Perspective of Postpartum Depression Theories: A Narrative

Literature Review
Fatemeh Abdollahi, Munn-Sann Lye,1 and Mehran Zarghami2

Author information Copyright and License information Disclaimer

This article has been cited by other articles in PMC.

Abstract
Go to:

Introduction
The postpartum period is recognized as the time when many women are vulnerable to a variety
of emotional symptoms.[1] The most prevalent mental or emotional problem associated with
childbirth is postpartum depression (PPD).[2,3] A latest review reported its prevalence to be 1.9
to 82.1% and 5.2 to 74.0% in developing and developed countries, respectively, using a self-
reported questionnaire. Its prevalence has also been reported to vary from 0.1 to 26.3% using a
structured clinical interview.[4]
Given that PPD is one of the psychiatric conditions that is amenable to treatment, early
recognition is a significant task for all physicians who are working with women during prenatal
and postnatal period and can help them in providing treatment plans to reduce their distress.[5,6]
Despite scholars’ efforts, the etiology of depression after birth is inconsistent and unknown.[7,8]
Numerous etiologies have been suggested; however, no single hypothesis can elucidate this
phenomenon.[7,9]
Because there is no single etiology for developing PPD, a single modality could not be effective
for treatment of all women. Some scholars affirm that theoretical perspectives should be
evaluated before taking a decision regarding treatment options. This article is a review of the
possible theories proposed for PPD.
Go to:

Biological Theories
Beck (2002) stressed that one of the theoretical bases of PPD is the medical model which is
considered as an illness as well as a medical condition. It is also a personal pathological mood
disorder which is not considered to be a result of social or environmental conditions. From this
point of view, women are passive individuals in the medical model who are under influence of
biological factors.[10] They suffer more from depression episodes around particular periods
during their lifespan.[11]
Different theories exist regarding pathophysiological hormonal effects on PPD including the
withdrawal theory,[12] interaction among the hypothalamic–pituitary–gonadal system and the
hypothalamic–pituitary–adrenal system (HPA),[13,14] and change in the levels of gonadal
hormones.[15]
In the prenatal period, HPA axis and women's reproductive system changes with strong
interaction between them. It is possible that the HPA axis functions differently in women who
are susceptible to depression through the suppression of corticotrophin-releasing hormone (CRH)
during postpartum period in the hormonal pathway for affective disorders.[16,17] On the other
hand, other studies have demonstrated that CRH suppression does not correlate with mood
fluctuation, and therefore the HPA axis in the physiology of PPD is possibly not well-founded.
[18]
Hormones such as estrogen, progesterone, beta-endorphin, human chorionic gonadotrophin, and
cortisol increase during pregnancy and significantly drop after birth.[12,19] Quick shifts in
hormones, such as estrogen in the puerperium, changes the levels of these hormones either too
high or too low leading to PPD.[6] Moreover, a sharp decline in reproductive hormone levels
that occurs after delivery is assumed to be the main cause of PPD in women by some researchers.
[6,13] This modification is said to be a trigger for changes in the peripheral and central
monoamine centers.[12,20] Sudden withdrawal of these hormones could be a trigger of
depression and women with a history of PPD may respond differently and more sensitively to
sudden decrease of plasma levels of gonadal steroids.[12]
Reduced estradiol plasma levels with depressed group in contrast with the control group was
reported.[13] Estrogen and progesterone have an effect on neurotransmitters which are involved
in the emotional and cognitive processes.[12] The function of estrogen is to keep serotonin stable
in order to keep more transmitters in the brain. Furthermore, estrogen has an influence on
adrenaline, norepinephrine, and serotonin receptors. The latter interaction could be due to
antidepressant function and depression.[21] Moreover, neuropeptides have various roles in
physiological and behavioral parts of the cerebral nervous system (CNS).[22] Levels of estrogen
decrease prior to menstruation, after delivery, and during menopause. In addition, gonadal
hormones keep the rate of depression down during pregnancy.[23] This effect manifests itself
during the last trimester of pregnancy. Within a few days after childbirth, gonadal hormones
decrease markedly, which demonstrates a probable correlation with an unexpected increase in
the development of nonpsychotic and psychotic mental illness.[23,24] However, other research
findings did not find hypogonadal levels of estrogen and progesterone to be a risk factor for
PPD.[25]
It has been also suggested that the serotonin (5HT) system has a significant role in prenatal and
postnatal depression because depressed mothers respond well to serotonergic antidepressants.
[26] According to this study results, 5HT1A serotonin receptor binding decreased from 20 to
28% in the depressed group in comparison with the control group.[26]
Even though, many scholars have concluded that physiological fluctuations are the causes of
PPD, hormonal cause for the PPD is not supported consistently by the literature.[6] While the
genetic basis of varying sensitiveness to gonadal steroids remains unclear, genetic
polymorphisms in genes that regulate reproductive hormones may make some women
susceptible to mood disorders.[24]
A correlation between personality and genetic factors such as Cytochrome P4502D6 (CYP2D6)
has been demonstrated.[27,28] The presentation of CYP2D6 is prevalent under the genetic
control.[29] The rate of CYP2D6 metabolism in pregnant and postpartum depressed mothers was
more than anticipated in a general population.[29]
To sum up, the previous studies did not reach a unified conclusion. It appears that an internal
abnormal reaction to hormonal changes contributes to PPD.[20]
Go to:

Psychosocial Theory
Specific neurophysiological and neurochemical changes in the brain are triggered by
psychosocial stressors and interpersonal events that significantly change the neurotransmitter
balance. It is considered that depression is related with psychosocial stressors, as described
below.[30]

Psychodynamic theory
The psychodynamic point of view supports the idea that some unfinished business in women's
childhood or family may cause more psychological troubles after birth.[31] Women have a
tendency to imitate their own mother's role as soon as they become mother after birth, however,
if there is a rejection in accepting their own mother's role, they have trouble coping or adapting
to their new role of motherhood.[30] The outcome of the mother's role conflict can lead to
rejecting the female identity as well as threaten her feminism.[30] Some experts have also noted
that childbirth results in loss of their identity and leads to withdrawal of love, affection, and loss
of independence.[31,32] Moreover, family's negative attitude affects women's well-being and
results in the maladjustment of coping mechanisms.[31]

Cognitive psychology theory

The cognitive approach instead of postulating internal conflicts in psychodynamic theory
emphasizes certain characteristics of personality which predispose new mothers to PPD. It is the
unrealistic expectation of childbirth and motherhood which may cause mothers to be anxious,
controlling, perfectionist, and exhibit compulsive tendencies.[33] Beck (1967) postulated that
depressed mood is the result of thought disturbances.[34] Pessimism toward oneself, the world,
and the future contributes to a depressive mood.[31,33,35] In addition, in the absence of suitable
role models, the woman feels loss of control and anxiety resulting in a lack of a capability to
cope with infant's demands and care.[31]

Social and interpersonal theory

Egeline (2008) contends that environment plays a significant role in an individual's life.[36]
Attachment theory says that interpersonal struggles in an individual's life have significant
influences on mental health. It is obvious that an individual requires affection which needs to be
fulfilled in the initial stage of a relationship. Uncertainties concerning a relationship may result
to disappointment and bring about depression and anxiety.[37] A number of interpersonal factors
play a role in women's distress and sensitivity makes them prone to develop postpartum
disorders. These include insufficient social support and marital conflicts.[38] Childbirth is a
significant transitional event in life and support at this stage can potentially affect women's
mental status after delivery.[39] Sudden psychosocial fluctuations within motherhood and its
challenges coupled with stresses could be other factors that may trigger PPD.[20]

Behavioral theory
According to the behavioral theory, depressive episode can result from major life events that
disrupt an individual's normal support pattern.[40] Life stressors and psychological problems
such as parent's divorce, low parental emotional support, mother-daughter conflict, and self-
esteem are predictors of PPD.[38]
The theory of operant condition paradigm claims that depression is a consequence of a decrease
in the positive efficient reinforced behavior and could be a sign of obvious punishment for
nonconformant behavior. It is also the result of a decrease in the accessibility of reinforcement
events, personal ability to maneuver the environment, the impact of variety of events, or a
combination of the above. Moreover, a negative feedback of social reinforcement behaviors may
result from unavailability of support from family and other social networks such as social
withdrawal. However, a low rate of positive reinforcement for mood-enhancing behavior and
high rate of positive reinforcement for depressive behavior may be experienced by people who
experience major stress originating from unexpected events.[40]

Evolutionary theory
Scholars have suggested relevant adaptive functions for PPD which are consistent with ideas of
evolutionary theorists. Usually the women experiences negative effects such as gloomy and
depressed mood due to problems concerning the infant, marital problems, and lack of social
support associated with the social and family environment. Some women, who suffer from major
PPD and with symptoms such as psychomotor retardation, weight loss, loss of interest in
activities, lack of concentration, and constant suicidal thoughts may sometimes not seek social
support. Moreover, actions that women take to reduce these psychological problems predispose
her to PPD.[41]
From an evolutionary perspective, there are situations when it would be in the women's best
interest to decrease her investment for a baby, for instance when there is a lack of sufficient
social support to raise the newborn or when the child has a problem.[31,41]
According to evolutionary theorists, PPD results from an adaptive function that signals a
potential fitness cost to the mother. Thus, PPD is not a dysfunction but rather an adaptive
mechanism. It signals a mother who has suffered a social cost motivating her to evaluate whether
to continue to or cease to provide care to her offspring. From this viewpoint, PPD is a universal
phenomenon that appears in women around the world. As a result, in societies that give rise to
the circumstances, its prevalence is reduced.[42]
Go to:

Summary
There is no common consensus among theorists regarding the nature of PPD. Three theoretical
perspectives on PPD have been reviewed in this paper. One theory or combination of theories
may be suspected for a postpartum depressed woman. Biological theory, such as physiological
fluctuations of hormones, psychosocial theory, such as interpersonal struggles in an individual's
life, and finally evolutionary theory that suggests adaptive functions as a model for PPD were
discussed.
The most important factor that affects health care providers and clinicians’ choice of intervention
(prevention or treatment) is their theoretical perspectives on PPD.[10] In some cases,
combination of these theories may be applied. For example, antidepressant therapy (medical
model) along with psychotherapy (psychosocial model) may be employed for treatment.
Healthcare providers should inform depressed women about the range of treatment approaches
available that are set based on appropriate theories and help them to make informed choices
regarding their treatment.

Financial support and sponsorship

In her 2001 paper “Predictors of Postpartum Depression: An Update,” researcher

Cheryl Tatano Beck presents the most common risk factors associated with
postpartum depression in women. Postpartum depression occurs when women
experience symptoms such as tearfulness, extreme mood changes, and loss of
appetite for a lengthened period after giving birth. At the University of
Connecticut in Storrs, Connecticut, nursing professor Beck updated a previous
study of hers by analyzing literature about postpartum depression published in
the 1990s. Beck found four predictors of postpartum depression that she had not
included in her previous study. “Predictors of Postpartum Depression: An
Update” presents risk factors that healthcare professionals can use to predict
whether pregnant women are more likely to develop postpartum depression.
The postpartum period is the six-to-eight-week period following childbirth, during
which the woman’s body undergoes physical changes to return to its pre-
pregnancy state. During that period, the woman also adjusts to a new lifestyle as
she cares for her infant. While giving birth and raising a child are usually socially
celebrated efforts, women can experience difficulties that include physical
tiredness, interrupted sleep, and anxiety over the infant’s well-being. Women who
have just given birth may experience various mood disorders ranging from
postpartum blues, which last a few weeks and require no treatment, to
postpartum psychosis, which is extremely rare and can require hospitalization.
Postpartum depression occurs in approximately ten to fifteen percent of women
who give birth. The symptoms, which include mood swings, excessive crying,
suicidal ideation, and feelings of inadequacy and inability to cope with the infant,
are similar to postpartum blues. However, postpartum blues, also known as
maternity blues, occur within days to weeks after delivery and last a couple days
to a couple weeks after delivery. Conversely, postpartum depression can develop
gradually within six months after delivery and the symptoms are more intense
and long-lasting than postpartum blues. The impact of postpartum depression
can be severe on the well-being of the woman, her family, and the health and
development of the infant.
During the late twentieth and early twenty-first century, medical researchers have
directed attention to postpartum mood disorders. Such researchers have
conducted a large number of qualitative and quantitative studies on postpartum
depression to determine how to anticipate and prevent its onset. Whereas
qualitative studies like literature reviews are summaries of a set of literature,
meta-analyses involve statistical analyses of the results of a set of literature. In
both of Beck’s meta-analyses, the author analyzed how strongly different risk
factors were associated with postpartum depression. In other words, Beck
examined which risk factors had stronger connections to postpartum depression
and which factors had less.
Many studies, including Beck’s updated study, focus on the symptoms of
postpartum depression in an effort to identify and treat the disorder. According to
Beck, early identification and treatment of postpartum depression is difficult
because the symptoms are not obvious, though early identification and treatment
can shorten the duration and severity of patient suffering. Some symptoms, such
as sleep disturbance and anxiety, are common among women who have just
given birth, even if they do not have postpartum depression. But when symptoms
persist and expand to include severe anxiety and mood swings, tearfulness,
fatigue, loss of appetite, insomnia, difficulty bonding with the infant and feelings
of worthlessness, women may have postpartum depression. At that point,
healthcare professionals recommend that women experiencing such symptoms
contact a physician and seek treatment.
Beck argues that women experiencing postpartum depression may not seek
professional help because of the social stigma associated with postpartum
depression and women’s difficulties adjusting to a new role as caregiver. She
states that women are often unwilling to admit to emotional disorders relating to
childbirth, and their friends and families may not provide an accepting audience.
For her second meta-analysis, an update to her work on 1980s postpartum
literature, Beck searched for publications between 1990 and 2000 using search
terms such as postnatal depression, puerperal depression, predictors, and risk
factors. That allowed her to collect many articles related to postpartum
depression. Her final sample totaled eighty-four studies from over fifteen
countries, including the US, Canada, the UK, and New Zealand.
Across the eighty-four studies, Beck found thirteen significant predictors of
postpartum depression. The original nine predictors were prenatal depression,
childcare stress, prenatal anxiety, life stress, social support, marital relationship,
history of previous depression, infant temperament, and maternity blues. Several
of the predictors like prenatal depression, prenatal anxiety, life stress, and
history of previous depression, related to the anxiety and stress level of the
woman prior to giving birth. Several factors, such as social support, infant
temperament, and maternity blues, related to the women’s postpartum
experience after giving birth.
Beck found four new predictors in her updated study, which were low self-
esteem, single marital status, low socioeconomic status, and unplanned or
unwanted pregnancy. Overall, the thirteen predictors related to the woman’s
mental and physical health before giving birth, her life experiences after giving
birth, her social interactions, and her demographic variables. According to the
studies Beck analyzed, women experiencing one or more of the thirteen risk
factors were more likely to develop postpartum depression.
Following the identification of thirteen factors, Beck measured the strength of
each predictor, or how strongly it predicted whether a woman would develop
postpartum depression. She did that by finding a statistical r number for each
factor, which accounted for the number of studies, number of human subjects,
and the quality of the data that was linked to that specific predictor. To judge the
quality of each study, Beck scored all eighty-four studies according to eleven
categories such as the sample size of subjects, the method of postpartum
depression measurement, the research design, and the type of data analysis.
Any factor tied to postpartum depression had an r effect size greater than zero.
Larger r effect sizes indicated a larger effect, or stronger connection, between
the predictor and the likelihood of developing postpartum depression. Beck
interpreted the findings according to statistician Jacob Cohen’s guidelines, which
specified that a small effect size is 0.10, a medium effect size is 0.30, and a
large effect size is 0.50.
Using the r numbers, Beck found that the strongest predictors of postpartum
depression were prenatal depression, low self-esteem, childcare stress, and
prenatal anxiety. All of those predictors had r effect sizes greater than 0.40.
Three of the predictors, marital status, socioeconomic status, and unplanned or
unwanted pregnancy, had small r numbers below 0.30 and were thus weaker
predictors of a woman developing postpartum depression. Those results meant
that the marital status of the woman giving birth and her socioeconomic status
were not as strong indicators of postpartum depression development as prenatal
depression and low self-esteem.
In her updated meta-analysis, Beck concludes that the findings from her first
meta-analysis, the original nine predictors, are still relevant. Additionally, she
identifies four new risk factors for postpartum depression as low self-esteem,
single marital status, low socioeconomic status, and unplanned or
unwanted pregnancy. Because two of the factors, marital status and
socioeconomic status, are demographic variables, Beck presents a potential
profile of women who are more likely to develop postpartum depression. The
profile is of women who are unmarried with low household incomes. In the
conclusion of her updated meta-analysis, Beck recommends that physicians use
the thirteen predictors to identify women who may be at risk for developing
postpartum depression and design specific interventions targeted at different
predictors.
Since Nursing Research published “Predictors of Postpartum Depression: An
Update” in 2001, the article has served as a starting point for further research
into preventive methods and diagnostic tools relevant to postpartum depression.
In 2004, researchers at Toronto General Hospital in Toronto, Canada, conducted
a literature review of pre-birth, or antenatal, postpartum depression risk factors
and included Beck’s meta-analyses from 1996 and 2001. Similarly to Beck, those
authors concluded that women most likely to develop postpartum depression
were women who experienced depression, anxiety, or stressful life events during
their pregnancies, women with a previous history of depressive illness, and
women with low levels of social support. Additionally, the Toronto researchers
recommended that more research be conducted on specific groups of women,
including teenage mothers and immigrant women. Specifically, they highlighted
that the lack of social support is significant to immigrant women who are
culturally and physically separated from their support systems.
As of 2016, “Predictors of Postpartum Depression: An Update” has been cited
over 1500 times.

Sources
 Beck, Cheryl Tatano. “A Meta-Analysis of Predictors of Postpartum
Depression.” Nursing Research 45 (1996): 297–303.
 Beck, Cheryl Tatano. “Predictors of Postpartum Depression: An Update.”  Nursing
Research 50 (2001): 275–85.
 Beck, Cheryl Tatano, and Jeanne Driscoll.  Postpartum mood and anxiety
disorders: a clinician’s guide. Sudbury: Jones and Bartlett Publishers, 2006.
 Cohen, Jacob. “A Power Primer.” Psychological Bulletin 112 (1992): 155–
59. http://www2.psych.ubc.ca/~schaller/528Readings/Cohen1992. pdf  (Accessed August
9, 2017).
 Mayo Clinic staff. “Postpartum depression.” Mayo Clinic: Diseases and
Conditions. http://www.mayoclinic. org/diseases-conditions/postpartum-
depression/basics/treatment/ con-20029130  (Accessed August 9, 2017).
 March of Dimes. “Postpartum depression.” March of
Dimes. http://www.marchofdimes.org/pregnancy/ postpartum-depression.aspx  (Accessed
August 9, 2017).
 Robertson, Emma, Sherry Grace, Tamara Wallington, and Donna E. Stewart.
“Antenatal risk factors of postpartum depression: a synthesis of recent
literature.” General Hospital Psychiatry 26 (2004): 289–95.

How to cite
Chou, Cecilia, ""Predictors of Postpartum Depression: An Update” (2001), by Cheryl
Tatano Beck". Embryo Project Encyclopedia (2017-09-14). ISSN: 1940-5030
http://embryo.asu.edu/handle/10776/12986.

Show full item record

Publisher
Arizona State University. School of Life Sciences. Center for Biology and Society.
Embryo Project Encyclopedia.
Rights
Copyright Arizona Board of Regents Licensed as Creative Commons Attribution-
NonCommercial-Share Alike 3.0 Unported (CC BY-NC-SA 3.0)
http://creativecommons.org/licenses/by-nc-sa/3.0/

Last modified
Wednesday, July 4, 2018 - 04:40

Topic
Publications

Subject
Postpartum Period; PUERPERAL DISORDERS; PSYCHOTIC DISORDERS; Postpartum
Women; Puerperium; Depression, Postpartum; Depression; Depressive Disorder;
Postpartum depression; Pregnancy; Postnatal depression; Depression, Mental; Beck,
Cheryl Tatano; Literature