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Diet in the Aetiology and Management of Postpartum Depression: Knowing the Facts

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Studies suggest that pregnancy and childbirth are key times in women’s lives when they are more susceptible to mental health problems. Prevalence of postpartum depression (PPD) is increasing worldwide and has potentially detrimental effects on both the mother and the offspring. Postpartum depression has a multifactorial aetiology. Genetic predisposition, environmental factors, as well as a number of social, psychological and biological parameters have been identified as key risk factors of the condition. It has been postulated that the diet during and after pregnancy may be associated with the onset of PPT. Evidence suggests that depletion of nutrient reserves throughout pregnancy can increase the risk of PPD. The nutrient that has received the most attention has been the n-3 essential fatty acids with many randomized controlled trials, cohort studies and ecological studies suggesting a positive association between low n-3 levels and a higher incidence of maternal depression. There is also good evidence that increasing the dietary omega-3 intake in late pregnancy or following delivery may reduce the risk of PPD. The role of the inadequate intake of folate, calcium, zinc and iron intake on the onset of PPD has also been investigated, with conflicting results. The need for more, better designed studies is identified, to elucidate the possible role of nutrition on PPD, which could lead to the formation of specific dietary recommendations for the prevention and management of this serious condition.
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2009
V.R. Preedy et al. (eds.), Handbook of Behavior, Food and Nutrition,
DOI 10.1007/978-0-387-92271-3_129, © Springer Science+Business Media, LLC 2011
Keywords Postpartum depression Diet Fish oils
Abbreviations
PPD Postpartum depression
EPDS Edinburgh postnatal depression scale
PUFA Polyunsaturated fatty acids
EPA Eicosapentaenoic acid
DHA Docosahexaenoic acid
RCT Randomized Controlled Trial
BDI Beck depression inventory
FFQ Food frequency questionnaire
129.1 Introduction
Postpartum depression (PPD) is a condition that affects women who have recently delivered a baby,
with most cases occurring in the first 6 months after delivery. It is a serious mental health problem
characterized by a prolonged period of emotional disturbance, occurring at a time of major life
change and increased responsibilities (Almond 2009).
Prevalence of postpartum depression worldwide is approximately 13–20%; however, these are
probably conservative estimates because the condition is often underreported or underdiagnosed
(Halbreich and Karkun 2006). It is important to note that a study conducted in the UK found that the
incidence of PPD is approximately 27% in minority ethnic women (black, Asian and other) compared
to 15% in white women (Onozawa et al. 2003) which indicates that women from ethnic minorities
are probably a high-risk group for depression in the postpartum.
Symptoms of depression in the postpartum period may persist for any length of time after birth
and range from postpartum blues to severe depression. Postpartum blues can be defined as short
episodes of depressive symptoms, such as anxiety, disturbed sleeping patterns, decreased appetite
Chapter 129
Diet in the Aetiology and Management
of Postpartum Depression: Knowing the Facts
Vassiliki Costarelli
V. Costarelli (*)
Human Ecology Laboratory, Department of Home Economics and Ecology,
Harokopio University, 70 El. Venizelou Ave, 17671 Kallithea, Athens, Greece
e-mail: costarv@hua.gr
2010 V. Costarelli
and irritability, normally taking place on day 4 after delivery but may commence up to 2 weeks after
delivery (Gurel and Gurel 2000). However, the symptoms of PPD which are described in detail in Fig.
129.1, are usually more severe and could include feelings of suicide, obsessive thoughts and extreme
petulance (Wisner et al. 2002; Hatton et al. 2005). Postpartum psychosis, on the other hand, is the
most severe form of postpartum psychiatric illness and will not be discussed in the current chapter.
The consequences of PPD can be significant for both the new mother and the child. It is important
to stress that, higher rates of emotional, behavioural and cognitive problems have been reported in
the children of mothers with PPD (O’Brien et al. 2004; Stewart 2007). Table 129.1 summarizes the
main adverse effects reported in infants and children of mothers with PPD.
The causes of PPD remain unclear, with research suggesting a multifactorial aetiology (Verkerk
et al. 2003). More specifically, evidence suggests that the key risk factors for PPD include genetic
predisposition and environmental factors, together with a number of social, psychological and bio-
logical factors (Craddock and Forty 2006; Almond 2009; Leung and Kaplan 2009). The main risk
factors of PPD are described in Table 129.2. The strongest predictors of postpartum depression seem
to be the personal and family history of depression, antenatal depression and anxiety and most
importantly the lack of social support. Two metaanalyses also found a higher risk of postpartum
depression among socially disadvantaged women (O’Hara and Swain 1996; Beck 2002).
The biological risk factors linked with PPD are more difficult to determine. Biological factors that
play a part to the pathophysiology of the condition include hormonal influences (Bloch et al. 2000;
Murakami et al. 2008), neurotransmitter function (Dunlop and Nemeroff 2007) and nutrient defi-
ciencies because of malnutrition or poor diet quality (Bodnar and Wisner 2005).
Loss of interest
& pleasure in
activities of life
Sleep changes
Slowing of
thoughts &
physical
movement or
agitation
Changes in
appetite which
can lead to
weight gain or
loss
Somatic
symptoms such
as headache,
constipation,
diarrhea and
severe anxiety
Fatigue & loss
of energy
Recurrent
thoughts of
death or suicide
Difficulty
concentrating or
indecisiveness
Feeling
worthless or
guilt
Depressed mood
Symptoms of
Postpartum
Depression
Fig. 129.1 Main symptoms of postpartum depression
20 11
129 Diet in the Aetiology and Management of Postpartum Depression: Knowing the Facts
Evidence suggests that inadequate intake of specific nutrients might be a substantial contributor
to the development of depression in women in the postpartum period (Bodnar and Wisner 2005).
Plausible associations between nutrient inadequate intake and mood have been reported for folate,
vitamin B12, calcium, iron, selenium, zinc and omega-3 fatty acids (Alpert et al. 2000; De Vriese
et al. 2003). In the case of maternal and postpartum depression, the nutrient that has received the
most attention has been the omega-3 essential fatty acids (Chiu et al. 2004). Finally, it is important
to underline that one of the symptoms of PPD is changed appetite (increased or decreased), which
would contribute to the poor dietary intake and nutritional status of women in the postpartum and
hence deteriorate the management of the condition.
The purpose of the current short chapter is to present and discuss the main dietary factors impli-
cated in the aetiology and management of PPD based on a thorough review of the scientific literature
to date.
129.2 Diet and Postpartum Depression
Research on the relationship between nutrition and brain function is very large. However, while
specific nutrients have been associated with depression in the general population, little is known
about low nutrient levels in the aetiology and management of postpartum depression (Derbyshire
and Costarelli 2008). It is well documented that pregnant women are especially susceptible to the
effects of low nutrient intakes (Bodnar and Wisner 2005; Derbyshire et al. 2009) as during preg-
nancy and lactation, nutritional requirements are increased (Picciano 2003). In addition, there is
evidence that nutrient inadequacies in pregnant women who consume a typical western diet might be
Table 129.1 Postulated adverse effects on children of mothers with postpartum depression
(Stein et al. 2009)
Impairment in mother-infant interaction
Infants and toddlers became withdrawn, irritable and inconsolable
Higher rates of emotional and behavioural problems as children approach school age
Poorer cognitive development
Higher risk of mood and anxiety disorders in adolescence
This table lists the main negative effects on children of mothers with postpartum depression
Table 129.2 Main risk factors implicated in the aetiology of postpartum depression
Hormonal changes after childbirth
Previous experience of depression or anxiety
Family history of depression or mental illness
Stress involved in caring for a newborn and managing new life changes
Having a challenging baby who cries more than usual, is hard to comfort, or whose sleep and
hunger needs are irregular and hard to predict
Having a baby with special needs (premature birth, medical complications, illness)
First-time motherhood, very young motherhood, or older motherhood
Other emotional stressors, such as the death of a loved one or family problems
Financial & employment problems
Isolation and lack of social support
Source: American Psychiatric Association (APA)
The main risk factors in the aetiology of postpartum are described in this table
2012 V. Costarelli
much more common than researchers and clinicians anticipated. A number of studies have reported
inadequate intakes of omega-3 fatty acids, folate, B vitamins, iron and calcium in pregnant women
(Giddens et al. 2000; Derbyshire et al. 2009). A British study found a significant percentage of preg-
nant women did not meet the estimated average requirement for folate (69%), for calcium (40%) and
iron (67%) (Mouratidou et al. 2006). Similarly, a study of pregnant adolescents and adults living in
the USA found mean intake for energy, iron, zinc, calcium, magnesium, folate and vitamins D and
E to be below recommended standards (Giddens et al. 2000). Depletion of nutrient reserves through-
out pregnancy could increase a woman’s risk for maternal and postpartum depression. It is likely that
the Mediterranean Dietary Pattern could be protective of PPD. More specifically, adherence to a
Mediterranean Dietary Pattern ensures an adequate intake of fruits, nuts, vegetables, cereals, legumes
or fish, important sources of nutrients linked to depression prevention (Sanchez-Villegas et al. 2006).
A recent study investigating depression in the elderly has found that lower intake of seed oils and
higher intake of olive oil prospectively predict a healthier affective state in the elderly. Most impor-
tantly, olive oil intake, in particular, predicts a lower chance of scoring in the highest part of the
geriatric depression scale (Kyrozis et al. 2009). However, no studies have been found investigating
the possible role of the Mediterranean style diet in PPD so far.
Finally, recent studies have also showed that insulin affects the secretion of serotonin in the brain.
It is likely that PPD might be linked to the sudden fall in insulin levels occurring after delivery. A diet
with a high-glycemic index, which would stimulate the secretion of insulin and thereby facilitate the
transport of tryptophan, the precursor of serotonin, in the brain, would alleviate the above condition
(Chen et al. 2006). However, a recent study investigating the link between glycemic load and PPD
failed to substantiate a clear inverse relationship between them (Murakami et al. 2008). This hypoth-
esis warrants further investigation given the plausibility of the above mechanism.
129.2.1 Omega-3 Fatty Acids and PPD
The nutrient that has received the most attention from nutrition researchers with respect to depression
in pregnancy and the postpartum period has been the n-3 essential fatty acids. (Hibbeln 2002; Freeman
et al. 2006a; Miyake et al. 2006b). Several studies, such as cohort studies, randomized controlled trials
as well as ecological studies, have found mainly positive links between low n-3 levels and a higher
incidence of maternal depression. Oily fish are a rich source of omega-3 fatty acids in particular
eicosapentaenoic acid (EPA) and docohexaenoic acid (DHA) which are very important for brain
development and function (Browne et al. 2006). It is known that omega-3 fatty acids are essential for
receptor function, neurotransmitter uptake and signal transmission. More specifically, evidence indi-
cates that adequate levels of the above fatty acids may help to regulate neurotransmitter levels,
which are thought to be reduced in cases with depressive symptoms (Sapolsky 2000). In addition, it
has been proposed that high concentrations of DHA located in non-myelin cell membranes of the
central nervous system may help support synaptic transmissions (Holman et al. 1991).
The intake of n-3 fatty acids in the modern diet has declined with the decreased intake of sources
of omega-3 fatty acids (particularly those coming from marine sources). The latest National Diet and
Nutrition Survey undertaken in the United Kingdom identified that 53 g of oily fish was consumed
per week, the equivalent to just 0.35 weekly servings (Henderson et al. 2002). In addition, studies
suggest that there has been an increase in the amount of n-6 fatty acids in the modern diet, which can
interfere with the metabolism and synthesis of DHA and EPA (Meyer et al. 2003). In addition, it has
been shown that omega-3 fatty acids are transferred from the mother to fetus and baby, throughout
gestation and while breastfeeding, which may result in their depletion (Browne et al. 2006).
2013
129 Diet in the Aetiology and Management of Postpartum Depression: Knowing the Facts
Fish oils supplements high in omega-3 fatty acids, has been used as psychotropic medications for the
treatment of major depression with conflicting results (van Strater and Bouvy 2007; Freeman et al.
2008). Other studies however, seem to support the theory that dietary and supplemental sources of
omega-3 fatty acids are associated with fewer PPD symptoms (Hibbeln 2002; Freeman et al. 2006a;
Miyake et al. 2006b). In addition, other studies revealed that women, with lower levels of plasma DHA
in late pregnancy and the early postpartum period, may be more likely to experience postpartum depres-
sive symptoms (Otto et al. 2003). De Vriese and colleagues also found that n-3 blood levels were con-
siderably lower in women who developed PPD than in women who did not (De Vriese et al. 2003).
One of the largest investigations to date, the Osaka Maternal and Child Health Study carried out a
prospective cohort in 865 Japanese women. Fourteen percent of Japanese women were diagnosed with
PPD and omega-3 and DHA intakes were inversely associated with PND (Miyake et al. 2006b).
An analysis of ecological studies from 23 countries revealed that high DHA levels in breast milk
and higher seafood consumption were positively predictive of lower rates of postpartum depression
(Hibbeln 2002). A review of epidemiological evidence and intervention studies reported an associa-
tion between low n-3 intake and depression (Rees et al. 2005), however, another review found incon-
sistent results in clinical trials with EPA and/or DHA (Freeman et al. 2006b). Similarly, Hosli and
colleagues in another review, found mixed results also; clinical studies contradicted observational
studies and findings from a meta-analysis were inconsistent (Hosli et al. 2007). Recent studies inves-
tigating the association between omega-3 fatty acids with both maternal depression and PPD and
their results are summarized in Table 129.3.
It is important to underline that the sample size and duration of follow-up and methodologies used
were problematic in some of the studies. It is also important to consider that occasionally different
diagnostic criteria for depression were used in many of these studies. Although most studies utilized
the Edinburgh Postnatal Depression Scale (EPDS), different cutoff points have been used, which
could explain partly, the above conflicting results.
129.2.2 Other Nutrients and PPD
The research on vitamins and minerals dietary intake and postnatal depression is limited (Abou-Saleh
et al. 1999; Miyake et al. 2006a). The few studies examining the effect of specific nutrients in relation
to mood disorder in women in pregnancy and the postpartum period, summarized in Table 129.4,
produce varying results, possibly due to the limitations on the study designs and methodologies used
(e.g. examining a single nutrient, small number of subjects, different methods assessing depression).
129.2.2.1 Calcium
Calcium seems to act as an intracellular messenger and stimulates the release of neurotransmitters
from the cerebral vesicles (calcium influx into a cell acts as a trigger, releasing neurotransmitters
from their storage vesicles) (Llinas 1977). In a randomized controlled trial, participants were divided
into two groups, one consuming 2,000 mg calcium per day, or a placebo (between 11 and 21 weeks
of gestation, n = 293). Depression was evaluated in the puerperium using the EPDS. Results indi-
cated that symptoms of depression were significantly reduced in subjects consuming calcium
carbonate tablets (P = 0.07) (Harrison-Hohner et al. 2001).
In another study, 4,589 women received either 1,000 mg of calcium or placebo tablets with their
morning and evening meals and a daily prenatal supplement (50 mg calcium, 30 mg iron, 400 IU
2014 V. Costarelli
Table 129.3 Studies investigating the association between omega-3 fatty acids with both maternal depression and PPD
Author, year Design and sample size Main findings
Strøm et al. (2009) Data from a large prospective cohort linked
with high-quality registers, n = 54,202
women. Intake of fish and omega-3
PUFAs was assessed in midpregnancy
with a food-frequency questionnaire
Weak evidence to support an
association between intake
of fish or omega-3 PUFAs
and PPD.
Su et al. (2008) Randomized controlled 8-week trial, n = 36
pregnant women, comparing omega-3
PUFAs (3.4 g/day) with placebo in
pregnant women with major depressive
disorder
Omega-3 PUFAs may have
therapeutic benefits in
depression during
pregnancy
Browne et al. (2006) Prospective cohort, n = 80 postnatal women,
41 diagnosed with depression and 39
controls. EPDS and BDI were used and an
FFQ during pregnancy
Both postnatal w-3 status and
fish consumption in
pregnancy were not
associated between PPD
Freeman et al. (2006a) Randomised controlled trial, n = 16 with PPD
who consumed a 0.5 g/day, 1.4 g/day or
2.8 g/day w-3 supplement daily for
8-weeks. Both the EPDS and Hamilton
Rating scale were used
Omega-3 fatty acids may play a
role in the treatment of PPD
Miyake et al. (2006a) Prospective cohort, n = 865 women who
completed a diet history questionnaire
during pregnancy alongside the EPDS
No significant association
found between dietary fish
and fat intake with PPD
Otto et al. (2003) Prospective cohort, n = 112 pregnant women.
Venous blood samples were collected at
week 36 of pregnancy, after delivery and
32 weeks after delivery, use of EPDS
DHA levels were significantly
lower in women with
depressive symptoms in
comparison to women
without depressive
symptomatology
De Vriese et al. (2003) Cross-sectional study, n = 48, 10 with PPD
and 38 without. Blood samples taken after
delivery analyzed for serum phospholipids
and cholesteryl esters.
Fatty acids concentration was
lower in women with
depression in comparison to
women without depression
Llorente et al. (2003) Randomized control trial in breast feeding
women. DHA (200 mg/day) n = 44 or
placebo (n = 45) for a 4 month period.
Plasma phospholipid fatty acids were
measured and depression was assessed
with a self-rating questionnaire and
interview
No difference between the two
groups on diagnosed or
self-rated depression. The
levels of DHA were
significantly higher in the
treatment group
Makrides et al. (2003) Cross-sectional cohort, n = 380 postpartum
women who completed the EPDS and
iron, zinc and DHA status were measured
For every 1% elevation in
plasma DHA there was a
significant 59% reduction in
symptoms of depression
Hibbeln (2002) Published prevalence data for postpartum
depression were included that used the
EPDS (n = 14532 subjects in 41 studies)
and measured the DHA, EPA and AA
content of breast milk (studies across 23
countries)
Higher concentrations of DHA
in mothers’ milk and
greater seafood consump-
tion both predicted lower
prevalence rates of
postpartum depression
Peet et al. (1998) Cross-sectional study, n = 30, 15 depressed
and 15 without
Women with depression
had significantly lower
levels of omega-3 fatty
acids and DHA
There is also good evidence that increasing the dietary omega-3 intake in late pregnancy or following delivery may
reduce the risk of PPD
2015
129 Diet in the Aetiology and Management of Postpartum Depression: Knowing the Facts
vitamin D) beginning before 22 weeks of gestation until delivery. Six weeks postpartum, the mean
EPDS scores were similar between treatment groups, however at 12 weeks, a significantly larger
proportion of women in the placebo group (15.3%) had EPDS scores >14 compared with the calcium
treated group (5.7%) (P = 0.014) (Levine et al. 1997).
It is possible that calcium supplementation may serve to stabilize calcium regulation at the intra-
cellular level in individuals with low calcium diets, which in turn would help to alleviate PPD; how-
ever, this is yet to be investigated.
129.2.2.2 Zinc
Another nutrient associated to mood is zinc, mainly through its possible influence on serotonin
uptake (Levenson 2006). There is also evidence that intervention with zinc has possible antidepres-
sant effects. In addition, studies have reported an association between low zinc status and depression
(Nowak et al. 2005; Levenson 2006). A relationship between decreased serum zinc concentration
and higher scores on the EPDS have been reported by Wójcik and colleagues. More specifically,
Table 129.4 Studies investigating the association between of selected mineral and vitamins and PPD
Author, year Design and sample size Nutrient Main findings
Wojcik et al. (2006) Observational, intervention study,
n = 66. Women received
standard vitamin, zinc and
magnesium supplementation.
Women completed EPDS 3
days and 30 days postpartum.
Serum zinc and magnesium
levels were also determined
Zinc (Zn) and
Magnesium (Mg)
The severity of postpartum
depression may be
associated with lower
serum zinc concentra-
tions but not
magnesium
Miyake et al. (2006b) Cross-sectional ecological study,
n = 865 Japanese women, diet
history questionnaire during
pregnancy alongside the EPDS
Riboflavin (B2) Riboflavin intake (3rd
quartile) was inversely
associated with a
decreased risk of
postpartum depression
Beard et al. (2005) Prospective, randomized,
controlled, intervention trial
was conducted in South Africa
nonanemic controls and anemic
mothers, n = 95. Mothers of
full-term normal birth weight
babies were followed from 10
weeks to 9 months postpartum
Iron (Fe) Strong relationship
between maternal iron
status and depression
Harrison-Hohner
et al. (2001)
Randomized intervention study, n
= 247. Women consumed either
a placebo or a 2,000 mg
calcium supplement daily for 6
weeks. At 6 weeks postpartum
women completed the EPDS
Calcium (Ca) Women in the calcium
interventions group had
significantly fewer
symptoms of
depression
Abou-Saleh
et al. (1999)
Case-control study, 23 pregnant
and 38 non pregnant controls.
The EPDS was completed 7
days after birth. Plasma
concentrations of tryptophan,
B12 and folate were measured
Folate and B12 Women with depressive
symptoms consumed
significantly lower
levels of folate
compared to the
controls.
The studies examining the effect of specific nutrients in relation to mood disorder in women in pregnancy and the
postpartum period, summarized in this table, produce varying results
2016 V. Costarelli
serum zinc concentrations 30 days postpartum were associated with alleviated symptoms of depression.
In the same study, no statistically significant findings were reported with regard to serum magnesium
concentrations and depressive symptoms (Wojcik et al. 2006).
129.2.2.3 Iron
It is documented that iron deficiency can lead to reduced memory and learning ability, impaired
mood and cognition or behavioural abnormalities. As far as PPD is concerned, Beard and colleagues
reported a strong relationship between maternal iron status and depression in a study that followed
mothers of full-term normal-birth-weight babies from 10 weeks to 9 months postpartum (Beard et al.
2005). However, more studies are needed to confirm the above findings.
129.2.2.4 Folate and Other Vitamins
Folate is needed for the biosynthesis of the neurotransmitters: serotonin, dopamine and norepineph-
rine. In addition, it has been shown that the active metabolite of folate, 5-methyltetrahydrofolate, is
required for remethylation of homocysteine in the production of methionine, which is involved in a
number of biochemical processes involving the above neurotransmitters (Miller 2008). As a result,
it is likely that a deficiency in folate would affect the production and function of these important
neurotransmitters. Vitamin B6 is also involved in neurotransmitter pathways as a cofactor in the pro-
duction of serotonin from tryptophan. Low plasma levels of the B6 derivative, pyridoxal phosphate,
have been associated with symptoms of depression (Hvas et al. 2004). In addition, vitamin B12 plays
an important role in the neurological function as a cofactor in the formation of Sadenosylmethionine,
an intermediate for production of the neurotransmitters (Coppen and Bolander-Gouaille 2005).
A very small number of studies were set out to examine the effects of folate and other B vitamin
consumption in relation to the development of PPD (Abou-Saleh et al. 1999; Miyake et al. 2006a). In a
large recent epidemiological study conducted by Miyake et al. (2006b), 865 Japanese women were
asked to complete a diet history questionnaire and the EPDS at 2–9 months postpartum. No associations
were identified in this investigation between dietary intakes of vitamin B6, B12 or dietary folate in rela-
tion to the onset of postnatal depression with the exception of riboflavin (mean intake 1.4 mg/day)
which was inversely associated with symptoms of PPD (Miyake et al. 2006a). In another study, Abou-
Saleh et a.l (1999) monitored plasma folate and vitamin B12 concentrations and screened women (n = 62)
for depression using the EPDS in the puerperium. Cases with PPD had lower folate levels when com-
pared with controls (P < 0.01), whereas, multiple regression analysis revealed that high vitamin B12
concentrations were associated with increased EPDS scores (P < 0.01) (Abou-Saleh et al. 1999).
Further studies are needed in this field in order to elucidate the possible role of folate and other B
vitamins in the prevention and management of PPD.
129.3 Conclusions
Proper nutrition during pregnancy is vital as evidence suggests that nutrient intake can be a key factor
in a woman’s vulnerability to postpartum depression. It has been proposed that depletion of nutrient
reserves throughout pregnancy and a lack of recovery postpartum may increase a woman’s risk for
2017
129 Diet in the Aetiology and Management of Postpartum Depression: Knowing the Facts
postpartum depression. Research indicates that an inadequate intake of omega 3 during pregnancy
and the perinatal period may be strongly associated with the onset of PND. It is possible that omega-3
and other fatty acids may protect against the onset of PND; however, much larger investigations
using prospective methodologies and larger sample sizes are now required to reinforce the findings
of these investigations. Further research is also needed to evaluate the safety and recommended lev-
els of fish oil consumption since methlymercury and additional contaminants may be present in
larger oily fish.
Weaker relationships have been identified between symptoms of PND and folate, B12, calcium
and zinc intake. More studies are needed to investigate the role of diet and nutrition in the aetiology
and management of PPD so that specific dietary recommendations can be formed.
129.4 Applications to Other Areas of Health and Disease
Midwifery and nursing: It would be useful to educate midwifes and nurses on the role of diet on the
aetiology and management of PPD, so that they can better inform women in pregnancy and in the
postpartum.
Social work and counseling: A higher risk of postpartum depression has been reported among
socially disadvantaged women and women of ethnic minority groups; as a result, alerting social
workers and counsellors on the important of nutrition on PPD would be beneficial.
Nutrigenomics: It would be interesting to investigate in the future the possible provision of tailor-
made nutritional advice to women with a specific genome, predisposing them to PPD.
Nutrition and PPD
Nutrient inadequacies in
pregnant women might
be associated with PPD
Decreased or increased
appetite in the
postpartum due to the
onset of PPD might
further affect nutrition
status
Low dietary intake of
omega-3 fatty acids
(EPA, DHA)
Low dietary intake of
calcium, magnesium,
selenium and iron
Low dietary intake of
folate and B vitamins
Depletion of nutrient
reserves throughout
pregnancy and lack of
recovery in the
postpartum
Omega-3 fatty acids are
transferred from the mother
to fetus and baby in the 3rd
trimester of gestation and
whilst breastfeeding
Rapid decrease in insulin
levels during the
postpartum period
Carbohydrate-rich diet
may improve postpartum
mood disorders
Fig. 129.2 Keys points linking nutrition with PPD. Evidence suggests that depletion of nutrient reserves throughout
pregnancy can increase the risk of PPD. There is also good evidence that increasing the dietary omega-3 intake in late
pregnancy or following delivery may reduce the risk of PPD. The role of the inadequate intake of folate, calcium, zinc
and iron intake on the onset of PPD has also been investigated
2018 V. Costarelli
Summary Points
Prevalence of postpartum depression (PPD) is increasing worldwide and has potentially •
detrimental effects on both the mother and the offspring.
Depletion of nutrient reserves throughout pregnancy can increase a woman’s risk for PPD.•
Evidence suggests that inadequate intake of specific nutrients might be a substantial contributor •
to the development of depression in women in the postpartum period.
The role of the inadequate intake of folate, calcium, zinc and iron intake on the onset of PPD has •
been investigated, with conflicting results.
There is good evidence that increasing the dietary omega-3 intake in late pregnancy or following •
delivery may reduce the risk of PPD.
Definitions of Key Terms
Postpartum (or postnatal) depression: It is a condition that affects women who have recently
had a baby, with most cases occurring in the first 6 months after delivery. It is a serious mental
health problem characterized by a prolonged period of emotional disturbance.
Perinatal (or maternal) depression: This refers to major and minor episodes of depression dur-
ing pregnancy.
Postpartum blues: This is defined as short lived episodes of depressive symptoms such as anxi-
ety, disturbed sleeping patterns, decreased appetite and irritability, normally taking place on day
4 after delivery but may commence up to 2 weeks after delivery.
Postpartum psychosis: This is the most severe form of postpartum psychiatric illness. It is a
rare event that occurs in approximately 1–2 per 1,000 women after childbirth. Its presentation is
often dramatic, with onset of symptoms as early as the first 48–72 h after delivery.
Edinburgh postnatal depression scale: This is a 10-item questionnaire that may be used to iden-
tify women who have PPD. Usually a score of 12 or greater or an affirmative answer on question 10
(presence of suicidal thoughts) raise concern and indicate a need for more thorough evaluation.
Key facts of Postpartum Depression
Postpartum depression (PPD), also called postnatal depression, is a form of clinical depression
which can affect women after childbirth and has significant consequences for both the new
mother and family.
Prevalence of postpartum depression worldwide is approximately 13% to 20%; however, these
are probably conservative estimates because the condition is often underreported or
underdiagnosed.
Main symptoms of PPD include sadness, anxiety, fatigue, insomnia, appetite changes, crying
episodes, and irritability.
The causes of PPD remain unclear, with research suggesting a multifactorial aetiology. The stron-
gest predictors of postpartum depression seem to be the personal and family history of depression,
depression and anxiety during pregnancy and most importantly the lack of social support.
It has been suggested that postpartum depression can partly be attributed to depletion of
omega-3 fatty acids from the mother’s brain to support development of the brain of the fetus
or breast-fed infant. Ensuring a sufficient supply of omega 3 fatty acids in the mother’s diet is
very important.
2019
129 Diet in the Aetiology and Management of Postpartum Depression: Knowing the Facts
Acknowledgment Special thanks to Professor Victor Preedy for providing me with the opportunity to contribute to
the Current book by writing a chapter on such an interesting topic.
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Rutter's Child and Adolescent Psychiatry has become an established and accepted textbook of child psychiatry. Now completely revised and updated, the fifth edition provides a coherent appraisal of the current state of the field to help trainee and practising clinicians in their daily work. It is distinctive in being both interdisciplinary and international, in its integration of science and clinical practice, and in its practical discussion of how researchers and practitioners need to think about conflicting or uncertain findings. This new edition now offers an entirely new section on conceptual approaches, and several new chapters, including: neurochemistry and basic pharmacology brain imaging health economics psychopathology in refugees and asylum seekers bipolar disorder attachment disorders statistical methods for clinicians This leading textbook provides an accurate and comprehensive account of current knowledge, through the integration of empirical findings with clinical experience and practice, and is essential reading for professionals working in the field of child and adolescent mental health, and clinicians working in general practice and community pediatric settings.
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