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Postpartum depression
ICD-10 F530
ICD-9 648.4
OMIM [2]
DiseasesDB 10921
MedlinePlus 007215
eMedicine med/3408
MeSH {{{MeshNumber}}}

Postpartum depression (also called postnatal depression and referred throughout this article by the acronym PPD) is a form of clinical depression which can affect women, and less frequently men, after childbirth, in the postnatal period. Studies report prevalence rates among women from 5% to 25%, but methodological differences among the studies make the actual prevalence rate unclear.[1]

Relation to baby blues

Baby or maternity blues are a mild and transitory moodiness suffered by up to 80% of postnatal women (and in some cases fathers who also suffer from the baby blues and/or postpartum depression). Symptoms typically last from a few hours to several days, and include tearfulness, irritability, hypochondriasis, sleeplessness, impairment of concentration, isolation and headache. The maternity blues are not the same thing as postpartum depression, nor are they a precursor to postpartum depression or postnatal psychosis.

Symptoms

Symptoms of PPD can occur anytime in the first year postpartum[2] and include, but are not limited to, the following:

  • Sadness[2]
  • Hopelessness[2]
  • Low self-esteem[2]
  • Guilt[2]
  • Sleep disturbances[2]
  • Eating disturbances[2]
  • Inability to be comforted[2]
  • Exhaustion[2]
  • Emptiness[2]
  • Inability to enjoy things one previously enjoyed[2]
  • Social withdrawal[2]
  • Low energy[2]
  • Easily frustrated[2]
  • Feeling inadequate in taking care of the baby (or feeling like one cannot take care of the baby)[2]

Epidemiology

Assessment

Risk factors

While not all causes of PPD are known, several factors have been identified as predictors of PPD. Beck (2001) conducted a meta-analysis of predictors of postpartum depression. She found that the following 13 factors were significant predictors of PPD (the effect size is given in parentheses, where larger values indicate larger effects):

  • Prenatal depression, i.e., during pregnancy (.44 to .46)
  • Low self esteem (.45 to. 47)
  • Childcare stress (.45 to .46)
  • Prenatal anxiety (.41 to .45)
  • Life stress (.38 to .40)
  • Low social support (.36 to .41)
  • Poor marital relationship (.38 to .39)
  • History of previous depression (.38 to.39)
  • Infant temperament problems/colic (.33 to .34)
  • Maternity blues (.25 to .31)
  • Single parent (.21 to .35)
  • Low socioeconomic status (.19 to .22)
  • Unplanned/unwanted pregnancy (.14 to .17)

These factors are known to correlate with PPD. "Correlation" in this case means that high levels of prenatal depression are associated with high levels of postnatal depression, and low levels of prenatal depression are associated with low levels of postnatal depression. But this does not mean the prenatal depression causes postnatal depression—they might both be caused by some third factor. In contrast, some factors, such as lack of social support, almost certainly cause postpartum depression. (The causal role of lack of social support in PPD is strongly suggested by several studies, including O'Hara 1985, Field et al. 1985; and Gotlib et al. 1991.)

In addition to Beck’s meta-analysis cited above, other academic studies have shown a correlation between a mother’s race, social class and/or sexual orientation and postpartum depression. In 2006 Segre et al, conducted a study "on the extent to which race/ethnicity is a risk factor" for PPD.[3] Studying 26,877 postpartum women they found that 15.7% were depressed. Of the women suffering from PPD, 25.2% were African American, 22.9% where American Indian/Native Alaskan, 15.5% were White, 15.3% were Hispanic, and 11.5% were Asian/Pacific Islander. Even when "important social factors such as age, income, education, marital status, and baby’s health were controlled, African American women still emerged with significantly increased risk for…PPD".[3] These findings suggest that there are powerful racial/ethnic disparities to be addressed in society as they pertain to decreasing social risk factors for African American women, and other minorities.

Segre et al, also found a correlation between a mother’s social class and PPD. Not surprisingly, women with fewer resources indicate a higher level of postpartum depression and stress than those with more financial resources. Rates of PPD decreased as income increased as follows:

  • <$10,000 — 24.3%
  • $10,000-$19,000 — 20.0%
  • $20,000-$29,000 — 18.8%
  • $30,000-$39,000 — 15.3%
  • $40,000-$49,000 — 13.7%
  • $50,000 — 10.8%[3]

Likewise, a study conducted by Howell et al in 2006 confirms Segre’s findings that women who are nonwhite and in lower socioeconomic categories have more symptoms of PPD.[4]

In a 2007 study conducted by Ross et al, lesbian and bisexual mothers were tested for PPD and then compared with a heterosexual sample. Ross et al found that "lesbian and bisexual biological mothers had significantly higher Edinburgh Postnatal Depression Scale (EPDS) scores than the…sample of heterosexual women."[5] The Ross study suggests that PPD may be more common among lesbian and bisexual mothers. From a study conducted in 2005 by Ross, the higher rates of PPD in lesbian/bisexual mothers than heterosexual mothers may be due to less "social support, particularly from their families of origin and…additional stress due to homophobic discrimination" in society.[6]

Although profound hormonal changes after childbirth are often claimed to cause PPD, there is little evidence that variation in pregnancy hormone levels is correlated with variation in PPD levels: Studies that have examined pregnancy hormone levels and PPD have usually failed to find a relationship (see Harris 1994; O'Hara 1995). Further, fathers, who are not undergoing profound hormonal changes, suffer PPD at relatively high rates (e.g., Goodman 2004). Finally, all mothers experience these hormonal changes, yet only about 10–15% suffer PPD. This does not mean, however, that hormones do not play a role in PPD.[7] For example, found that, in women with a history of PPD, a hormone treatment simulating pregnancy and parturition caused these women to suffer mood symptoms. The same treatment, however, did not cause mood symptoms in women with no history of PPD. One interpretation of these results is that there is a subgroup of women who are vulnerable to hormone changes during pregnancy. Another interpretation is that simulating a pregnancy will trigger PPD in women who are vulnerable to PPD for any of the reasons indicated by Beck's meta-analysis (summarized above).

Profound lifestyle changes brought about by caring for the infant are also frequently claimed to cause PPD, but, again, there is little evidence for this hypothesis. Mothers who have had several previous children without suffering PPD can nonetheless suffer it with their latest child (Nielsen Forman et al. 2000). Plus, most women experience profound lifestyle changes with their first pregnancy, yet most do not suffer PPD.

Sometimes a pre-existing mental illness can be brought to the forefront through a postpartum depression. Postpartum depression can be hereditary.[How to reference and link to summary or text] Women with severe premenstrual syndrome most commonly suffer from postpartum depression.[How to reference and link to summary or text]

Evolutionary psychological hypothesis

Evolutionary approaches to parental care (e.g., Trivers 1972) suggest that parents (human and non-human) will not automatically invest in all offspring, and will reduce or eliminate investment in an offspring when the costs outweigh the benefits, that is, when the offspring is "unaffordable." Reduced care, abandonment, and killing of offspring have been documented in a wide range of species. In many bird species, for example, both pre- and post-hatching abandonment of broods is common (Ackerman et al. 2003; Cezilly 1993; Gendron and Clark 2000).

Human infants require an extraordinary degree of parental care. Lack of support from fathers and/or other family member will increase the costs borne by mothers, whereas infant health problems will reduce the evolutionary benefits to be gained (Hagen 1999). If ancestral mothers did not receive enough support from fathers or other family members, they may not have been able to afford raising the new infant without harming any existing children, or damaging their own health (nursing depletes mothers' nutritional stores, placing the health of poorly nourished women in jeopardy).

For mothers suffering inadequate social support or other costly and stressful circumstances, negative emotions directed towards a new infant could serve an important evolved function by causing the mother to reduce her investment in an unaffordable infant, thereby reducing her costs. Numerous studies support the correlation between postpartum depression and lack of social support or other childcare stressors (Beck 2001; Hagen 1999).

Mothers with postpartum depression can unconsciously exhibit fewer positive emotions and more negative emotions toward their children, are less responsive and less sensitive to infant cues, less emotionally available, have a less successful maternal role attainment, and have infants that are less securely attached; and in more extreme cases, some women may have thoughts of harming their children (Beck 1995, 1996b; Cohn et al. 1990, 1991; Field et al. 1985; Fowles 1996; Hoffman and Drotar 1991; Jennings et al. 1999; Murray 1991; Murray and Cooper 1996). In other words, most mothers with PPD are suffering some kind of cost, like inadequate social support, and consequently are mothering less.

On this view, mothers with PPD do not have a mental illness, but instead cannot afford to take care of the new infant without more social support, more resources, etc. Treatment should therefore focus on helping mothers get what they need. (See Hagen 1999 and Hagen and Barrett, n.d.)

Effects on the parent-infant relationship

Postpartum depression may lead mothers to be inconsistent with childcare. Women diagnosed with postpartum depression often focus more on the negative events of childcare, resulting in poor coping strategies (Murray).

There are four groups of coping methods, each divided into a different style of coping subgroups. Avoidance coping is one of the most common strategies used (Murray). It consists of denial and behavioral disengagement subgroups (for example, an avoidant mother might not respond to her baby crying). This strategy however, does not resolve any problems and ends up negatively impacting the mother’s mood, similarly of the other coping strategies used (Honey).

Four coping strategies:

  • Avoidance coping: denial, behavioral disengagement
  • Problem-focused coping: active coping, planning, positive reframing
  • Support seeking coping: emotional support, instrumental support
  • Venting coping: venting, self-blame

Security

Mothers who may be using avoidance coping and don’t respond to their infants needs may make the infant feel insecure. According to Edhborg’s article on long-term impacts, insecurity can lead to infant stress and infant avoidance, where the infant may become so subdued that it will not interact with the mother or any other adult. This is a concern because months two through six in an infant’s life are very important; it is in these months that the infant develops some interaction and cognitive skills. Parent-infant interaction is most essential during this time because it builds the connection not only with the mother, but others as well (Long-term). It is also the time of most risk for the child because of a possible increased onset of depression in the mother (Long-term). The lack of interaction can lead to difficulties in parent-infant communication and result in poorer infant performance (Murray).

Attachment study

Edhborg and some colleagues did a study on mother-child attachment by studying forty-five randomly selected mother-child pairs. These pairs were chosen using an Edinburgh Postnatal Depression Scale[8] (EPDS) form, measuring postpartum depression in the community. 326 women returned the form and of the 326, twenty-four scoring above twelve were recruited and twenty-one women scoring less than nine were recruited. Scoring above twelve is considered potentially depressed while those scoring less than nine are considered to have no form of depression. The forty-five mother-child pairs were then taken and videotaped, in their homes, for five minutes in three different situations. Mother and child were first put in a room with a standard set of toys, to represent a control play. In the second situation, the mother and child were allowed to play freely in an average toy room. In the third situation, the mother was asked to leave the room as if she had to check on something, like she would regularly do in their home environment, and then return.

Senior Psychologists then scored the interaction between mother and child. The first two taped situations were scored on a five point scale; 1 (being the area of most concern) to 5 (being an area of strength). In the third situation, the attachment behavior was put into three groups based on how the child reacted to the mothers return.

Three classified groups:

  • Secure and joyful attachment: consists of child greeting mother with joy and being comforted by her presence.
  • Secure attachment but restricted in expressed enjoyment and pleasure: consists of the child acknowledging the mother, but showing little joy than would normally be expected.
  • Insecure attachment: consists of child showing signs of avoidance and resistance. In the form of resistance the child would go to the mother, but then pull away and often repeat this action.

Analysis showed only one difference between the groups. In the free play situation, children with high EPDS scores showed less interest in playing with their mothers and exploring on their own than the children with low EPDS scores. The mothers too only showed one difference. Those with a high EDPS score showed little maternal emotional availability to the child.

Following the results, Edhborg performed a cluster analysis, keeping interest on the different interaction styles. Some children did show signs of depression, but when comparing the children it was found that there is no significance with the EPDS scores and the interaction styles. The study did find, however, that children of high EPDS scorers were less involved in the free play situation than the children of low EPDS scorers, showing that children of high EPDS are more likely to be insecure.

When performing the structured task from the first situation it showed that the mothers with high EPDS were “aware of their unavailability for the child in the early postpartum period and thus tried harder… to help their children succeed in the task” (Edhborg). This overreaction proves that too much interaction can cause a negative mood in the child and a continuing difficulty in mother-child communication.

Attachment issues have been shown to be a problem in older children, also. As a result of being exposed to the depression symptoms, as an infant, older children may have impaired cognitive and socio-emotional developments. The lack of attachment can also cause troubles in the interaction with others and personal independence (Long-term). Children with these issues have a higher risk of being diagnosed with depression later in life as well (Honey).

Prevention

Early identification and intervention improves long term prognoses for most women. Some success with preemptive treatment has been found as well. A major part of prevention is being informed about the risk factors, and the medical community can play a key role in identifying and treating postpartum depression. Women should be screened by their physician to determine their risk for acquiring postpartum depression. Currently, Alberta is the only province in Canada with universal PPD screening which has been in place since 2003. The PPD screening is carried out by Public Health nurses in conjunction with the baby's immunization schedule. Also, proper exercise and nutrition appears to play a role in preventing postpartum, and general, depression.

Nutrition

Proper nutrition may be a factor in preventing postpartum depression.[How to reference and link to summary or text] Pregnant, nursing and postpartum women are strongly encouraged to seek the medical advice of their obstetrician or primary care physician regarding optimal nutrition during pregnancy and after birth.

The following nutritional information may be beneficial in achieving a well-balanced diet during and after pregnancy, but studies are needed to confirm their role in preventing postpartum depression.

Omega-3 fatty acids: Some physicians agree that pregnant women have an increased need for omega-3 fatty acids and may recommend that pregnant women consume at least 1,000 mg (1 gram) of omega-3 oils every day.[How to reference and link to summary or text] This amount of oil can be obtained through any of the following examples (among many others): 2 teaspoons of walnut oil, 2–3 ounces cooked salmon, or 1/3 teaspoon of flaxseed oil.

Protein: Along with omega-3's, protein also plays an important role in the diet of a pregnant woman.[How to reference and link to summary or text] Physicians may recommend that nursing mothers ingest 71 grams of protein per day while non-nursing mothers need 46 grams.[How to reference and link to summary or text] Protein can be found in a wide variety of foods. Some examples follow: 3 ounces of most meat products contain 25 grams of protein, 3 large eggs have approximately 19 grams, and 3 ounces of Swiss cheese have about 15 grams.

Hydration: One of the most important roles in any diet (especially for pregnant and nursing mothers) is that of hydration. Some in the medical community argue that dehydration can cause feelings of fatigue and anxiety.[How to reference and link to summary or text] Physicians may recommend that pregnant women consume ten 8-ounce glasses of water every day. Mothers who are nursing are strongly urged to drink a tall glass of water, milk or juice before sitting down to breastfeed their child. Women should consult with their physicians about caffeine and alcohol consumption postpartum.

Vitamins: A pregnant and postpartum woman should speak with her physician for information about, and a recommendation for a daily prenatal/postnatal vitamin. Vitamins are not known to help prevent PPD but are considered by some physicians to be a beneficial part of proper nutrition.[How to reference and link to summary or text]

Appetite: If a woman finds herself with a loss of appetite or other eating disturbance, she should consult her physician. This may be a sign of postpartum depression and therefore should be discussed with a doctor.[2]

Treatment

Numerous scientific studies and scholarly journal articles support the notion that postpartum depression is treatable using a variety of methods. If the cause of PPD can be identified, as described above under “social risk factors,” treatment should be aimed at mitigating the root cause of the problem, including increased partner support, additional help with childcare, cognitive therapy, etc.

Women need to be taken seriously when symptoms occur. This is a two-fold practice: First, the postpartum woman will want to trust her intuition about how she is feeling and believe that her symptoms are real enough to tell her significant other, a close friend, and/or her medical practitioner; erring on the side of caution will go a long way in the treatment of PPD.[2] Second, the people in whom she confides must take her symptoms seriously as well, aiding her with treatment and support. Partners, friends and physicians may notice changes in a postpartum mother that she may not. Knowing that PPD is treatable with a variety of methods can make persistence in seeking treatment easier.

Various treatment options include:

  • Medical evaluation to rule out physiological problems
  • Cognitive behavioral therapy (aka: Psychotherapy)
  • Possible medication
  • Support groups
  • Home visits/Home visitors
  • Healthy diet
  • Consistent/healthy sleep patterns

An experienced medical professional will work with a postpartum mother to develop a treatment plan that is right for her. This plan may include any combination of the above options, and might include some discussion or feedback from/with a partner. If a woman suffering from PPD does not feel she is being taken seriously or is being recommended a treatment plan she does not feel comfortable with, she will want to seek a second opinion.[2] This is her right, and she is entitled to it.

A 1997 study conducted by Appleby et al., confirms that postpartum depressed mothers’ symptoms promptly improved at similar rates when treated with cognitive behavioral therapy or the antidepressant fluoxetine. “A group of 61 depressed mothers completed a 12-week treatment program with or without the antidepressant plus one session versus six sessions of counseling.” Improvement followed after “one to four weeks of either treatment.”[9] The findings of Appleby et al’s study conclusively showed that combining counseling with drug therapy did not add to the improvement of just drug therapy or just counseling.[9] This suggests that counseling is equally as effective a treatment for PPD as medication, and that the “the choice of treatment [psychotherapy vs. medication] may…be made by the women themselves”.[9] Other forms of therapy (like group therapy and home visitors) are also effective treatments for PPD.[2]

A woman will want to discuss the various treatment options available with her physician and, if considering drug therapy, should speak about which medications are safe to take while breastfeeding.

Treatment for PPD can reduce the length of suffering and its severity. Untreated, the Baby Blues may go away on its own (and does in most cases). PPD may or may not go away without treatment. Speaking to a health care provider as soon as symptoms occur is the safest way to ensure prompt treatment and return to normal life. Treatment for Postnatal Psychosis (PNP) is essential; it will not go away without medication and immediate professional attention.[2]

Postnatal psychosis

Postnatal psychosis or PNP, is a mental illness, which involves a complete break with reality. Although correctly termed as a postnatal stress disorder or postpartum depressive reaction, postnatal psychosis is different from postpartum depression. The majority of PNP occurs within the first 2–4 weeks after childbirth with a classic 10–14 day meltdown, likely caused by the radical hormonal changes combined with neurotransmitter overactivity. When correctly diagnosed at the earliest signs and immediately treated with anti-psychotic medication, the illness is recoverable within a few weeks. If undiagnosed, even for just a few days, it can take the woman months to recover. In cases of PNP, the sufferer is often unaware that she is unwell.[10]

Symptoms of PNP can include:

  • Feelings of being ordered by God or a power outside of oneself to do things one would not normally do, like harming oneself or the baby[2]
  • Feelings of intense confusion or agitation[2]
  • Seeing or hearing things that others don't[2]
  • Extreme highs or extreme lows of energy or mood[2]
  • Inability to take care of the baby[2]
  • Experiencing thoughts and feelings as being out of one's control[2]
  • Memory lapses (periods of confusion similar to amnesia)
  • Random or uncontrollable anxiety attacks
  • Unintelligible speech or communication

Psychosis can also take place in combination with an underlying psychiatric disorder, such as bipolar affective disorder, schizophrenia, or undiagnosed depression. In some women, a postnatal psychosis is the only psychotic episode they will ever experience, but, for others, it is just the first indication of a psychiatric disorder. Only 1 to 2 women per 1,000 births (.1% to .2% of births) develop postnatal psychosis.[11] It is a rare condition, and often treatable. However, much media coverage of postpartum depression has focused on psychosis, especially following the Andrea Yates case. Whilst postnatal/puerperal psychosis is a serious psychiatric illness, the risks of a mother suffering this illness harming her baby are low: infanticide rates are estimated at 4%, and suicide rates in postnatal/puerperal psychosis are estimated at 5%.

PNP is also known as "postnatal stress disorder", because the patients are notably under emotional stress and exhibits unusual behavioral patterns not seen before their pregnancy or postpartum event.

Andrea Yates

Main article: Andrea Yates
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Please help Wikipedia by adding references. See the talk page for details.

After the National Organization for Women (NOW) insisted that Andrea Yates had postpartum depression, the Individualist Feminists of Ifeminist.com pointed out that postpartum depression is quite common and that most sufferers do not murder their children. In fact, Yates suffered from postnatal psychosis.[How to reference and link to summary or text] After Ifeminist.com pointed out that this stigmatized a large number of mothers and made them less likely to seek professional help, NOW removed their claims from their official website.[How to reference and link to summary or text] Some believe that Yates' fundamentalist church bears some responsibility for the murder, as the church allegedly urged her to ignore her psychiatrist's orders.

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Yates methodically drowned her children in a bathtub in her Clear Lake City, Houston, Texas house on June 20, 2001.

Melanie Blocker-Stokes

Melanie Blocker-Stokes, of Chicago, IL delivered a healthy baby girl in February 2001. In the weeks following the birth of her daughter, Ms. Blocker-Stokes developed postnatal psychosis and was in and out of Chicago area hospitals several times over period of a few months for medical assistance and care. Despite medical treatment and the support of her loving family and friends, Melanie Blocker-Stokes ended her life on June 11, 2001.[12]

Melanie's mother, Carol Blocker, started a website to raise awareness and initiate legislation on Postnatal Psychosis. Her website can be accessed here: http://www.melaniesbattle.org/index.html.

PPD legislation: “Melanie Blocker-Stokes Postpartum Depression Research and Care Act”

Following the suicide of Melanie Blocker-Stokes, Representative Bobby Rush (D-IL) introduced to Congress on June 28, 2001 the “Melanie Stokes Postpartum Depression Research and Care Act” as HR2380. This first-of-its kind legislation called for research into the causes and treatments of postpartum depressive conditions as well as awareness and education for those suffering from it. Unfortunately, on July 16, 2001 HR 2380 died on the floor of the House after a simple introduction with no debate or vote.[13]

Nevertheless, the “Melanie Blocker-Stokes Postpartum Depression and Care Act” went on to be reintroduced in the halls of American legislation several more times. Senator Richard Durbin (D-IL) introduced the bill to the Senate in the 107th Congress in 2001 and the 108th Congress in 2003, but both times the bill failed after receiving very few cosponsors and no debate. Additionally, Representative Bobby Rush continued his persistent fight in the House, reintroducing the bill to the 108th Congress in 2003 and the 109th Congress in 2005, each time failing with no debate and few cosponsors.[13]

Finally on January 4, 2007, Representative Rush introduced the “Melanie Blocker-Stokes Postpartum Depression Research and Care Act” to the House once again. It was scheduled for debate on September 27, 2007 and passed the House with near unanimous bi-partisan support (382 ayes to 3 nays) on Monday, October 15, 2007. The passage of the bill authorized $3 million be allocated to research and public awareness of postpartum depression in 2008, at a projected cost of just $1.00 per American citizen annually.[14]

The “Melanie Blocker-Stokes Postpartum Depression Research and Care Act” recognizes not only that postpartum mood changes are common among America women after delivery, but that the causes are of both a complex social and biological nature, and that the condition is treatable with a variety of methods if diagnosed properly and promptly. Likewise, the Act acknowledges that postpartum conditions are in need of increased research and activities and proposes an “expansion and intensification” of research and activities to both postpartum depression and psychosis by the Secretary of Health and Human Services, the National Institutes of Health and the National Institute of Mental Health. The Act also proposes an “establishment of program grants” to support project research as well as cost-effective and efficient delivery of essential services to individuals and their families suffering from postpartum depression. Finally, the Act requires that certain agreements be made, pertaining to the spending of allocated funds by the grant awardees (including but not limited to, “not more than 5% of the grant…[being] used for administration, accounting, reporting and program oversight functions”). In sum, the legislation passed in 2007 seeks to fund the research of postpartum conditions and essential medical care for patients suffering from it. Full text of HR20 can be found here: http://www.govtrack.us/congres/billtext.xpd?bill=h110-20

Speaking out not only for his constituent, Melanie Blocker-Stokes, but also for the women of America, Representative Bobby Rush and the multitude of non-profit and academic organizations as well as all of the Representatives who voted in favor of HR20 are “giving women the help they need in fighting this very, very difficult disease.”[15]

Controversy surrounding HR20

Some controversy surrounds the passage of HR20, as Representative Joe Pitts (R-PA) added an amendment to the bill, just prior to passage. This amendment added abortion and its mental health affects to the list of research topics, which could receive funding under the bill.[16]


See also

References

  1. Agency for Health Care Research and Quality: Perinatal Depression: Prevalence, Screening Accuracy, and Screening Outcomes [1]
  2. 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 2.19 2.20 2.21 2.22 2.23 2.24 2.25 The Boston Women's Health Book Collective: Our Bodies Ourselves, pages 489–491, New York: Touchstone Book, 2005
  3. 3.0 3.1 3.2 Segre, Lisa S, Mary E. Losch, Michael W. O’Hara. Race/Ethnicity and Perinatal Depressed Mood. Journal of Reproductive and Infant Psychology. Vol 24 No 2: 99–106
  4. Howell, Elizabeth A, Pablo Mora, Howard Leventhal. Correlates of Early Postpartum Depressive Symptoms. Maternal and Child Health Journal. Vol 10 No 2: 149–157
  5. Ross, Lori E, L Steele, C Goldfinger, and C Strike. Perinatal Depressive Symptomatology Among Lesbian and Bisexual Women. Archives of Women’s Mental Health. Vol 10 No 2: 53–59
  6. Ross, Lori E. Perinatal Mental Health in Lesbian Mothers: A Review of Potential Risk and Protective Factors. Women & Health. Vol 41 Issue 3: 113–128
  7. Block et. al. (2000)
  8. Edinburgh Postnatal Depression Scale
  9. 9.0 9.1 9.2 Appleby, Louis, Rachel Warner, Brian Faragher, and Anna Whitton. A Controlled Study of Fluoxetine and Cognitive-Behavioural Counseling in the Treatment of Postnatal Depression. British Medical Journal: 932–937. 314.n7085.
  10. Fray, Kathy: "Oh Baby...Birth, Babies & Motherhood Uncensored", pages 364–381, Random House NZ, 2005
  11. bcrmh.com
  12. Office of Legislative and Policy Analysis. 2007. "Melanie Blocker-Stokes Postpartum Depression Research and Care Act". http://olpa.od.nih.gov/legislation/108/pendinglegislation/postpartum.asp
  13. 13.0 13.1 GovTrack.us HR2380--107th Congress. 2001. "Melanie Stokes Postpartum Depression Research and Care Act. http://govtrack.us/congress/bill.xpd?bill=h107-2380
  14. GovTrack.us HR20--110th Congress. 2007. "Melanie Blocker-Stokes Postpartum Depression Research and Care Act. http://govtrack.us/congress/bill.xpd?bill=h110-20
  15. GovTrack.us 2007. "Record Text - Rep Bobby Rush to House October 15, 2007". http://govtrack.us/congress/record.xpd?id=110-h20071014-24&bill=h110-20
  16. HR20. 2007. "Melanie Blocker-Stokes Postpartum Depression Research and Care Act." http://www.govtrack.us/congress/billtext.xpd?bill=h110-20

Further reading

  • Ackerman, J. T., Eadie, J. M., Yarris, G. S., Loughman, D. L., & Mclandress R. M. (2003) Cues for investment: nest desertion in response to partial clutch depredation in dabbling ducks. Animal Behaviour, 66, 871–883.
  • Beck, C.T. The effects of postnatal depression on maternal-infant interaction: a meta-analysis. Nursing Research 44:298–304, 1995.
  • Beck, C.T. A meta-analysis of predictions of postpartam depression. Nursing Research 45:297–303, 1996a.
  • Beck, C.T. A meta-analysis of the relationship between postpartum depression and infant temperament. Nursing Research 45:225–230, 1996b.
  • Beck, C.T. (2001) Predictors of Postnatal Depression: An Update. Nursing Research, 50, 275–285.
  • Canadian Pediatric Society. "Depression in Pregnant Women and Mothers: How Children are Affected." October 2004. Accessed 22 November 2005 at
  • Cezilly, F. (1993) Nest desertion in the greater flamingo, Phoenicopterus ruber roseus. Animal Behaviour, 45, 1038–1040.
  • Cohn, J.F., Campbell, S.B., Matias, R., and Hopkins, J. Face-to-face interactions of postpartum depressed and nondepressed mother-infant pairs at 2 months. Developmental Psychology 26:15–23, 1990.
  • Cohn, J.F., Campbell, S.B., and Ross, S. Infant response in the still-face paradigm at 6 months predicts avoidant and secure attachment at 12 months. Special Issue: Attachment and developmental psychopathology. Development and Psychopathology 3:367–376, 1991.
  • Edhborg, Maigun. “The long-term impact of postnatal depressed mood on mothers + child interaction: a preliminary study.” Journal of Reproductive and Infant Psychology 19 (2001):61–71.
  • Edhborg, Maigun. “‘Struggling with Life’: Narratives from women with signs of postpartum depression.” Scandinavian Journal of Public Health 33 (2005):261–267.
  • Field, T., Sandburg, S., Garcia, R., Vega-Lahr, N., Goldstein, S., and Guy, L. Pregnancy problems, postpartum depression, and early mother-infant interactions. Developmental Psychology 21:1152–1156, 1985.
  • Fowles, E.R. Relationships among prenatal maternal attachment, presence of postnatal depressive symptoms, and maternal role attainment. Journal of the Society of Pediatric Nurses 1:75–82, 1996.
  • Gendron, M. & Clark, R. G. (2000) Factors affecting brood abandonment in gadwalls (Anas strepera). Canadian Journal of Zoology, 78, 327–331.
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