregnant, I hadn’t had a depressive episode in over two years, which ironically made me less responsive to the signs that I was developing PPD. I also had no idea I was at a greater risk for PPD because of my history of depression. 

Treatment
The most common treatments for postpartum depression include antidepressant medications such as SSRIs, and psychotherapy. Emerging research on a new drug, brexanolone, which is delivered by injection is also showing promising results. Therapeutic approaches such as Mindfulness-Based Cognitive Therapy have strong research support in global samples.

However, treatment only works if it’s accessible, which means addressing the barriers to treatment is as important as the treatment itself. Fear is a common barrier to reporting symptoms - many women fear they will be judged by providers if they open up about their PPD symptoms, while others are concerned they will be at risk for having their children taken from them, especially if they share they are having thoughts of hurting themselves. Additionally, quality of maternal health is dramatically stratified by race, Black and Brown women have almost twice the risk of death during pregnancy and childbirth as White women in the US. This creates a bi-directional dynamic where BIPOC clients may not trust their providers to be responsive if they report PPD symptoms, and providers may be less attuned to indicators of PPD in these patients. 

Screening is also critical to detection, prevention, and treatment, but there’s mixed evidence that primary care settings are equipped to either identify or treat PPD. Common assessments such as the Edinburgh Depression Scale can help to flag possible PPD cases, but these rely on open, accurate patient reporting, which is only likely to happen in the context of a trusting patient-doctor relationship. 

A therapist with a background in Perinatal Mood Disorders and a physician with experience treating PPD are the best places to start addressing your symptoms. Learning about PPD can also help to relieve some of the judgment and unfair expectations we put on ourselves. Letting trusted family and friends know that we may need extra help, extra sleep, and asking them to be on the lookout for indicators that we need urgent medical attention (such as expressing suicidal thoughts or plans) can also help us navigate the murky terrain of PPD.

After I was finally diagnosed with PPD 4 months after having my son, I started Lexapro, a commonly-prescribed SSRI. As the emotional fog of guilt, sadness, and fear began to lift, I was able to start doing more of the activities that have always supported my mental health, like running, only now I had a sweet little guy (that I could actually enjoy) to join me on my jogs. 

If you or someone you care about may be experiencing PPD, Postpartum Support International has resources that can help. 

Written for Fitness Blender by Candice Creasman Mowrey, PhD
Licensed Clinical Mental Health Counselor Supervisor