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 Table of Contents  
EDITORIAL
Year : 2022  |  Volume : 6  |  Issue : 3  |  Page : 199-201

Postpartum depression: Recommendations to bridge the missing gaps


De Sousa Foundation, Mumbai, Maharashtra, India

Date of Submission28-Sep-2022
Date of Decision06-Oct-2022
Date of Acceptance07-Oct-2022
Date of Web Publication31-Oct-2022

Correspondence Address:
Dr. Avinash De Sousa
Carmel, 18, St. Francis Road, Off SV Road, Santacruz West, Mumbai - 400 054, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aip.aip_162_22

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How to cite this article:
Lodha P, Sousa AD. Postpartum depression: Recommendations to bridge the missing gaps. Ann Indian Psychiatry 2022;6:199-201

How to cite this URL:
Lodha P, Sousa AD. Postpartum depression: Recommendations to bridge the missing gaps. Ann Indian Psychiatry [serial online] 2022 [cited 2022 Dec 6];6:199-201. Available from: https://www.anip.co.in/text.asp?2022/6/3/199/360076



Postpartum phenomenology is characterized by a range of emotions from transient mood lability, irritability, and weepiness, to marked agitation, delusions, confusion, and delirium. Postpartum depression (PPD) is the most common psychiatric complication of childbearing. Postpartum blues or baby blues affect up to 80% of women and meta-analyses reveal that PPD is prevalent in about 22% of mothers.[1] Time and again, research has emphasized the higher share of the burden of PPD seen in low- and middle-income countries. The mental health burden around and following pregnancy is well documented since the 1970s. PPD is associated with increased chronic medical disorders and risk-related behaviors such as tobacco smoking and alcohol abuse. Universal screening is an optimal approach to the detection of new mothers who are suffering from depression following childbirth.

The substantial negative impact of PPD on mothers and their newborn infants is well-established. Postdelivery maternal depression disrupts the relationship between the mother and her infant, contributing to a higher risk for poor infant and child developmental outcomes. PPD psychiatric disorder may be present as antenatal depression or may occur as a postnatal condition, after delivery. It can predispose to either chronic or recurrent depression and has negative consequences for the mother, infant, and family. PPD also negatively impacts a woman's everyday functioning as well as her relationship with her partner and social relationships. Importantly, the maternal relationship with the child not only affects the child's normal social, emotional, and cognitive development but also interferes with basic needs such as feeding. Children of mothers with PPD have greater cognitive, behavioral, and interpersonal problems compared with the children of nondepressed mothers.[2]

The scarcity of available mental health resources, inequities in their distribution, and inefficiencies in their utilization are key obstacles to optimal mental health, especially in lower resource countries. Other key obstacles are lack of awareness and sociocultural perceptions. As we conducted research among mothers and their family members in Mumbai, a key finding that was drawn from the research, we found out that 93% of the respondents (n = 106) were unfamiliar with the concept of PPD/perinatal depression. Roughly, half of the respondents did not believe that women could experience mental health problems during and after delivery (45% and 50%, respectively). The overall findings of the research highlight an exigency to foster increased awareness of perinatal depression among expectant mothers and their family members. One of the most important stakeholders responsible for the same are clinicians followed by researchers and mental health advocates.[3]

The number of women affected by PPD in the pandemic, 2020, stood at a count of one in every five women. COVID-19 has had a significant effect on peripartum mental health outcomes, mothers were more stressed. A study conducted in the USA reveals that of the 670 postpartum patients, 1 in 3 women screened positive for PPD and 1 in 5 screened positive for major depression. India fared no better in this regard, as is focused on by research.[4]

Figures of India outline that half of the pregnant mothers access private facilities. During COVID, the lack of access to maternal health care and absence of face-to-face interactions with health-care providers added to the stress and depression that pregnant women are often prone to. Women with pregnancy complications and who had adverse pregnancy outcomes in earlier pregnancies may experience more severe depression which can have detrimental effects on the health and well-being of both women and fetus if not treated in the beginning. The situation is only worse when it comes to rural India where the basic health infrastructure is underdeveloped.[5] A small-scale survey of obstetrician-gynecologists suggests perinatal anxiety – a predictor of postpartum anxiety (PPA) and PPD – was as high as 68% among pregnant women in India during the lockdown.[6] Anecdotally, obstetrician-gynecologists and psychiatrists across the country report treating record numbers of PPA and PPD cases that they all attribute to the stress of the ongoing pandemic and earlier lockdown.[7]

This prompted us to write recommendations to bring to light the need to identify and treat the existing PPD.


  Recommendations to Reduce the Risk for Postpartum Depression and Better Management of Postpartum Depression Top


The treatment protocols as well as management/risk reduction to dos concerned with PPD are in place. However, the challenge continues to remain with low awareness levels. As aforementioned, since PPD is underdiagnosed, it is undertreated. Given the increased burden of PPD during and after the pandemic, the need for urgent identification of PPD and redressal of these complaints in young mothers is essential. Following are some guidelines that provide a roadmap to achieve the goal of reducing the risk of postpartum psychiatric problems, PPD:

  1. Need for affordable integration of health care: The foremost need as well as the most efficient way to tackle health problems for a mass of millions is to ensure an integrated health-care system. There is a greater need for having affordable facilities available under one roof that can be accessible and affordable for many. Adequate, affordable, and accessible mental health resources are key to overcome the obstacles to optimal maternal mental health, especially in lower-resource countries
  2. Need for better maternal mental health: The status of maternal health has been compromised with a decline in maternal mortality in India. In addition, maternal mental health is almost neglected. Although the budget for mental health is bare, it is still possible to accommodate maternal mental health given that there is an integrated approach to maternal health care. Stakeholders must consider to make available the required services to aid maternal mental well-being
  3. Preventive screening for perinatal depression: When women are admitted to the antenatal or prenatal wards, screening for PPD is absent in most private as well as public hospital settings. It must be understood that depression can set in before, during, or after pregnancy (perinatal depression), and at all stages, it needs immediate attention. Unidentified depression before and during pregnancy is also a risk for PPD. Given the high prevalence of PPD, it is a necessity to routinely screen for the same along with all relevant medical screening tests at a preventive level
  4. The administration of universal screening instrument: Although the prevalence rate as reported in meta-analyses and systematic reviews stands at about 22%, variation in the prevalence of PPD is seen across India. One of the major reasons is the lack of use of universal instruments to measure depression in mothers. Different screening tools reveal discrepant levels of depression which make resource allocation difficult. Contrarily, universal screening maximizes the likelihood of prompt identification of PPD, thus leading to prompt chances of treatment
  5. Urgent need for liaison practice: Obstetrician-gynecologists routinely evaluate postpartum women for a general health examination and review of family planning options at approximately 6 weeks after birth; therefore, they are well-positioned to identify PPD. However, this is restricted to private clinics only and does not ensure this benefit for the majority of women. This calls for liaison practice where a team of doctors inform the practice of regularly screening as well as immediate management of the postpartum phenomenon
  6. Onboarding mental health professionals: The second frequent treating professionals are mental health professionals. Psychiatrists and psychologists are trained to impart psychoeducation and manage PPD for the mother as well as the family members/caregivers. The treatment includes psychopharmacology as well as psychotherapy. It is essential to have mental health professionals stationed in maternal wards to ensure that PPD is promptly identified and treated
  7. Training the paramedical staff about perinatal depression and maternal mental health: It is necessary that the paramedical staff be trained in identifying first-line symptoms of perinatal depression and maternal mental health. Given that they spend the most amount of time with these mothers, their knowledge can aid in reducing the burden of maternal mental health and unidentified, untreated PPD. A soft-skills training on how to communicate and provide the first line of emotional support to patients including mothers can aid the overall well-being and compliance with treatment for all patients
  8. Judicious use of antidepressants: Patients with post-PPD must be started on treatment as early as possible and must not hesitate to administer antidepressants when needed to this population. There is a need for sometimes starting antidepressant therapy in the third trimester itself so as to prevent the advent of depression of postdelivery. One must screen for depression and a history of depression in all pregnant women across all trimesters of pregnancy and not hesitate to start medication when needed.




 
  References Top

1.
Sit DK, Wisner KL. Identification of postpartum depression. Clin Obstetr Gynecol 2009;52:456-68.  Back to cited text no. 1
    
2.
Upadhyay RP, Chowdhury R, Aslyeh Salehi, Sarkar K, Singh SK, Sinha B, et al. Postpartum depression in India: A systematic review and meta-analysis. Bull World Health Organ 2017;95:706-17C.  Back to cited text no. 2
    
3.
Goecker L. The Pandemic Has Caused a Postpartum Depression Crisis in India. Available from: https://theswaddle.com/the-pandemic-has-caused-a-postpartum-depression-crisis-in-india/. [Last accessed on 2022 Aug 12].  Back to cited text no. 3
    
4.
Lodha P, Jahangir T, Karia S, DeSousa A, Appasani R, Withers M. Perceptions of perinatal depression among low-income mothers and families in Mumbai, India. Asian J Psychiatr 2022;71:103048.  Back to cited text no. 4
    
5.
Shuman CJ, Peahl AF, Pareddy N, Morgan ME, Chiangong J, Veliz PT, et al. Postpartum depression and associated risk factors during the COVID-19 pandemic. BMC Res Notes 2022;15:102.  Back to cited text no. 5
    
6.
Jungari S. Maternal mental health in India during COVID-19. Public Health 2020;185:97.  Back to cited text no. 6
    
7.
Saha R, Jungari S. Fear of childbirth amid COVID-19 in India: Neglected aspect of maternal mental health. Int J Soc Psychiatry 2021;67:1074-6.  Back to cited text no. 7
    




 

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