Psychosocial and psychological interventions for prevention of postnatal depression: systematic review
BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7507.15 (Published 30 June 2005) Cite this as: BMJ 2005;331:15
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An obvious easily treatable cause of postnatal depression, common
nutritional deficiencies especially of zinc and fish oils, has not been
mentioned in the responses to the article on psychosocial and
psychological interventions by Cindy- Lee Dennis.1
In contrast, Bodnar and Wisner write that child bearing-aged women
are particularly vulnerable to the adverse effects of poor nutrition on
mood because pregnancy and lactation are major nutritional stressors to
the body.2 They believe that depletion of nutrient reserves throughout
pregnancy and a lack of recovery postpartum may increase a woman's risk of
depression. They also write that greater attention to nutritional factors
in mental health is warranted given that nutrition interventions can be
inexpensive, safe, easy to administer, and generally acceptable to
patients.
Wojcik and others demonstrated a relationship between the severity of
depressive symptoms and decreased serum zinc concentrations in postpartum
depression.3
Following observations of a possible association between elevated
serum copper levels and post-partum depression, Crayton and Walsh found
copper levels were significantly higher in women with a history of post-
partum depression compared both to non-depressed women and to depressed
women without a history of post-partum depression. The mean serum copper
level of 78 women with a history of post-partum depression was 131+/-
39microg/dL compared with 111+/-25microg/dL in 148 women without such a
history, and 106+/-20microg/dL in non-depressed controls (p<_0.001. p="p"/> Increases in progesterone and oestrogen levels during pregnancy raise
copper and lower zinc concentrations and I do not know why this is usually
ignored. I have seen patients with high copper (up to 263 microg/L) and
low zinc concentrations who have postnatal depression and premenstrual
psychotic feelings.
I am concerned that many pregnant women take nutritional supplements
containing 1mg or more of copper daily and continue to take these high
doses after childbirth. High doses of copper are common in several
multivitamin and mineral supplement combinations recommended for use in
pregnancy by companies selling such products.
1 Cindy- Lee Dennis. Psychosocial and psychological intervention for
prevention of postnatal depression: systematic review. BMJ 2005; 331:15.
2 Bodnar LM, Wisner KL. Nutrition and depression: implications for
improving mental health among childbearing-aged women. Biol Psychiatry.
2005;58:679-85.
3 Crayton JW, Walsh WJ. Elevated serum copper levels in women with a
history of post-partum depression. J Trace Elem Med Biol. 2007;21:17-21.
4 Wójcik J, Dudek D, Schlegel-Zawadzka M, Grabowska M, et al.
Antepartum/postpartum depressive symptoms and serum zinc and magnesium
levels. Pharmacol Rep. 2006;58: 571-6.
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir
In 1964 and 1971 I noted severe anaemia and/or folic acid deficiency
as a
precursor of severe post natal depression. Similiarly persistant anxiety--not
always evident unless psychological profiling was undertaken during the
pregnancy. This underlines the value of prospective epidemiological study.
Pural depression, a prospective epidemiological study.
Lancet 2. 1264-66 1964
Tod EDM pyschomatic medicine.
Gynaecology 3rd International congress. 1974 338-340
(Kagr,basl1972)
Yours sincerely
Dr E David Macrae Tod OBE FRCGPE
Competing interests:
None declared
Competing interests: No competing interests
21 October 2005
Dear Editor,
In a recent article in the BMJ a systematic review of psychological
and psychosocial strategies to prevent postnatal depression was reported
(Dennis, 2005). One of the conclusions was that “this systematic review
shows that there is no clear evidence to recommend the implementation of
antenatal and postnatal classes…” (p. 18).
Unfortunately this review did not include a Randomised Controlled
Trial (RCT) by myself and colleagues (Matthey et al., 2004), cited in both
Medline and PsycINFO (this latter database was not included in the
systematic review), and published within the timeframe of the systematic
review. This study found a specific psychological strategy, introduced at
antenatal classes with some postnatal components, was effective at
reducing the level of depressive symptomatolgy for women previously
assessed as having low self-esteem.
There are many reasons why other psychosocial interventions may not
have been effective, whereas ours was. These include the obvious one that
the interventions in these other studies were inherently ineffective
(which may be due in some cases to the lack of involvement of mental
health professionals, as suggested by Lumley, 2005); or as often occurs
the lack of involvement in the intervention by the participants (often due
to low attendance at multi-session programs). In addition, we discussed
how most prevention programmes only analyse the data for main effects,
rather than interaction effects (that is, is the intervention more
effective for particular sub-groups of participants? – in our case, women
with low self-esteem).
It is therefore important that clinicians realise that, contrary to
the review’s conclusion about the lack of usefulness of antenatal classes,
one rigorous RCT, using a strategy package not previously tested, has
found significant benefits for women in the early postnatal period. These
benefits led Ogrodniczuk (2004), in an independent review of the study, to
conclude “The intervention appears to be feasible in any context that
involves parenthood classes. It seems to offer a cost efficient approach
to reducing maternal distress. The findings should change clinical
practice.” (p. 116).
I, and my colleagues, certainly hope that this last statement is the
case!
References
Dennis C-L. Psychosocial and psychological interventions for
prevention of postnatal depression: systematic review. BMJ 2005; 331:15-
18.
Lumley J. Attempts to prevent postnatal depression. BMJ 2005; 331: 5-
6.
Matthey S, Kavanagh D J, Howie P, Barnett B, Charles M. Prevention of
Postnatal Distress or Depression: an evaluation of an intervention at
Preparation for Parenthood classes. J Affect Disord 2004;79:113-126.
Ogrodniczuk, JS (commentator). Increasing a partner’s understanding
of motherhood significantly reduces postnatal distress and depression in
first time mothers with low self esteem. Evid Based Ment Health 2004; 7:
116.
Yours sincerely,
Stephen Matthey, Ph.D.
Research Director: ICAMHS ,
Sydney South West Area Health Service,
NSW Australia.
E: stephen.matthey@swsahs.nsw.gov.au
Competing interests:
None declared
Competing interests: No competing interests
Cindy- Lee Dennis appears to have indirectly favoured the biological
aetiology of postpartum depression by portraying the failure or
deficiencies of diverse psychological and psychosocial intervention in
preventing postnatal depression although the author finds intense,
professional postpartum support targeted at risk women are beneficial.1
The aetiology of postpartum depression is still a moot point and is
multifactorial. Debate continues about its cause, definition, diagnostic
criteria and even its very existence as a separate disease entity.
Contributing factors may be physiological, psychological and genetic.
Biological factors are of paramount importance. Depression is twice
as common in woman as it is in men and a link between reproductive status
and the illness is further substantiated by its frequency during pre-
menstrual phase, the perimenopausal period and in the immediate postpartum
period 2.There is a large drop in circulating hormonal level between
pregnancy and puerperium. Thyroxin and progesterone require special
mention. The thyroid gland shows increased activity during pregnancy, but
the amount of circulating hormone rapidly falls after childbirth. A normal
level may not be regained for several months. Thyroxin is helpful in
treating frigidity following childbirth. Normally levels of oestrogen,
progesterone and cortisole fall dramatically within 48 hours after
childbirth. The fact may be that women who are going to develop PPD may be
more physically sensitive to the parturition related hormonal shirks. The
mechanism underlying such differential sensitivities remains undetermined.
Many psychological factors may operate. A child may be unwanted for
a variety of reasons. Fear of child birth, resentment of loss of freedom
or of added responsibilities, hostility to the husband, symbolic sex
connotations, recollection of one’s own sibling rivalry and added
financial stress may be some of them. Lack of emotional maturity is
generally a cause for postpartum reactions. Disorders of psychosexual
development in childhood may have a bearing in adult life. For example,
unresolved oedipal complex may lead woman to reject her baby. The risk of
major depression after miscarriage is high for women who are childless.
Infant temperamental problems and high level of child care stress could
lead to PPD. Feelings of loss of an old identity after the first child
birth, feeling overwhelmed with responsibilities of motherhood, feeling
less attractive physically and sexually, frustrations of not able to loose
weight are contributing psychological factors.
There are suggestions that PPD is an evolutionary adaptation by way
of expressing negative emotions of helplessness in order to get greater
level of investment from others.3 Evolutionary psychologists propose that
humans and non-humans will not invest in their offspring when the cost
outweigh benefits. Reduced care, abandonment, and killing of offspring
have been documented in a wide range of species. In many bird species,
both pre and post hatch abandonment of brood is common. Unlike non-human
offspring, human infant demands extraordinary parent care. These
etiological factors are only clues, straws in the wind.
In the ancient cultures, there is a time-honoured practice of 40 days
of “confinement”, and the family and relatives relieve her of her
household chores so the new mother get enough rest for revitalising before
she resumes her normal activities. Consequently there is less incidence of
PPD in traditional cultures. Does this finding point towards a prominent
psychosocial aetiology of postpartum depression?
1.Cindy- Lee Dennis. Psychosocial and psychological intervention for
prevention of postnatal depression: systematic review. BMJ. 2005; 331:15.
2. Yonker KA, Chantilis SJ. Recognition of depression in
Obstetrics/Gynaecological practice. American Journal of Obstetrics &
Gynaecology. 1995; 173(2): 632-638.
3.Trivers R L. Parental investment and sexual selection. In B
Campbell(Ed) Sexual Selction and the Descent of man. 1972;p136-179.
London: Heinemann.
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor,
Self-reports and clinical experience suggest that unresolved feelings
about a prior pregnancy loss, involuntary or voluntary, may play an
important role postpartum depression.(1) The explanation offered is that
feelings and conflicts about the prior loss that were once successfully
repressed are aroused by the birth of a subsequent child.
If prior pregnancy loss is a risk factor for postpartum depression,
it could be a very useful tool for screening higher risk patients may
provide helpful directions for more useful interventions. It does not
appear, however, that this possible association has ever been
statistically tested. Perhaps Professor Lee could review the studies she
examined to verify or correct this observation.
The possible connection between pregnancy loss and postpartum
depression is indirectly supported by numerous studies linking pregnancy
loss with higher risk of subsequent adverse psychological problems. For
example, women with a history of abortion are more likely to use emotional
altering substances during subsequent pregnancies(2,3) and depression(4)
and general anxiety disorder.(5)
Both miscarriage and abortion are associated with a significant
increased risk of suicide.(6) Also, a small record based study in
Denmark,(7) and a larger study in California, have also shown
significantly elevated rates of psychiatric admissions(8) and outpatient
psychiatric treatment(9) following induced abortion. The latter also found
that patterns of pregnancy outcomes effected subsequent admission rates.
Sincerely,
David C. Reardon, Ph.D.
Elliot Institute
(1) Burke T, Reardon DC. Forbidden grief: the unspoken pain of
abortion. Springfield (IL): Acorn Books, 2002.
(2) Coleman PK, Reardon DC, Cougle J. Substance use among pregnant
women in the context of previous reproductive loss and desire for current
pregnancy.
Br J Health Psychol. 2005; 10:255-68.
(3) Coleman PK, Reardon DC, Rue VM, Cougle J. A history of induced
abortion in relation to substance use during subsequent pregnancies
carried to term. Am J Obstet Gynecol. 2002;187(6):1673-8.
(4) Cougle JR, Reardon DC, Coleman PK. Depression associated with
abortion and childbirth: a long-term analysis of the NLSY cohort. Med Sci
Monit. 2003 Apr;9(4):CR105-12.
(5) Cougle JR, Reardon DC, Coleman PK. Generalized anxiety following
unintended pregnancies resolved through childbirth and abortion: a cohort
study of the 1995 National Survey of Family Growth. J Anxiety Disord.
2005;19(1):137-42.
(6) Gissler G, Hemminki E, Lonnqvist J. Suicides after pregnancy in
Finland: 1987-94: register linkage study. BMJ. 1996; 313:1431-4.
(7) David H, Rasmussen N, Holst E. (1981). Post-abortion and
postpartum psychotic reactions. Fam Plann Perspect. 1981 Jan-Feb; 13(1):
32-4.
(8) Reardon DC, Cougle JR, Rue VM, Shuping MW, Coleman PK, Ney PG.
Psychiatric admissions of low income women following abortion and
childbirth. Can Med Assoc J. 2003; 168(10):1253-7.
(9) Coleman PK, Reardon DC, Rue VM, Cougle J. State-funded abortions
versus deliveries: a comparison of outpatient mental health claims over 4
years. Am J Orthopsychiatry. 2002 Jan;72(1):141-52.
Competing interests:
The Elliot Institute's mission includes researching the impact of abortion and raising public awareness of abortion's risks.
Competing interests: No competing interests
Copper in post-natal depression
I would be supportive of Dr Ellen Grant`s contribution to these rapid
replys. Most doctors have little or no interest in nutritional psychiatry
so a whole range of psychiatric problems are being treated indequately
using medication only where the biochemistry should be sorted out too.
Copper levels double during pregnancy, probably because it appears to be
required for the formation of blood vessels in the foetus. If the copper
level does not drop quickly after delivery depression appears to be
likely.It seems then that giving zinc after delivery should protect
against post-natal depression.Further research is needed to prove that
definitively but as zinc competes with copper in passing through the gut
wall it seems entirely logical.
There is a whole world of biochemical treatments available for such
varied conditions as autism and Alzheimers too but nobody seems to care as
no drug company can make money out of natural nutrients-amino
acids,vitamins,minerals and essential fatty acids.
Competing interests:
None declared
Competing interests: No competing interests