Postpartum depression: Etiology, treatment and consequences for maternal care
Section snippets
Steroid hormones: ovarian hormones
Steroid hormones play a significant role in depression including PPD (Bloch et al., 2003, Brummelte and Galea, 2010b). During pregnancy and postpartum, levels of steroid and peptide hormones fluctuate dramatically which could contribute to the etiology of PPD (Bloch et al., 2003, Brummelte and Galea, 2010b). These changes in hormone levels, such as estradiol, corticosterone, corticotropic releasing hormone (CRH) and oxytocin, occur in rodents and humans albeit with different profiles and
Neurobiology of MDD
The hippocampus, prefrontal cortex (PFC) and amygdala are implicated in the neurobiology of depression (McKinnon et al., 2009). A meta-analysis determined that depressed patients have a smaller hippocampus volume after 2 years with depression and that smaller hippocampal volume was seen in children and middle-aged or older adults (McKinnon et al., 2009), suggesting that gonadal hormones may buffer changes in hippocampal volume in young adults. Antidepressant use protects against hippocampal
Neurobiology of PPD
There are relatively few studies examining the neurobiology of PPD. It is important to remember that the postpartum period is associated with neuroplastic changes in the hippocampus and PFC, irrespective of mood. For example total brain volume decreases during pregnancy and increases to normal levels within 6 months postpartum (Oatridge et al., 2002). In rodents, primiparity is associated with reduced dendritic branching in the CA1 and CA3 regions (Pawluski and Galea, 2006), reduced cell
Animal models of PPD based on steroid hormones
Most animal models of PPD have been created on the basis of ovarian hormone withdrawal, chronic stress during pregnancy or glucocorticoid exposure during the postpartum (Brummelte and Galea, 2010b). Galea and her colleagues found that withdrawal from a hormone-simulated pregnancy induced depressive-like behaviors including increased immobility in the forced swim test (FST) and sucrose anhedonia (Galea et al., 2001, Green et al., 2009). Furthermore withdrawal from a hormone-simulated pregnancy
PPD and maternal care
The neurobiological changes due to motherhood and contributing to maternal behaviors are described in detail elsewhere (Bridges, 2015, Brunton and Russell, 2008). However, not much is known about whether these alterations are affected by PPD. Rodent models suggest that chronic stress prevents some of the peripartum induced adaptations in the brain and behavior (Hillerer et al., 2012). Further, chronic treatment with CORT in the postpartum reduced neurogenesis in the hippocampus as well as
Maternal care in animal models of depression
In line with human reports, studies using animal models of maternal depression have also reported altered maternal care in rodents (Brummelte et al., 2006, Perani and Slattery, 2014, Smith et al., 2004, Zhou et al., 2014). The most common models of PPD include gestational stress and high maternal corticosterone (CORT) postpartum (Brummelte et al., 2006, Brummelte and Galea, 2010b, Leuner et al., 2014). Disruptions in maternal care with exogenous glucocorticoids are seen across a variety of
Ovarian hormones
Estrogens and progesterone levels during gestation also play a role in maternal care in women (Fleming et al., 1997, Glynn et al., submitted for publication) and in rodents (Rosenblatt, 1980). A study by Fleming et al. (1997) showed that a high estradiol to progesterone ratio was associated with depression in postpartum women. Furthermore women with a low estradiol lo progesterone ratio during gestation reported higher feelings of attachment in the early postpartum. These findings were recently
Antidepressant use and child development
Certainly some depressed mothers who are taking antidepressant medication may be advised by their doctors not to breast-feed their infants depending on the type and dose of the medication (Bellissima et al., 2012). However, it is essential to distinguish between the effects of treated and untreated depression of the mother on the child. Many studies report the consequences of maternal depression without taking treatment or the mother's feeding choices (breastfeeding or not) into consideration.
Interventions for PPD
As noted above, children may be affected by pharmacological interventions in women with PPD. Women may be reluctant to take pharmacological antidepressants during pregnancy and/or the postpartum as only 18% of depressed mothers seek treatment (Marcus, 2009). This reluctance may be partly explained by the fact that antidepressants, such as SSRIs, remain active in breast milk and can potentially affect child development (Wisner et al., 1996). Although clinical evidence suggests that low levels of
Interventions for maternal behaviors
As indicated above, it is not always clear what the long-term effects of maternal antidepressant use are on child development (though for some recent reviews see: Grigoriadis, 2014, Hanley and Oberlander, 2014, Suri et al., 2014). Considering that some of the negative outcomes in children of depressed mothers are attributed to the disturbed mother–infant interaction, it is important to investigate the effects of depression treatment on maternal depressive symptoms as well as on maternal
Future outlook
There is little agreement supporting the efficaciousness of pharmacological antidepressants during the postpartum period (De Crescenzo et al., 2014, Hantsoo et al., 2014, Molyneaux et al., 2014, Sharma and Sommerdyk, 2013). However, some studies do show efficacy and it is important to establish when and why pharmacological treatments work in the postpartum. In this endeavor it will be particularly important to clarify whether it is the postpartum environment that lends itself to inefficacy such
Conflict of interest
All authors declare that they have no conflict of interest.
Acknowledgments
SB is supported by a start-up fund by Wayne State University and LAMG is supported by operating grants from Canadian Institutes for Health Research (CIHR MOP102568) and Natural Sciences and Engineering Research Council of Canada (NSERC).
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