Normalizing postpartum depression

Postpartum depression, also known as peripartum depression (PPD), affects one in seven new mothers. Whether due to the stigma surrounding the condition or a lack of resources, as many as 50% of new mothers with PPD go undiagnosed and 40% of new mothers do not attend a postpartum visit, precluding them from PPD screenings entirely. The condition doesn’t just affect the birthing parent: in up to 3.18% of couples, both parents will experience PPD.

New research from Evernorth Research Institute shows that the prevalence of PPD increased by more than 30% during the pandemic—with nearly half of these new parents receiving no treatment. Normalizing PPD is essential to providing support for the many who experience the condition.

What causes postpartum depression?

There is no single reason why new parents experience PPD—it can be attributed to a variety of factors, including:

• Hormonal factors - Production of estrogen and progesterone, two important reproduction hormones, increases significantly during pregnancy and then drops off after delivery. Levels of oxytocin, another reproductive hormone, increase to stimulate labor and lactation. This hormonal roller coaster following childbirth can contribute to PPD.
• Societal factors - Lower income, a lack of social support and the financial strain of new parenthood can all affect a patient’s mental wellbeing. Having a baby in 2023 costs an average of $18,865, and those costs can increase without proper health insurance coverage.
• Emotional factors - The birth of a child is a major life event and can cause stress and interpersonal conflict between partners or family members.
• Genetic factors - A personal or family history of depression or PPD means a greater likelihood of experiencing PPD. For patients who have already experienced PPD, their risk level increases for subsequent pregnancies.

Effects and symptoms of postpartum depression

The severity and presentation of PPD can vary greatly depending on the person. Some of the most common symptoms are:

• Depression, anxiety, panic attacks, crying spells and other mental health issues, including suicidal ideation
• Difficulty bonding with the baby
• Withdrawing from family and other support systems
• Changes in appetite, sleep and other vital behaviors

A very rare and severe condition related to PPD called postpartum psychosis affects between 320 and 9,400 births in the U.S. each year. Symptoms include hallucinations, delusions, paranoia and attempts by the new parent to harm themself or their baby.

What are some misconceptions about postpartum depression?

Unfortunately, the stigma surrounding PPD has led to many widespread misconceptions about the condition, perhaps most damagingly that PPD is simply a character flaw or weakness. PPD is occasionally dismissed as the “baby blues,” a less severe issue that affects up to 80% of new mothers. While mothers experiencing the baby blues also endure symptoms like mood changes, anxiety, sadness and insomnia, effects typically clear up within two weeks.

The truth is, mental health conditions are the leading cause of pregnancy-related deaths, ahead of hemorrhage and cardiac conditions. As many as 52% of these maternal deaths occur up to a year postpartum, underscoring the need for new mothers to be able to access robust and continuous mental health care following childbirth. Without the knowledge that PPD is both one of the most serious and common medical complications of pregnancy, many new mothers may not seek treatment because they’re afraid they’ll be deemed incompetent or unfit.

Many people might assume that a diagnosis of PPD must happen in the first few days or weeks after childbirth. In reality, PPD can appear up to a year later and can even begin during pregnancy, which is why peripartum depression is the preferred term for the condition.

If a patient successfully recovers from PPD after their first child, they may think that they are in the clear for future pregnancies. In actuality, a diagnosis of PPD increases a patient’s risk level to 30% for subsequent pregnancies.

PPD is commonly thought of as a condition that only new mothers suffer from, but about 10% of new fathers also experience PPD as a result of changes in their hormone levels, new relationship dynamics and increased feelings of pressure or guilt associated with parenthood. The arrival of a new child can also affect adoptive parents, with anywhere from 10-32% experiencing post-adoption depression syndrome.

Postpartum depression treatment options

In order to properly diagnose PPD, new mothers should have a care visit within three weeks of childbirth followed up with ongoing check-ins, rather than the previously recommended six-week appointment. These initial postpartum care visits should include a full, standardized screening of the patient’s mood and emotional wellbeing. One screening tool in particular, the Edinburgh Postnatal Depression Scale, can help medical providers recognize symptoms of PPD in under five minutes and allows them to provide new parents with necessary support.

That support can take many forms. Therapy is a first-line treatment for PPD, especially due to the uncertain safety of taking antidepressants while breastfeeding. Interpersonal psychotherapy helps patients manage difficult life transitions and relationships, which they may be experiencing with their newborn or partner. Virtual therapy can be a great option for mothers who don’t feel comfortable leaving the house or their baby while they get the treatment they need. Support groups can help form connections between people with PPD, reducing feelings of isolation.

For some new parents, the benefits may outweigh the risks of taking medications like antidepressants or PPD-specific psychopharmaceuticals such as Zulresso (brexanolone) and zuranolone (pending FDA approval).

For mothers who aren’t initially diagnosed with PPD it’s important to implement continued screening, education and access to resources to avoid later onset PPD and to encourage overall well-woman care. And because PPD recurrence is common, it’s also essential to screen during subsequent pregnancies.

The importance of plan sponsor support for postpartum depression

Plan sponsors should keep in mind that when left untreated, PPD can cause:

• Poor care adherence and exacerbation of existing medical conditions
• Partner violence, separation and divorce
• Decreased productivity, fatigue and lack of focus
• Increased tobacco, alcohol and drug use
• Child neglect and abuse
• Postpartum psychosis, which may lead to infanticide, homicide or suicide if untreated

PPD and its related effects can carry an annual economic burden of up to $14.2 billion, with an average cost of about $32,000 per untreated mother-child pair. Maintaining strong support systems at work and providing substantial maternal leave policies and benefits can empower new parents to take care of themselves and their children when they are at their most vulnerable.

Providing access to affordable care is critical, especially when more than half of low-income mothers are potentially affected by PPD and low income is a factor that can lead to disparities in utilizing postpartum care. It’s also key for plan sponsors to implement systems that encourage new mothers to begin their ongoing care early in their pregnancy journey. The use of prenatal care is the strongest indicator of postpartum care utilization, and ultimately the best way to manage a PPD diagnosis.

Most importantly, those suffering from PPD should remember that it is a common, treatable condition and that there are many resources available to them. It’s vital to reach out for help and to schedule regular appointments with a postpartum care team in order to achieve full recovery.