Papers

Maternity blues and major endocrine changes: Cardiff puerperal mood and hormone study II

Department of Psychological Medicine, University of Wales College of Medicine, Cardiff CF6 2YA Department of Medical Computing and Statistics, University of Wales College of Medicine Department of Psychiatry, Leighton Hospital, Crewe CW1 4QJ Steroid Assay Laboratory, Tenovus Institute, University Hospital of Wales, Cardiff CF4 4XW Correspondence to: Dr Harris.

Abstract

Objectives : To define relation between mood and concentrations of progesterone and cortisol during perinatal period to test hypothesis that rapid physiological withdrawal of steroid hormones after delivery is associated with depression.
Design : Prospective study of primiparous women from two weeks before expected date of delivery to 35 days postpartum.
Setting : Antenatal clinic in university hospital, obstetric inpatient unit, patients' homes.
Subjects : 120 of 156 primiparous women interviewed. Remainder excluded because of major marital, socioeconomic, or medical problems or because caesarean section required.
Main outcome measures : Concentrations of progesterone and cortisol in saliva samples; women's moods assessed by various scores for depression. Results - Changes in salivary progesterone and cortisol concentrations were similar to those already characterised for plasma. Peak mean score for maternity blues (5.3 on Stein scale) was on day five postpartum (P<0.02 compared with mean scores on other postpartum days). High postpartum scores for maternity blues were associated with high antenatal progesterone concentrations on day before delivery (P<0.05), with high rate of rise of antenatal progesterone concentrations (P<0.05), with decreasing progesterone concentrations from day of delivery to day of peak blues score (P>=0.01), and with low progesterone concentrations on day of peak blues score (P<0.01). Seventy eight women were designated as having maternity blues (peak score >=8 on Stein scale) while 39 had no blues. Women with blues had significantly higher antenatal progesterone concentrations and lower postnatal concentrations than women without blues (geometric mean progesterone concentrations: one day before delivery 3860 pmol/l v 3210 pmol/l respectively, P=0.03; ten days postpartum 88 pmol/l v 114 pmol/l, P=0.048). Cortisol concentrations were not significantly associated with mood.
Conclusion : Maternal mood in the days immediately after delivery is related to withdrawal of naturally occurring progesterone.

Introduction

Maternity blues refers to the tearfulness, irritability, hypochondriasis, sleeplessness, impairment of concentration, and headache that occurs in the 10 days or so postpartum.^1,2 A peak in symptoms occurs around the fourth to fifth day after delivery,^3,4 coinciding with maximal hormonal changes.⁵ These include falling concentrations of progesterone, oestradiol, and cortisol and rising prolactin concentrations. Such hormonal changes may have a causal relation to blues. Changes in concentrations of progesterone and its derivatives are of particular interest because of its well documented anaesthetic action.*RF 6-8* During pregnancy, progesterone concentrations slowly rise to a maximum at term, when they are several hundred times higher than normal.⁵ After delivery and the withdrawal of the placenta there is a precipitate drop in progesterone concentration. It is therefore possible that the symptoms of maternity blues are related to progesterone withdrawal. Cortisol concentrations also rise during pregnancy to several times their normal values. They rise further during the stress of labour and then slowly return to normal within 15 days of delivery.

Monitoring concurrent changes in mood and hormone concentrations has been difficult, however, because frequent venepuncture is unacceptable and because total hormone concentrations are usually measured ⁹ whereas only a small fraction of the hormone is free and biologically active.¹⁰ Over the past 15 years saliva sampling has been developed as an alternative to blood sampling for measuring cortisol and progesterone concentrations by means of sensitive radioimmunoassay techniques.¹¹ Concentrations in saliva accurately reflect plasma concentrations of free hormone even under conditions of altered saliva flow.^12,13 It has also been shown that concentrations of steroid hormones in the cerebrospinal fluid are closely correlated with plasma concentrations of unbound hormone¹⁴ so that salivary concentrations are likely to accurately reflect concentrations in cerebrospinal fluid.

The purpose of the present study was to test the hypothesis that postnatal depressed mood is related to the withdrawal of progesterone or cortisol after delivery.

Subjects and methods

Primiparous women, who were booked to remain in hospital for five days after delivery according to the normal obstetric practice in Cardiff, underwent an initial screening interview by two research nurses two weeks before the expected date of delivery. The study design was similar to that of Nott et al.⁹ Women were given an informal explanation in the antenatal clinic some weeks before entry into the study. They were also given an information sheet and were told that they would be paid £ 10 on completing the study.

The screening process and entry were completed at the routine antenatal clinic. Only eight women refused to be involved in the study, and 156 women were interviewed by one of the research nurses. The women were asked to discuss their relationship with their husband or partner and then to rate it on a simple scale as excellent, very good, good, fair, or poor. Women who rated their relationship as fair or poor were excluded from the study. Similarly, those with physical illness that required continuing treatment or who had had admissions to hospital during their pregnancies were excluded. Women who were homeless or in considerable financial difficulties were also excluded from the study.

Altogether, 26 women were excluded because of substantial marital, health, or socioeconomic problems. The resultant sample of 130 women was about 5% of the total number of primiparous women who delivered at the hospital during the two years of the study. This sample size was calculated to yield a power of about 80% to detect a correlation of 0.25 with a 5% level hypothesis test.

Assessment of mood

At the initial interview the women gave their full informed consent for participation and completed questionnaires for self rating of mood - based on the Edinburgh postnatal depression scale,¹⁵ the Stein scale for maternity blues,¹⁶ and the Beck depression rating inventory.¹⁷ After delivery the women completed a questionnaire based on the Stein scale each evening for 10 days. At 35-40 days after delivery each mother was assessed at a home visit (to be reported elsewhere) by an experienced psychiatrist (BH or LL). A clinical assessment was made using criteria for major depression (Diagnostic and Statistical Manual of Mental Disorders, third edition, revised), followed by completion of questionnaires based on the Montgomery and Asberg depression rating scale and the Edinburgh postnatal depression scale. Life events that had occurred during the preceding year were noted on the Paykel life events schedule, and each mother was given a Beck depression rating inventory for later completion and return by post.

Measurement of hormone concentrations

Saliva sampling - The women were shown how to collect saliva and were asked to take samples at 0800 and 2200 hours daily until delivery; at 0800, 1400, and 2200 hours daily for the next five days; and then again at 0800 and 2200 hours daily until the home visit. Saliva samples and it were kept in the ice box compartment of a fridge or in a deep freeze.

Blood sampling - Blood samples were collected at the initial screening interview and at one, five, and 35 days after delivery.

Hormone assays - Plasma concentrations of progesterone and oestradiol were measured with commercial radioimmunoassay kits (Coat-A-Count and Double Antibody, Diagnostic Products, Caernarfon), and concentrations of plasma cortisol, salivary cortisol, and salivary progesterone were determined as described previously.^18,19 All 9654 saliva samples (75% compliance) were processed for progesterone. However, only 4862 selected samples were assayed for cortisol: patients were graded according to their scores on the Edinburgh depression scale that they completed at their final psychiatric assessment, and saliva samples were assayed from the 20 highest scoring women, the 20 lowest scoring, and the 20 scoring nearest the middle of the range.

Statistical methods

Progesterone and cortisol concentrations were log transformed for analyses because of gross positive skewness. All comparisons between women who developed maternity blues and whose who did not are thus ratios. Decrements in log concentrations of progesterone and cortisol were calculated by comparing postnatal values with an average of prenatal values from seven to two days before delivery. To measure associations between prenatal progesterone concentrations and postnatal blues, each woman was assigned log progesterone concentrations for days 14 and 1 before delivery and a gradient of increasing progesterone log concentration from day 14 to day 1 based on an individual regression model. The slope was calculated only if based on 10 or more readings. The log concentration for day 1 before delivery was taken from the regression equation if there were 10 or more readings, otherwise a simple average of available readings was used. The log concentration for day 14 was fitted only if 10 or more readings as early as this were available. Because of the nature of the Stein scale, and notwithstanding the use of log transformation, associations were measured by the Spearman rank correlation.

Results

None of the 130 women recruited into the study delivered a stillborn or severely handicapped child, but only 120 had vaginal deliveries - 71 were spontaneous and 49 were induced. The 10 women who required a caesarean section were excluded from the study. The remaining women were aged 18-40 with a mean (SD) of 26.4 (4.4) years. At the final interview 57 women were breast feeding and 61 were bottle feeding (feeding status was not recorded for two women). Nine of those breast feeding and 15 of those bottle feeding were taking oral contraceptives.

Psychometry

Most women experienced some symptoms of blues in the 10 days after delivery: Stein scores ranged from 0 to 24, and 80 (67%) of the women scored 8 or above (the cut off point for having maternity blues suggested by Stein) on one or more days. The trimmed mean score (based on the middle 90% of values) fell from 5.0 on day 1 postpartum to 3.9 on day 3, rose to 5.3 on day 5, and fell to 3.7 on day 10 (Friedman test, P<0.02; two way analysis of variance on normal scores, P<0.001).

Individual subjects' profiles of Stein scores did not approximate to smooth curves, and there was no clear pattern of the timing of their peak scores. Peak Stein scores were associated with symptoms of antenatal depression (based on antenatal score for Edinburgh postnatal depression scale) (Spearman rank correlation, r=0.31, P<0.001).

Hormone concentrations

Figure 1 shows the changes in salivary concentrations of progesterone during the last two weeks of pregnancy and the first 35 days after delivery. There was no circadian variation in concentration but a continual significant rise before delivery up to a concentration of 3855 pmol/l on the day before delivery (plasma equivalent 694.8 nmol/l). In the first four to five days after delivery the concentration dropped precipitately to typical values of 150 pmol/l by day 5 postpartum and 80 pmol/l by day 10; (plasma equivalents 7.7 nmol/l and 2.7 nmol/l respectively).

View larger version (29K): [in this window] [in a new window]   FIG 1 - Salivary progesterone concentrations in women during perinatal period. Statistical analysis of results described by Harris et al20

Figure 2 shows salivary cortisol concentrations. Evening concentrations rose slowly during the last 30 days of pregnancy with a highly significant rise on the evening before delivery. There was also a slow but significant fall in morning cortisol. Diurnal rhythm was still detectable the day before delivery with morning saliva concentrations of 13.3 nmol/l falling to 5.5 nmol/l by day 15 postpartum (plasma equivalents 530 nmol/l and 200 nmol/l respectively). Of those subjects for whom cortisol concentrations were assayed, 23 had had induced deliveries with artificial rupture of the membranes. There was no significant difference in the profiles of cortisol concentrations for these women compared with those for women who had spontaneous delivery: in both groups concentrations returned to normal by about day 15 postpartum.

View larger version (28K): [in this window] [in a new window]   FIG 2 - Salivary cortisol concentrations in women during perinatal period. Statistical analysis of results described by Harris et al20

Plasma progesterone, oestradiol, and cortisol concentrations in late pregnancy and immediately after delivery were similar to those reported by other workers^5,10,21 (detailed results available from the authors).

Associations of hormone concentrations and psychometric scores

Table I shows that there were significant positive associations between women's blues scores on early postpartum days and their antenatal morning and evening progesterone concentrations. Also, the steeper the rise in antenatal progesterone concentrations the higher the peak blues score. Table II shows that the greater the postnatal fall in progesterone concentrations (from the average concentration on days 7 to 2 before delivery) the higher the peak Stein score. Of a total of 66 correlations between the morning and evening progesterone concentrations on prenatal days 14 and 1, and the gradients between those days, with the Stein scores on each of the postpartum days, 16 reached the 5% level of significance (table I) whereas only three or four would be expected to occur by chance.

TABLE I - Associations (Spearman rank correlations) of prenatal salivary
progesterone concentrations with postpartum Stein scores for maternity blues
(Stein scale)
------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                           Gradient of concentration increase
               Concentration one day before delivery        Concentration 14 days before delivery                 (from day 14 to day 1)

                  Morning                  Evening              Morning                 Evening               Morning                  Evening

             r Value     No of       r Value     No of      r Value       No of     r Value     No of      r Value     No of      r Value      No of
            (P Value)   subjects    (P Value)   Subjects   (P value)    Subjects   (P value)   Subjects   (P value)   Subjects   (P value)   Subjects
------------------------------------------------------------------------------------------------------------------------------------------------------
  Day 1       0.25        70         0.28         69         0.33          38        0.18         38         0.15        47         0.32         47
             (0.03)                 (0.02)                  (0.05)                  (0.27)                  (0.33)                 (0.03)
  Day 2       0.17       105         0.22        104         0.16          60        0.09         61         0.26        74         0.42         73
             (0.08)                 (0.02)                  (0.23)                  (0.47)                  (0.03)                 (0.001)
  Day 3       0.17       105         0.22        104         0.30          60        0.29         61        -0.03        74         0.01         73
             (0.08)                 (0.02)                  (0.02)                  (0.03)                  (0.83)                 (0.91)
  Day 4       0.22       104         0.29        103         0.24          60        0.21         61         0.03        74         0.05         73
             (0.03)                 (0.004)                 (0.07)                  (0.11)                  (0.83)                 (0.67)
  Day 5       0.13        99         0.08         98         0.18          56        0.13         57         0.23        70         0.05         69
             (0.21)                 (0.44)                  (0.18)                  (0.32)                  (0.05)                 (0.66)
  Day 6       0.11        99         0.13         98         0.04          57        0.02         58         0.20        71         0.13         70
             (0.26)                 (0.19)                  (0.78)                  (0.86)                  (0.10)                 (0.28)
  Day 7       0.07        98         0.06         97        -0.11          56       -0.04         57         0.25        70         0.12         69
             (0.49)                 (0.58)                  (0.42)                  (0.74)                  (0.04)                 (0.33)
  Day 8       0.14        97         0.09         96         0.06          55        0.09         56         0.17        69         0.08         68
             (0.16)                 (0.40)                  (0.68)                  (0.52)                  (0.14)                 (0.50)
  Day 9       0.00        98         0.02         97        -0.01          56       -0.03         57         0.09        70         0.04         69
             (0.90)                 (0.82)                  (0.97)                  (0.80)                  (0.43)                 (0.70)
  Day 10      0.02        95         0.03         94         0.14          54        0.16         55         0.02        68        -0.04         67
             (0.84)                 (0.80)                  (0.30)                  (0.26)                  (0.87)                 (0.75)
Peak Stein    0.20       105         0.21        104         0.13          60        0.12         61         0.22        74         0.14         73
  score      (0.04)                 (0.03)                  (0.32)                  (0.38)                  (0.06)                 (0.25)
  (recorded
  during days
  1-10)

TABLE II - Associations (Spearman rank correlations) of peak Stein scores for maternity blues with postnatal
salivary concentrations of progesterone and cortisol and with changes in these concentrations
--------------------------------------------------------------------------------------------------------------
                                                              Correlation with peak Stein score

                                                        Progesterone                       Cortisol

                                                            No of                            No of
                                                r Value   subjects    P value    r Value   subjects   P value
--------------------------------------------------------------------------------------------------------------
Concentrations on days after delivery*:
 Evening value on day 4                          -0.22       89         0.04      +0.11       51       0.45
 Decrement to morning value on day 5             +0.23       89         0.03      -0.10       49       0.48
 Decrement to evening value on day 5             +0.08       80         0.47      +0.07       40       0.67
 Morning value on day 5                          -0.22       93         0.003     +0.12       54       0.39
 Average morning value for days 9-11             -0.24      100         0.02      -0.19       54       0.17
 Average evening value for days 9-11             -0.20       96         0.05      +0.01       52       0.95
 Morning value on day of peak Stein score        -0.28       86         0.008     -0.19       49       0.18
 Decrement to morning value on day of peak
  Stein score                                    +0.28       82         0.01      +0.17       46       0.28
 Gradient from day 2 to day 10                   -0.28       81         0.01      -0.25       39       0.12
--------------------------------------------------------------------------------------------------------------
 *All changes relative to an average of log concentrations for each subject on days 7 to 2 before delivery.

For the whole group there was an inverse association between the blues score on a particular day and the progesterone concentration on that day. There was also an inverse association between peak blues score and the drop in progesterone concentration from days 2 to 10 postpartum (table II). Of 50 correlations between the peak Stein score and various prenatal and postnatal progesterone concentrations (including the decrements from prenatal to postnatal days), 10 reached the 5% level of significance and four reached the 1% level or beyond. The Stein score on day 5 postpartum correlated positively with the progesterone concentration on day 4 (r=0.22, P=0.05, n=78), possibly indicating an association with the fall in progesterone concentration between days 4 and 5 postpartum.

Of the 118 subjects who completed antenatal Stein questionnaires, 78 scored >=8 (the cut off point for maternity blues) at some time after delivery, while the remaining 39 women scored below the cut off point. There was a significant tendency for the antenatal progesterone concentrations to be higher and the postnatal progesterone concentrations to be lower in the group of women with blues compared with those without blues. For example, the geometric mean progesterone concentrations on the morning of the day before delivery were 3860 pmol/l for 68 women with blues and 3210 pmol/l for 36 women without blues, giving an estimated ratio of 1.20 (95% confidence interval 1.02 to 1.42) (t=1.15, P=0.027). Also, the geometric means of the ratio of progesterone concentration on day of peak Stein score to the prenatal value were 0.043 for 55 women with blues and 0.072 for 27 women without blues (estimated ratio 0.60 (0.42 to 0.86), t=2.82, P=0.006).

Statistical analyses were also applied to saliva cortisol concentrations, but no significant associations emerged (table II). Spearman rank correlations were also calculated for peak Stein scores with plasma hormone concentrations and changes in these across delivery. There were no associations of blues with plasma hormones, neither their mean concentrations at the times of plasma sampling nor the decrements in concentrations from before delivery to day 5 postpartum.

Discussion

The high prevalence of maternity blues and its relative ease of detection has led to many investigations of possible causes. Steroid hormones, body weight, fluid and electrolytes,²² calcium concentrations,²³ monoamines,²⁴ tryptophan,²⁵ and platelet receptors²⁶ have all been studied for associations with blues. So far as steroid hormones are concerned, there are practical implications: severe blues often progresses into a major depressive episode,²⁷ and some have advocated treatment with progesterone,²⁸ assuming that depressed mood is linked to falling progesterone levels.

Our results show that there is a weak but significant association of maternity blues with higher antenatal salivary progesterone concentrations, lower concentrations shortly after delivery, and greater decreases in concentration from antenatal to postnatal values. This was not confirmed with plasma progesterone, possibly because total plasma progesterone concentration (only a small proportion of which is free and biologically active) was measured. A similar negative finding was reported by O'Hara et al, who also measured total plasma progesterone.²⁹ Anderson et al showed that, despite the progesterone concentration rising several hundred times in late pregnancy, the amount of free progesterone remains relatively small, being at most 2.8% of the total.¹⁰ The development of blues can therefore be explained at least partly in terms of withdrawal of naturally occurring progesterone.

Animal studies have shown that progesterone has an anaesthetic action, especially the pregnanolone derivatives.^6,8,30 These occur in women and may be more closely related with blues than progesterone itself. This possibility was partly predicted by Selye,^8,31 who suggested the possible use of such hormones as "sleeping pills, tranquillizers," or for "treatment for mental derangements."

Our results are supported by Nott et al, who in a much smaller group of 27 women found that the greater the drop in progesterone concentration from antenatal values the more likely were subjects to rate themselves as depressed within 10 days of delivery. So far as cortisol is concerned, our work gives no support to the idea that its withdrawal is important in generating blues.

Further research should concentrate on the possible association of maternity blues with the pregnanolone derivatives of progesterone and on the effect of treatment with progesterone on the severity of blues.

This work was financed by a grant from the Wellcome Trust. We thank the research nurses Sister Mildred Jones and Sister Eirlys Davies for their work.

1. Victoroff VM. Dynamics and management of para partum neuropathic reactions. Diseases of the Nervous System 1952;13:291-8.
2. Pitt B. Maternity blues. Br J Psychiatry 1973;122:431-3. [Medline]
3. Kendell RE, McGuire RJ, Connor Y, Cox JL. Mood changes in the first 3 weeks after childbirth. J Affective Disord 1981;3:317-26. [Medline]
4. Kennerley H, Gath D. `maternity blues' 1: Detection and measurement by questionnaire. Br J Psychiatry 1989;155:356-62. [Abstract/Free Full Text]
5. Martin MC, Hoffman PG. The endocrinology of pregnancy. In: Greenspan FS, Forsham PH, eds. Basic and clinical endocrinology. 2nd ed. Los Altos, CA: Lange, 1986:476-500.
6. Gyermek L, Soyka LF. Steroid anaesthetics. Anaesthesiology201975;42:331-43.
7. Majewska MD, Harrison NL, Schwartz RD, Barker JL, Paul SM. Steroid hormone metabolites are barbiturate like modulators of the GABA receptor. Science 1986;232:1004-7. [Abstract/Free Full Text]
8. Selye H. The anaesthetic effect of steroid hormones. Proc Soc Exp Biol Med 1941;46:116-21.
9. Nott PN, Franklin M, Armitage C, Gelder MG. Hormonal changes and mood in the puerperium. Br J Psychiatry 1976;128:379-83. [Abstract/Free Full Text]
10. Anderson PJB, Hancock KW, Oakey RE. Non-protein bound oestradiol andprogesterone in human peripheral plasma before labour and delivery. J Endocinol 1985;104:7-15. [Abstract]
11. Read GF, Riad-Fahmy D, Dyas J. Immunoassays employing magnetisable, solid phase, anti-steroid sera. In: Hunter WM, Corrie JET, eds. Immunoassays for clinical chemistry. Edinburgh: Churchill Livingstone, 1983:163-9.
12. Harris B, Watkins S, Cook N, Walker RF, Read GF, Riad-Fahmy D. Comparisons of plasma and salivary cortisol determinations for the diagnostic efficacy of the dexamethasone suppression test. Biol Psychiatry 1990;27:897-904. [Medline]
13. Riad-Fahmy D, Read GF, Walker RF, Walker SM, Griffiths K. Determination of ovarian steroid hormone levels in saliva. J Reprod Med 1987;32:254-72. [Medline]
14. Backstrom T, Carstensen H, Sodergad R. Concentration of estradiol, testosterone and progesterone in cerebrospinal fluid compared to plasma unbound and total concentrations. J Steroid Biochem 1976;7:469-72. [Medline]
15. Cox JL, Holden JM, Sagovsky R. Detection of post-natal depression. Development of the 10-item Edinburgh post-natal depression scale. Br J Psychiatry 1987;150:782-6. [Abstract/Free Full Text]
16. Stein GS. The pattern of mental change and body weight in the first post partum week. J Psychosom Res 1980;24:1165-71.
17. Beck AT, Ward CH, Mendelson M, Mock J, Baugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961;4:561-71.
18. Cook N, Harris B, Walker R, Hailwood R, Jones E, Johns S, et al. Clinical utility of the dexamethasone suppression test assessed by plasma and salivary cortisol determinations. Psychiatry Res 1986;18:143-50. [Medline]
19. Walker RF, Read GF, Riad-Fahmy D. Radio immunoassay of progesterone in saliva: application to the assessment of ovarian function. Clin Chem 1979;25:2030-7. [Abstract/Free Full Text]
20. Harris B, Lovett L, Roberts L, Read G, Riad-Fahmy D. Cardiff puerperal mood and hormone study. Paper 1: Saliva steroid hormone profiles in late pregnancy and the puerperium: endocrine factors and parturition. Horm Res 1993;39:138-45. [Medline]
21. Monheit AG, Cousins L, Resnick R. The puerperium, anatomic and physiological readjustments. Clin Obstet Gynecol 1980;23:973. [Medline]
22. Stein GS, Marsh A, Morton J. Mood, weight and urinary electrolytes in the first post-partum week. J Psychosom Res 1981;25:395-401. [Medline]
23. Riley DM. A study of serum calcium in relation to puerperal mental illness. In: Carenza L, Zichella L, eds. Emotions and reproduction. Vth international congress of psychosomatic obstetrics and gynaecology, Rome 1977. London: Academic Press, 1979:829-36.
24. Treadway CR, Kane FJ, Jarreni-Zadeh A, Lipton MA. A20psychoneuroendocrine study of pregnancy and the puerperium. Am J Psychiatry 1969;125:1380-92. [Abstract/Free Full Text]
25. Handley SL, Dunn TL, Waldron G, Baker JM. Tryptophan, cortisol and puerperal mood. Br J Psychiatry 1980;136:498-508. [Abstract/Free Full Text]
26. Metz A, Stump K, Cowen PJ, Elliott JM, Gelder MG, Grahame-Smith DG. Changes in platelet 2 adrenoceptor binding post partum: possible relation to maternity blues. Lancet 1983;i:495-8.
27. Cox JL, Connor Y, Kendell RE. Prospective study of the psychiatric disorders of childbirth. Br J Psychiatry 1982;140:111-7. [Abstract/Free Full Text]
28. Dalton K. Successful prophylactic progesterone for idiopathic post- natal depression. International Journal of Prenatal and Perinatal Studies 1989:322 -7.
29. O'Hara MW, Schlechte JA, Lewis DA, Wright EJ. Prospective study of post partum blues. Arch Gen Psychiatry 1991;48:801-6. [Abstract]
30. Arafat ES, Hargrove JT, Maxson WS, Desiderio DM, Wentz AC, Anderson RN. Sedative and hypnotic effects of oral administration of micronized progesterone may be mediated through its metabolites. Am J Obstet Gynecol 1988;159:1203-9. [Medline]
31. Selye H. The general adaption syndrome. J Clin Endocrinol 1946;6:117-230.

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

Relevant Article

Management of postnatal depression

Charles Musters, Elizabeth McDonald, and Ian Jones
BMJ 2008 337: a736. [Extract] [Full Text]

This article has been cited by other articles:

• Musters, C., McDonald, E., Jones, I. (2008). Management of postnatal depression. BMJ 337: a736-a736 [Full text]  
• Halari, R., Kumari, V., Mehrotra, R., Wheeler, M., Hines, M., Sharma, T. (2004). The Relationship of Sex Hormones and Cortisol with Cognitive functioning in Schizophrenia. J Psychopharmacol 18: 366-374 [Abstract]  
• Miller, L. J. (2002). Postpartum Depression. JAMA 287: 762-765 [Full text]  
• Paoletti, A. M., Floris, S., Mannias, M., Orrù, M., Crippa, D., Orlandi, R., Del Zompo, M., Melis, G. B. (2001). Evidence That Cyproterone Acetate Improves Psychological Symptoms and Enhances the Activity of the Dopaminergic System in Postmenopause. J. Clin. Endocrinol. Metab. 86: 608-612 [Abstract] [Full text]  
• NAPPI, R. E., PETRAGLIA, F., LUISI, S., POLATTI, F., FARINA, C., GENAZZANI, A. R. (2001). Serum Allopregnanolone in Women With Postpartum "Blues". Obstet Gynecol 97: 77-80 [Abstract] [Full text]  
• Hendrick, V., Altshuler, L. L., Suri, R. (1998). Hormonal Changes in the Postpartum and Implications for Postpartum Depression. Psychosomatics 39: 93-101 [Abstract] [Full text]  
• Ploeckinger, B., Dantendorfer, K., Ulm, M., Baischer, W., Derfler, K., Musalek, M., Dadak, C. (1996). Rapid decrease of serum cholesterol concentration and postpartum depression. BMJ 313: 664-664 [Full text]  
• Ramsay, R., Fahy, T. (1995). Recent Advances: Psychiatry. BMJ 311: 167-170 [Full text]  
• (1994). A HORMONAL CAUSE FOR THE POSTPARTUM BLUES?. JWatch General 1994: 7-7 [Full text]