Postnatal depression can affect 12‑25% of mothers with potentially devastating results for both mother and child so it is very important that it be diagnosed and treated quickly. Depressed mothers are also more likely to stop breastfeeding earlier leading to negative health effects for both mother and baby1. This article looks at the symptoms and causes of depression and treatments compatible with breastfeeding.
What is postnatal depression?
Postnatal depression (PND) or postpartum depression (PPD) are the names given to depression (feelings of sadness and low mood) that can sometimes follow childbirth. Symptoms might include:
- difficulty sleeping (unrelated to baby waking for feeds)
- unable to enjoy the baby or anything else
- feeling very tired, overwhelmed, unable to cope, unmotivated
- difficulty remembering things and making decisions
- feeling sad, hopeless, negative or irritable
- excess anxiety, panic attacks, crying
- loss of appetite (or comfort eating)
- thoughts about self harm
Identifying postnatal depression
For more information including how to spot the signs of depression in yourself or loved ones, and other related conditions, see Postnatal Depression (NHS, 2016).
Feeling tearful a few days after birth is often called the baby blues and seems to be associated with the sudden change in hormones after birth. A few days of rest and support are usually all that are needed and it usually passes in a few days. This is quite different to postnatal depression which continues for weeks or months.
What causes depression?
Postnatal depression has many risk factors that will vary between individuals. Stress, pain, lack of sleep, diet, pre-existing depression, birth trauma and lack of support are all important risk factors. Although it is common place to link depression to hormonal changes after birth there is not yet much scientific support for this theory2
#1 Stress and inflammation
Research has found that the immune system plays a role in stress and depression. Stressed mothers have high levels of specific cells (cytokines) produced by the immune system that, when in excess, promote inflammation. Researchers have found that when the inflammation level is very high this causes symptoms of depression and disrupts the levels of cortisol and serotonin in the body (substances that help the body regulate stress, mood, appetite and sleep).
Kathleen Kendall-Tackett, a health psychologist and International Board Certified Lactation Consultant specialising in women’s health explains how both physical and mental stress can trigger an inflammatory response and this is a key factor in depression 3. Women who have just given birth are particularly at risk of both physical and mental stress including pain and sleep disturbance. Kendall-Tackett concludes that lowering a mother’s stress and reducing inflammation may prevent or reduce depression.
Childbirth can be associated with many causes of pain and pain can increase inflammation and disturb a mother’s sleep. Although breastfeeding can reduce stress and protect a mother’s mood (see below), breastfeeding problems such as severe nipple pain, or not being able to breastfeed as long as a mother wanted to can increase the risk of depression and must be looked at promptly. Contact an International Board Certified Lactation Consultant if breastfeeding is painful and see Why Does Breastfeeding Hurt?
#3 Lack of sleep
Getting enough sleep is very important for mental health. Disturbed sleep and being extremely tired are risk factors for depression. Because being tired can be a symptom of depression as well as a risk factor for it, sleep and depression are intricately connected. Lack of sleep also has an effect on the immune system and the levels of inflammation in the body which negatively affects the ability to sleep in a self perpetuating cycle.
Breastfeeding and sleep
Breastfed babies usually need to feed often during the night and it is a common assumption that breastfeeding mothers must get less sleep than formula-feeding mothers. However research has shown that breastfeeding mothers get more sleep. Lack of sleep due to breastfeeding is not therefore thought to be a risk factor for depression4.
Getting enough sleep
For more ideas about getting enough sleep with your breastfed baby and coping with depression see Sweet Sleep: Nighttime and Naptime Strategies for the Breastfeeding Family, LLLI, 2014 especially Chapter 10 Your Own Sleep Needs. There is a book review here.
#4 Traumatic birth
A traumatic birth is a highly stressful event. A woman may feel out of control, anxious, unsupported, overwhelmed, disrespected, violated or in severe pain. Traumatic birth can be associated with depression or post traumatic stress disorder (PTSD) particularly if the mother is already prone to depression. Traumatic births can make breastfeeding more difficult and can cause a delay to the milk coming in due to high levels of stress hormone (cortisol) (Kendall-Tackett, 2017). Counselling for a traumatic birth can be very helpful. Breastfeeding can also be very healing as long as it runs smoothly. Difficulty breastfeeding could add to the feelings of stress and trauma.
Low levels of essential fatty acids (EFAs) in the diet, especially two known as EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid), may increase the risk of depression in mothers. These long-chain omega-3 fatty acids (omega-3s) are found in fish and fish-oil products. There is more information in the article below by Kathleen Kendall-Tackett.
#6 Thyroid, iron, and blood sugar levels
In Mother Food, the author discusses four other common health issues that can contribute to post natal depression; anaemia (low iron), low levels of potassium, low blood sugar and low thyroid function (hypothyroidism), explaining that each of these can lead to exhaustion, irritability, and depression.
#7 Lack of support
Lack of help and support for the new mother is another risk factor for depression along with stressful life events, the mother’s age (e.g. very young or older mothers), low income and cultural support.
#8 Other factors
Other factors that might affect a mother’s risk of depression include:
- Personality traits, psychiatric history, prior trauma or abuse
- Physical inactivity, smoking, allergic disorders, vitamin D deficiency. Vaccinations and changes to our gut microbiome might also increase the risk of inflammatory diseases (Kendall-Tackett, 2017).
- Baby’s personality or health. A very demanding or poorly baby can be a challenge to a mother’s mental wellbeing.
Breastfeeding and depression
Depression increases the risk of stopping breastfeeding early. And breastfeeding problems increase the risk of having depression. One study found that mothers who have postnatal depression at one week after birth are more likely to stop breastfeeding in the first couple of months, be unhappy with how they are feeding their baby and have significant breastfeeding problems 7. A recent study with mice suggests depression may have a negative effect on milk supply 8.
Effect of depression on the baby
Depressed mothers may not be as responsive to their babies’ cues and studies have found that they interact less, and more negatively with their babies. This may influence the infants’ sleeping patterns and behaviour 9 so it is important for both mother and child that depression is taken seriously and treated promptly.
Breastfeeding—protection for baby
Breastfeeding can help to protect babies from the harmful effects of their mother’s depression through more frequent positive interactions and healthier brain activity 10.
Can breastfeeding protect mothers against depression?
Breastfeeding can reduce stress
Breastfeeding is thought to be protective against depression because it can reduce stress and promote nurturing behaviours1112 and breastfeeding hormones oxytocin and prolactin have antidepressant effects and can reduce anxiety 13.
Breastfeeding can protect maternal health
Breastfeeding can protect maternal mental health1415, although breastfeeding mothers can still get depression. Borra et al looked at how breastfeeding influenced the risk of PND. They found that for mothers who weren’t already depressed during pregnancy, a higher risk of postnatal depression was found in mothers who wanted to breastfeed but hadn’t gone on to breastfeed. And a lower risk of PND for those who wanted to breastfeed and succeeded to meet their goals 16. Another study found that breastfeeding reduced the risk of PND for subsequent children, but not for the first born child (Mezzacappa and Endicott, 2007).
Treatments for depression
Talk to your GP if you think you might have postnatal depression and they will help you find the right support and treatment. Most treatments are compatible with breastfeeding. Treatment can include measures such as changes to diet, exercise, light therapy, counselling, herbs and medication.
Omega-3 fatty acids
Omega-3 fatty acids have anti inflammatory properties and are found in some plants and fatty fish. In contrast omega-6 fatty acids found in vegetable oils are pro inflammatory in excess. Many diets today contain such a high ratio of omega-6 to omega-3 that it can have a negative impact on our health. Omega-3 fatty acids are said to have a role in not only preventing depression but treating it too:
The long-chain Omega-3 fatty acids, EPA and DHA, have been used successfully to both prevent and treat depression. Both of these are found in fatty fish. EPA is the Omega-3 that actually treats depression because it specifically addresses the physiologic consequences of depression and lowers the stress response. It has been used by itself or has been combined with medications. When it is used with medications, it makes medications work more effectively.
For a guide to eating fish in pregnancy and breastfeeding see Should Pregnant and Breastfeeding Women Avoid Some Types of Fish? (NHS website, 2015).
Other nutrients may have a role to play in helping depression. Vitamin D deficiency increases inflammation and has been linked to inflammatory diseases such as rheumatoid arthritis, diabetes and depression17. S-Adenosyl methionine (SAMe) is a substance that occurs naturally in the body and is involved in regulating serotonin, melatonin, dopamine and adrenaline. Vitamin D, folate and S-Adenosyl methionine (SAMe) are considered in this analysis published on the NHS Choices website Vitamin D, Fish Oil and Folates May Enhance Antidepressants, 2016.
Exercise can work as an antidepressant because it lowers inflammation and can be used on its own or combined with other treatments. Kathleen Kendall Tackett says:
Exercise can treat even major depression. Yes, you can exercise instead of taking antidepressants. Traditionally, exercise has been recommended for people with mild-to-moderate depression. But clinical trials that compared exercise to antidepressants found that exercise was as effective in treating major depression as medications. Exercise can also be safely combined with other modalities.
Bright light therapy
Bright light therapy has been used as a treatment for seasonal affective disorder (SAD) for many years but may have a role for non seasonal depression, PND and some eating and sleep disorders. For more information see Non-Drug Treatments for Depression in Pregnant and Breastfeeding Women (by Kathleen Kendall-Tackett).
Interpersonal psychotherapy and cognitive behavioural therapy are types of counselling that can help mothers with postnatal depression and co-occurring conditions e.g. anxiety, obsessive compulsive disorder, and chronic pain.
St John’s wort
St John’s wort is a widely used herbal antidepressant compatible with breastfeeding 18. Always discuss taking herbal medications with your doctor. St John’s wort should not be taken in conjunction with prescription antidepressants and can react with several medications.
For some mothers prescription antidepressants will be the best choice of treatment. There are several antidepressants that can be used when breastfeeding. As with any drug, there may be a risk of side effects when using antidepressants, but the risk of not treating the depression may be higher still. All the risks and benefits must be carefully weighed up for each mother and baby.
Which antidepressants can I take?
Antidepressants and Breastfeeding (2017) is a drugs fact sheet by The Breastfeeding Network in UK which describes the compatibility of many antidepressants with breastfeeding, the drug levels in breast milk, and the potential side effects for mother or baby.
In her article below Kathleen Kendall-Tackett states that paroxetine, sertraline and nortriptyline are unlikely to lead to detectable or elevated plasma drug levels in a breastfeeding infant.
breastfeeding infants’ exposure to paroxetine, sertraline and nortriptyline are unlikely to have detectable or elevated plasma drug levels. In contrast, infants exposed to fluoxetine had higher medication levels, especially if they had also been exposed prenatally. Citalopram may lead to elevated levels in some infants, but more data are needed. Although these appear safe for the majority of babies, some adverse effects have been identified through case studies. Therefore, breastfeeding mothers should be advised to watch for any possible signs of adverse reactions including irritability, poor feeding, or uneasy sleep. Premature babies or other with impaired metabolite efficiency should especially be monitored for adverse effects.
There are several resources online that discuss drug compatibility with breastfeeding. See Medications and Breastfeeding for links and further information.
A number of risk factors can be associated with postnatal depression such as stress and inflammation, pain, diet, and lack of sleep. Breastfeeding is not a risk factor when feeding is going well as it can reduce stress, nurture more contact between mother and baby and breastfeeding mothers get more sleep than formula feeding mothers. Breastfeeding problems should be addressed quickly however as pain and difficulty can add to feelings of depression. Depression is a major risk factor for stopping breastfeeding. There are several treatments for depression that are compatible with breastfeeding including prescription antidepressants.