What causes depression in pregnancy and the postnatal period?
Risk factors for depression in pregnancy and the postnatal period
Knowing about the causes and risk factors for depression can help you to better understand why depression can occur and how best to deal with it. It’s important to know that depression is not a sign of personal weakness, failure, or ‘all in the mind’. Each individual is uniquely different and will respond differently when exposed to either environmental, social or psychological triggers.
There is no simple or single explanation for what causes depression during pregnancy and the postnatal period. Current theories about depression recognise that there are a variety of causes or ‘triggers’ which include biological, psychological, social, environmental factors. The precise combination of triggers will vary from person to person, as will their personality and coping style in response to stressors.
melancholic and psychotic types of depression are known to be influenced more by genetic and biochemical processes than by psychological, social or environmental causes.
The non-melancholic types of PND are thought to be caused mostly by the impact of psychological, social, and environmental stressors on functioning in genetically predisposed individuals.
Read more about the causes of depression
For the non-melancholic types of PND there are a number of likely psychosocial risk factors. Often, more than one of these factors is present at any one time. Risk factors act as stressors that challenge coping skills and at times these overcome a person’s resilience. Individuals respond and cope differently with stresses that appear on the surface to be similar to those faced by other people, such as those associated with labour, childbirth or the postnatal adjustment to living with a new baby.
For the melancholic types of depression, biological (genetic and biochemical) factors are the primary cause. Onset of an episode may appear to be linked to psychosocial stress, but stress itself is not the primary risk factor, just the trigger. A previous history of a mood disorder is a more significant predictor of whether or not someone will develop the melancholic type of PND.
Risk factors that have been shown in research studies to be associated with an increased risk of PND include:
Illness, especially when including pain and discomfort, can change the way the body functions as can our reaction to being ill. Extreme nausea and vomiting during pregnancy are often associated with depressed mood as is imbalance of the thyroid hormone. Some medications used to treat an illness can have mood swings as a side-effect.
Post-operative mood swings can be a reaction to the surgery itself, to the anaesthetic used, or to side effects from prescribed medications. Medical assessment is needed to rule out such causes of depression for example following operative delivery by caesarean, or where there is a family history of thyroid disease, or a woman is anaemic.
Short episodes of mood swings often resolve without treatment. Women with a previous history of a mood disorder severe enough to require treatment including counselling or medication are at greater risk of developing depression during pregnancy than a women with no prior history of a mood disorder. Depression during pregnancy goes on to PND in 40% of women.
The way in which we experience being cared for by our parents when we are children sets the foundations for our patterns of relating through life. We form attitudes about ourselves, about relationships in general, and about parent-child relationships in particular on the basis of these early bonding experiences. Feelings of self confidence, optimism about life, patterns of social relationships, coping skills in emotional resilience in adulthood tend to reflect early life experiences. Our own parents can become our role models for parenting so positive experiences of being parented as a child correlate highly with favourable adjustment to the role of parenting as an adult.
When Karen remembered her childhood it brought back feelings of warmth and memories of family times, such as having dinner around the table together, when each of the children would talk about the day.
“Mum would cook mostly and we would sometimes help her in the kitchen. In the holidays we would all go and stay in places near the beach or in the mountains which was fun. Dad couldn't always spend all of the holidays with us because he had to work but he would join us for some of the time. When I was sick once –as a small child- I remember mum making me honey and lemon to sip because my throat hurt and I didn’t want to each much, and reading to me until I went off to sleep. Mum and dad were happy together and they always managed to make special times for each one of us”
Patterns of low self-esteem, insecurity, feelings of inadequacy, social isolation, and pessimism can also be linked to our relationships with our parents during childhood. Experiences of being unwanted or unloved, subjected to criticism, hostility, rejection, overly-protective styles of parenting or absence of a parent all influence subsequent adjustment. The task of parenting can be perceived as more stressful and more complex for women who have inadequate role models than for those who have strong role models.
When Madeline thought about her experiences growing up she found it hard to recall much about her early childhood. They had lived in a nice house when she was little but that all changed after her father died and they had to move. Her mother had three young children and had to work as well as look after the family.
“I was the eldest and I had to look after my brothers after school when my mum was working. She was tired when she got home and she would get quite short with us if we played up. Sometimes she was sick and I used to worry that something bad would happen to her as well.
I know she loved us all and she would make a special effort on our birthdays but she seemed unhappy a lot of the time and I used to wish things could go back to before Dad died. We used to have fun then, go places, and play jokes on Dad. Mum was happier then and she would spend more time with us and paid more attention."
Recent Stresses: When these occur in close proximity to pregnancy or childbirth they can add to stress levels.
Past and chronic stress: There is evidence to show that growing up in an abusive or uncaring family, or exposure to physical, sexual, or emotional abuse can lead to low self-esteem, patterns of social avoidance, and vulnerability to depression in later life.
These experiences can lead to heightened distress or feelings of increased vulnerability in the face of subsequent stressful life events. Childbirth itself can trigger memories of past events that involved pain or distress including physical or sexual abuse.
Practical help, social and emotional support assists a new mother with the adjustments required after the birth of a baby and allows her to get necessary rest and time to spend with her new baby.
After a miscarriage, stillbirth, or termination of a pregnancy it is usual for a period of grieving for the loss to occur. This can spill over into an episode of clinical depression.
Heightened levels of discomfort, pain, stress and anxiety during labour and childbirth are normal especially the first time a woman gives birth. However childbirth-related stress levels can be heightened after: delivery of a very preterm or sick baby; an emergency delivery; a long and painful labour and birth perhaps including instruments to aid the delivery; birth of a baby that is slow to breathe or has an abnormal appearance. It is the way the mother experiences the labour and birth that determines whether it is stressful for her, rather than the way the partner or the doctor perceives the process
Stress levels for all the family are increased when a baby does not settle easily into routines for feeding and sleeping. Increased levels of fatigue lead to disrupted family routines and lower levels of emotional resilience for parents. It is important to seek advice from your doctor, or Child and Family Health Nurse if you are concerned about your baby’s sleeping and feeding routines or any other health matter.
Personality is the combination of qualities, style of social interaction and behaviours that reflect our individual nature or character. Some personality types appear to be associated with an increased risk of developing depression during pregnancy and after childbirth. The risks are increased if there are a combination of stresses present at the same time such as a sick baby, moving house, and financial pressures. People usually have a mixture of personality attributes that influence how they react and cope with life events.
Understanding more about personality types can be helpful when assessing risk for the non-melancholic type of depressive disorders or when treatment methods are being considered as individuals vary in terms of the approach that is likely to suit them best. Personality is less significant as a risk factor for the melancholic form of PND, Bipolar Disorder, or Puerperal Psychosis.
Tends to feel worried a lot of the time and often focussed around the baby’s health and behaviour. Difficult to reassure. Pessimistic attitudes.
After Jonathon was born Jody found it very hard to settle at night even after he was sleeping soundly. Her mind would be filled with worries that he was “too hot”, “too cold”, “he might stop breathing if I don’t stay awake listening”. During the day it was also hard to relax. There was always too much to do and Jonathon wanted attention all the time when he was awake. Jody felt guilty if she did not stop what she was doing and spend the time with him. His vaccinations were due and she had read everything she could lay her hands on about vaccination reactions and how they could cause autism and now she couldn’t decide what to do … she was feeling exhausted.
Lacks self-confidence, doesn’t mix much socially, tends to stay at home, often spends a lot of time alone with the baby. Thought patterns might be “people will be looking at me and judging me if I go out in public with the baby … nobody talks to me when I do go out ... I don’t know what to say when some-one strikes up a conversation … it is easier to stay home and not disrupt the baby’s routines…”.
Likes to maintain high standards often in relation to order and cleanliness. Prefers to be in control of situations and may feel inadequate when not in control. Can find the lack of clear patterns and routines associated with parenting quite challenging and stressful.
Christine was delighted as was her husband when she found that she was pregnant with Joshua. They anticipated that he would fit in easily with their lifestyle and routines. Motherhood would be a breeze after running her business which employed 30 people. Christine planned to keep working until he was due and then to work from home part-time afterwards whilst he was sleeping... and at nights when he had gone down for the night.
Joshua was born pre-term and spent the first six weeks in hospital in the intensive care nursery where he had breathing difficulties. The hospital was a three-quarter hour drive from home. When Joshua came home he was restless and difficult to settle. He needed feeding three hourly at a maximum and he sometimes wouldn’t settle after his feeds. Christine was beside herself with the stresses of trying to cope with work and with the demands of her baby son. And at nights she was lucky to get two or three hours sleep at a stretch. After Joshua had been home for six weeks she was at breaking point. She felt overwhelmed, was teary most days, the house was a mess...
Has low self-esteem and feels unworthy in comparison with others according to own self-judgement. Has difficulty accepting positive input from others. Thought patterns might be “I am not good at this ... everyone else seems so organised and in control when I see them out with their babies … I don’t know what to do….”
Page last updated: 23-Apr-2008
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