Humorism

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Humorism

 

16th-century German illustration of the four humors: Flegmat (phlegm), Sanguin (blood), Coleric (yellow bile) and Melanc (black bile), divided between the male and female sexes

Humorism, the humoral theory, or humoralism, was a system of medicine detailing a supposed makeup and workings of the human body, adopted by Ancient Greek and Roman physicians and philosophers.

Humorism began to fall out of favor in the 17th century and it was definitively disproved with the discovery of microbes.

Origin

See also: Ancient Greek medicine

The concept of "humors" may have origins in Ancient Egyptian medicine, or Mesopotamia, though it was not systemized until ancient Greek thinkers. The word humor is a translation of Greek χυμός, chymos (literally 'juice' or 'sap', metaphorically 'flavor'). Early texts on Indian Ayurveda medicine presented a theory of three or four humors (doṣas), which they sometimes linked with the five elements (pañca-bhūta): earth, water, fire, air, and space.

The concept of "humors" (chemical systems regulating human behaviour) became more prominent from the writing of medical theorist Alcmaeon of Croton (c. 540–500 BC). His list of humors was longer and included fundamental elements described by Empedocles, such as water, earth, fire, air, etc. Hippocrates is usually credited with applying this idea to medicine. In contrast to Alcmaeon, Hippocrates suggested that humors are the vital bodily fluids: blood, phlegm, yellow bile, and black bile. Alcmaeon and Hippocrates posited that an extreme excess or deficiency of any of the humors (bodily fluid) in a person can be a sign of illness. Hippocrates, and then Galen, suggested that a moderate imbalance in the mixture of these fluids produces behavioral patterns. One of the treatises attributed to Hippocrates, On the Nature of Man, describes the theory as follows:

The Human body contains blood, phlegm, yellow bile, and black bile. These are the things that make up its constitution and cause its pains and health. Health is primarily that state in which these constituent substances are in the correct proportion to each other, both in strength and quantity, and are well mixed. Pain occurs when one of the substances presents either a deficiency or an excess, or is separated in the body and not mixed with others. The body depends heavily on the four humors because their balanced combination helps to keep people in good health. Having the right amount of humor is essential for health. The pathophysiology of disease is consequently brought on by humor excesses and/or deficiencies.

The existence of fundamental biochemical substances and structural components in the body remains a compellingly shared point with Hippocratic beliefs, despite the fact that current science has moved away from those four Hippocratic humors.

Although the theory of the four humors does appear in some Hippocratic texts, other Hippocratic writers accepted the existence of only two humors, while some refrained from discussing the humoral theory at all. Humoralism, or the doctrine of the four temperaments, as a medical theory retained its popularity for centuries, largely through the influence of the writings of Galen (129–201 AD). The four essential elements—humors—that make up the human body, according to Hippocrates, are in harmony with one another and act as a catalyst for preserving health. Hippocrates' theory of four humors was linked with the popular theory of the four elements (earth, fire, water, and air) proposed by Empedocles, but this link was not proposed by Hippocrates or Galen, who referred primarily to bodily fluids. While Galen thought that humors were formed in the body, rather than ingested, he believed that different foods had varying potential to act upon the body to produce different humors. Warm foods, for example, tended to produce yellow bile, while cold foods tended to produce phlegm. Seasons of the year, periods of life, geographic regions, and occupations also influenced the nature of the humors formed. As such, certain seasons and geographic areas were understood to cause imbalances in the humors, leading to varying types of disease across time and place. For example, cities exposed to hot winds were seen as having higher rates of digestive problems as a result of excess phlegm running down from the head, while cities exposed to cold winds were associated with diseases of the lungs, acute diseases, and "hardness of the bowels", as well as ophthalmies (issues of the eyes), and nosebleeds. Cities to the west, meanwhile, were believed to produce weak, unhealthy, pale people that were subject to all manners of disease. In the treatise, On Airs, Waters, and Places, a Hippocratic physician is described arriving to an unnamed city where they test various factors of nature including the wind, water, and soil to predict the direct influence on the diseases specific to the city based on the season and the individual.

A fundamental idea of Hippocratic medicine was the endeavor to pinpoint the origins of illnesses in both the physiology of the human body and the influence of potentially hazardous environmental variables like air, water, and nutrition, and every humor has a distinct composition and is secreted by a different organ. Aristotle's concept of eucrasia—a state resembling equilibrium—and its relationship to the right balance of the four humors allow for the maintenance of human health, offering a more mathematical approach to medicine.

The four humors as depicted in an 18th-century woodcut: phlegmatic, choleric, sanguine and melancholic

The imbalance of humors, or dyscrasia, was thought to be the direct cause of all diseases. Health was associated with a balance of humors, or eucrasia. The qualities of the humors, in turn, influenced the nature of the diseases they caused. Yellow bile caused warm diseases and phlegm caused cold diseases. In On the Temperaments, Galen further emphasized the importance of the qualities. An ideal temperament involved a proportionally balanced mixture of the four qualities. Galen identified four temperaments in which one of the qualities (warm, cold, moist, or dry) predominated, and four more in which a combination of two (warm and moist, warm and dry, cold and dry, or cold and moist) dominated. These last four, named for the humors with which they were associated—sanguine, choleric, melancholic and phlegmatic—eventually became better known than the others. While the term temperament came to refer just to psychological dispositions, Galen used it to refer to bodily dispositions, which determined a person's susceptibility to particular diseases, as well as behavioral and emotional inclinations.

Disease could also be the result of the "corruption" of one or more of the humors, which could be caused by environmental circumstances, dietary changes, or many other factors. These deficits were thought to be caused by vapors inhaled or absorbed by the body. Greeks and Romans, and the later Muslim and Western European medical establishments that adopted and adapted classical medical philosophy, believed that each of these humors would wax and wane in the body, depending on diet and activity. When a patient was suffering from a surplus or imbalance of one of the four humors, then said patient's personality and/or physical health could be negatively affected.

Therefore, the goal of treatment was to rid the body of some of the excess humor through techniques like purging, bloodletting, catharsis, diuresis, and others. Bloodletting was already a prominent medical procedure by the first century, but venesection took on even more significance once Galen of Pergamum declared blood to be the most prevalent humor. The volume of blood extracted ranged from a few drops to several litres over the course of several days, depending on the patient's condition and the doctor's practice.

Four humors

Even though humorism theory had several models that used two, three, and five components, the most famous model consists of the four humors described by Hippocrates and developed further by Galen. The four humors of Hippocratic medicine are black bile (Greek: μέλαινα χολή, melaina chole), yellow bile (Greek: ξανθὴ χολή, xanthe chole), phlegm (Greek: φλέγμα, phlegma), and blood (Greek: αἷμα, haima). Each corresponds to one of the traditional four temperaments. Based on Hippocratic medicine, it was believed that for a body to be healthy, the four humors should be balanced in amount and strength. The proper blending and balance of the four humors was known as eukrasia.

Humorism theory was improved by Galen, who incorporated his understanding of the humors into his interpretation of the human body. He believed the interactions of the humors within the body were the key to investigating the physical nature and function of the organ systems. Galen combined his interpretation of the humors with his collection of ideas concerning nature from past philosophers in order to find conclusions about how the body works. For example, Galen maintained the idea of the presence of the Platonic tripartite soul, which consisted of "thumos (spiritedness), epithumos (directed spiritedness, i.e. desire), and Sophia (wisdom)". Through this, Galen found a connection between these three parts of the soul and the three major organs that were recognized at the time: the brain, the heart, and the liver. This idea of connecting vital parts of the soul to vital parts of the body was derived from Aristotle's sense of explaining physical observations, and Galen utilized it to build his view of the human body. The organs (named organa) had specific functions (called chreiai) that contributed to the maintenance of the human body, and the expression of these functions is shown in characteristic activities (called energeiai) of a person. While the correspondence of parts of the body to the soul was an influential concept, Galen decided that the interaction of the four humors with natural bodily mechanisms were responsible for human development and this connection inspired his understanding of the nature of the components of the body.

Galen recalls the correspondence between humors and seasons in his On the Doctrines of Hippocrates and Plato, and says that, "As for ages and the seasons, the child (παῖς) corresponds to spring, the young man (νεανίσκος) to summer, the mature man (παρακµάζων) to autumn, and the old man (γέρων) to winter". He also related a correspondence between humors and seasons based on the properties of both. Blood, as a humor, was considered hot and wet. This gave it a correspondence to spring. Yellow bile was considered hot and dry, which related it to summer. Black bile was considered cold and dry, and thus related to autumn. Phlegm, cold and wet, was related to winter.

Galen also believed that the characteristics of the soul follow the mixtures of the body, but he did not apply this idea to the Hippocratic humors. He believed that phlegm did not influence character. In his On Hippocrates' The Nature of Man, Galen stated: "Sharpness and intelligence (ὀξὺ καὶ συνετόν) are caused by yellow bile in the soul, perseverance and consistency (ἑδραῖον καὶ βέβαιον) by the melancholic humor, and simplicity and naivety (ἁπλοῦν καὶ ἠλιθιώτερον) by blood. But the nature of phlegm has no effect on the character of the soul (τοῦ δὲ φλέγµατος ἡ φύσις εἰς µὲν ἠθοποιῗαν ἄχρηστος)." He further said that blood is a mixture of the four elements: water, air, fire, and earth.

These terms only partly correspond to modern medical terminology, in which there is no distinction between black and yellow bile, and phlegm has a very different meaning. It was believed that the humors were the basic substances from which all liquids in the body were made. Robin Fåhræus (1921), a Swedish physician who devised the erythrocyte sedimentation rate, suggested that the four humors were based upon the observation of blood clotting in a transparent container. When blood is drawn in a glass container and left undisturbed for about an hour, four different layers can be seen: a dark clot forms at the bottom (the "black bile"); above the clot is a layer of red blood cells (the "blood"); above this is a whitish layer of white blood cells (the "phlegm"); the top layer is clear yellow serum (the "yellow bile").

Many Greek texts were written during the golden age of the theory of the four humors in Greek medicine after Galen. One of those texts was an anonymous treatise called On the Constitution of the Universe and of Man, published in the mid-19th century by J. L. Ideler. In this text, the author establishes the relationship between elements of the universe (air, water, earth, fire) and elements of the man (blood, yellow bile, black bile, phlegm). He said that:

• The people who have red blood are friendly. They joke and laugh about their bodies, and they are rose-tinted, slightly red, and have pretty skin.
• The people who have yellow bile are bitter, short tempered, and daring. They appear greenish and have yellow skin.
• The people who are composed of black bile are lazy, fearful, and sickly. They have black hair and black eyes.
• Those who have phlegm are low spirited, forgetful, and have white hair.

Seventeenth century English playwright Ben Jonson wrote humor plays, where character types were based on their humoral complexion.

Blood

It was thought that the nutritional value of the blood was the source of energy for the body and the soul. Blood was believed to consist of small proportional amounts of the other three humors. This meant that taking a blood sample would allow for determination of the balance of the four humors in the body. It was associated with a sanguine nature (enthusiastic, active, and social). Blood is considered to be hot and wet, sharing these characteristics with the season of spring.

Yellow bile

Yellow bile was associated with a choleric nature (ambitious, decisive, aggressive, and short-tempered). It was thought to be fluid found within the gallbladder, or in excretions such as vomit and feces. The associated qualities for yellow bile are hot and dry with the natural association of summer and fire. It was believed that an excess of this humor in an individual would result in emotional irregularities such as increased anger or irrational behaviour.

Black bile

Black bile was associated with a melancholy nature, the word melancholy itself deriving from the Greek for 'black bile', μέλαινα χολή (melaina kholé). Depression was attributed to excess or unnatural black bile secreted by the spleen. Cancer was also attributed to an excess of black bile concentrated in a specific area. The seasonal association of black bile was to autumn as the cold and dry characteristics of the season reflect the nature of man.

Phlegm

Phlegm was associated with all phlegmatic nature, thought to be associated with reserved behavior. The phlegm of humorism is far from phlegm as it is defined today. Phlegm was used as a general term to describe white or colorless secretions such as pus, mucus, saliva, or sweat. Phlegm was also associated with the brain, possibly due to the color and consistency of brain tissue. The French physiologist and Nobel laureate Charles Richet, when describing humorism's "phlegm or pituitary secretion" in 1910, asked rhetorically, "this strange liquid, which is the cause of tumours, of chlorosis, of rheumatism, and cacochymia – where is it? Who will ever see it? Who has ever seen it? What can we say of this fanciful classification of humors into four groups, of which two are absolutely imaginary?" The seasonal association of phlegm is winter due to the natural properties of being cold and wet.

Humor production

Humors were believed to be produced via digestion as the final products of hepatic digestion. Digestion is a continuous process taking place in every animal, and it can be divided into four sequential stages. The gastric digestion stage, the hepatic digestion stage, the vascular digestion stage, and the tissue digestion stage. Each stage digests food until it becomes suitable for use by the body. In gastric digestion, food is made into chylous, which is suitable for the liver to absorb and carry on digestion. Chylous is changed into chymous in the hepatic digestion stage. Chymous is composed of the four humors: blood, phlegm, yellow bile, and black bile. These four humors then circulate in the blood vessels. In the last stage of digestion, tissue digestion, food becomes similar to the organ tissue for which it is destined.

If anything goes wrong leading up to the production of humors, there will be an imbalance leading to disease. Proper organ functioning is necessary in the production of good humor. The stomach and liver also have to function normally for proper digestion. If there are any abnormalities in gastric digestion, the liver, blood vessels, and tissues cannot be provided with the raw chylous, which can cause abnormal humor and blood composition. A healthy functioning liver is not capable of converting abnormal chylous into normal chylous and normal humors.

Humors are the end product of gastric digestion, but they are not the end product of the digestion cycle, so an abnormal humor produced by hepatic digestion will affect other digestive organs.

Relation to jaundice

According to Hippocratic humoral theory, jaundice is present in the Hippocratic Corpus. Some of the first descriptions of jaundice come from the Hippocratic physicians (icterus). The ailment appears multiple times in the Hippocratic Corpus, where its genesis, description, prognosis, and therapy are given. The five kinds of jaundice mentioned in the Hippocratic Corpus all share a yellow or greenish skin color.

A modern doctor will undoubtedly start to think of the symptoms listed in contemporary atlases of medicine after reading the clinical symptoms of each variety of jaundice listed in the Hippocratic Corpus. Despite the fact that the Hippocratic physicians' therapeutic approaches have little to do with contemporary medical practice, their capacity for observation as they described the various forms of jaundice is remarkable. In the Hippocratic Corpus, the Hippocratic physicians make multiple references to jaundice. At that time, jaundice was viewed as an illness unto itself rather than a symptom brought on by a disease.

Unification with Empedocles's model

Empedocles's theory suggested that there are four elements: earth, fire, water, and air, with the earth producing the natural systems. Since this theory was influential for centuries, later scholars paired qualities associated with each humor as described by Hippocrates/Galen with seasons and "basic elements" as described by Empedocles.

The following table shows the four humors with their corresponding elements, seasons, sites of formation, and resulting temperaments:

Humor	Season	Age	Element	Organ	Temperaments
Blood	Spring	Infancy	Air	Liver	Warm and moist	Sanguine
Yellow bile	Summer	Youth	Fire	Gallbladder	Warm and dry	Choleric
Black bile	Autumn	Adulthood	Earth	Spleen	Cold and dry	Melancholic
Phlegm	Winter	Old age	Water	Brain/Lungs	Cold and moist	Phlegmatic

Influence and legacy

Islamic medicine

See also: Medicine in medieval Islam and Unani

Medieval medical tradition in the Golden Age of Islam adopted the theory of humorism from Greco-Roman medicine, notably via the Persian polymath Avicenna's The Canon of Medicine (1025). Avicenna summarized the four humors and temperaments as follows:

Avicenna's (ibn Sina) four humors and temperaments

Evidence	Hot	Cold	Moist	Dry
Morbid states	Inflammations become febrile	Fevers related to serious humor, rheumatism	Lassitude	Loss of vigour
Functional power	Deficient energy	Deficient digestive power	Difficult digestion
Subjective sensations	Bitter taste, excessive thirst, burning at cardia	Lack of desire for fluids	Mucoid salivation, sleepiness	Insomnia, wakefulness
Physical signs	High pulse rate, lassitude	Flaccid joints	Diarrhea, swollen eyelids, rough skin, acquired habit	Rough skin, acquired habit
Foods and medicines	Calefacients harmful, infrigidants beneficial	Infrigidants harmful, calefacients beneficial	Moist articles harmful	Dry regimen harmful, humectants beneficial
Relation to weather	Worse in summer	Worse in winter		Bad in autumn

Perso-Arabic and Indian medicine

The Unani school of medicine, practiced in Perso-Arabic countries, India, and Pakistan, is based on Galenic and Avicennian medicine in its emphasis on the four humors as a fundamental part of the methodologic paradigm.

Western medicine

The humoralist system of medicine was highly individualistic, for all patients were said to have their own unique humoral composition. From Hippocrates onward, the humoral theory was adopted by Greek, Roman and Islamic physicians, and dominated the view of the human body among European physicians until at least 1543 when it was first seriously challenged by Andreas Vesalius, who mostly criticized Galen's theories of human anatomy and not the chemical hypothesis of behavioural regulation (temperament).

The four humors and their qualities

Typical 18th-century practices such as bleeding a sick person or applying hot cups to a person were based on the humoral theory of imbalances of fluids (blood and bile in those cases). Methods of treatment like bloodletting, emetics and purges were aimed at expelling a surplus of a humor. Apocroustics were medications intended to stop the flux of malignant humors to a diseased body part.

16th-century Swiss physician Paracelsus further developed the idea that beneficial medical substances could be found in herbs, minerals and various alchemical combinations thereof. These beliefs were the foundation of mainstream Western medicine well into the 17th century. Specific minerals or herbs were used to treat ailments simple to complex, from an uncomplicated upper respiratory infection to the plague. For example, chamomile was used to decrease heat, and lower excessive bile humor. Arsenic was used in a poultice bag to 'draw out' the excess humor(s) that led to symptoms of the plague. Apophlegmatisms, in pre-modern medicine, were medications chewed in order to draw away phlegm and humors.

Although advances in cellular pathology and chemistry criticized humoralism by the 17th century, the theory had dominated Western medical thinking for more than 2,000 years. Only in some instances did the theory of humoralism wane into obscurity. One such instance occurred in the sixth and seventh centuries in the Byzantine Empire when traditional secular Greek culture gave way to Christian influences. Though the use of humoralist medicine continued during this time, its influence was diminished in favor of religion. The revival of Greek humoralism, owing in part to changing social and economic factors, did not begin until the early ninth century. Use of the practice in modern times is pseudoscience.

Modern use

Humoral theory was the grand unified theory of medicine, before the invention of modern medicine, for more than 2,000 years. The theory was one of the fundamental tenets of the teachings of the Greek physician-philosopher Hippocrates (460–370 BC), who is regarded as the first practitioner of medicine, appropriately referred to as the "Father of Modern Medicine".

With the advent of the Doctrine of Specific Etiology, the humoral theory's demise hastened even further. This demonstrates that there is only one precise cause and one specific issue for each and every sickness or disorder that has been diagnosed. Additionally, the identification of messenger molecules like hormones, growth factors, and neurotransmitters suggests that the humoral theory has not yet been made fully moribund. Humoral theory is still present in modern medical terminology, which refers to humoral immunity when discussing elements of immunity that circulate in the bloodstream, such as hormones and antibodies.

Modern medicine refers to humoral immunity or humoral regulation when describing substances such as hormones and antibodies, but this is not a remnant of the humor theory. It is merely a literal use of humoral, i.e. pertaining to bodily fluids (such as blood and lymph).

The concept of humorism was not definitively disproven until 1858. There were no studies performed to prove or disprove the impact of dysfunction in known bodily organs producing named fluids (humors) on temperament traits simply because the list of temperament traits was not defined up until the end of the 20th century.

Culture

Theophrastus and others developed a set of characters based on the humors. Those with too much blood were sanguine. Those with too much phlegm were phlegmatic. Those with too much yellow bile were choleric, and those with too much black bile were melancholic. The idea of human personality based on humors contributed to the character comedies of Menander and, later, Plautus. Through the neo-classical revival in Europe, the humor theory dominated medical practice, and the theory of humoral types made periodic appearances in drama. The humors were an important and popular iconographic theme in European art, found in paintings, tapestries, and sets of prints.

The humors can be found in Elizabethan works, such as in The Taming of the Shrew, in which the character Petruchio, a choleric man, uses humoral therapy techniques on Katherina, a choleric woman, in order to tame her into the socially acceptable phlegmatic woman. Some examples include: he yells at the servants for serving mutton, a choleric food, to two people who are already choleric; he deprives Katherina of sleep; and he, Katherina and their servant Grumio endure a cold walk home, for cold temperatures were said to tame choleric temperaments.

The theory of the four humors features prominently in Rupert Thomson's 2005 novel Divided Kingdom.

Endless Forms Most Beautiful (book)

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Endless_Forms_Most_Beautiful_(book) 

 

Endless Forms Most Beautiful

Author	Sean B. Carroll
Subject	Evolutionary developmental biology (evo-devo)
Genre	Popular science
Publisher	W. W. Norton
Publication date	2005
Publication place	USA
Pages	331

Endless Forms Most Beautiful: The New Science of Evo Devo and the Making of the Animal Kingdom is a 2005 book by the molecular biologist Sean B. Carroll. It presents a summary of the emerging field of evolutionary developmental biology and the role of toolkit genes. It has won numerous awards for science communication.

The book's somewhat controversial argument is that evolution in animals (though no doubt similar processes occur in other organisms) proceeds mostly by modifying the way that regulatory genes, which do not code for structural proteins (such as enzymes), control embryonic development. In turn, these regulatory genes turn out to be based on a very old set of highly conserved genes which Carroll nicknames the toolkit. Almost identical sequences can be found across the animal kingdom, meaning that toolkit genes such as Hox must have evolved before the Cambrian radiation which created most of the animal body plans that exist today. These genes are used and reused, occasionally by duplication but far more often by being applied unchanged to new functions. Thus the same signal may be given at a different time in development, in a different part of the embryo, creating a different effect on the adult body. In Carroll's view, this explains how so many body forms are created with so few structural genes.

The book has been praised by critics, and called the most important popular science book since Richard Dawkins's The Blind Watchmaker.

Author

Sean B. Carroll in 2008

Sean B. Carroll is a professor of molecular biology and genetics at the University of Wisconsin–Madison. He studies the evolution of cis-regulatory elements (pieces of non-coding DNA) which help to regulate gene expression in developing embryos, using the fruit fly Drosophila as the model organism. He has won the Shaw Scientist Award and the Stephen Jay Gould Prize for his work.

Book

Context

Further information: Evolutionary developmental biology

The book's title quotes from the last sentence of Charles Darwin's 1859 The Origin of Species, in which he described the evolution of all living organisms from a common ancestor: "endless forms most beautiful and most wonderful have been, and are being, evolved." Darwin, however, was unable to explain how those body forms actually came into being. The early 20th-century modern synthesis of evolution and genetics, too, largely ignored embryonic development to explain the form of organisms, since population genetics appeared to be an adequate explanation of how forms evolved. That task was finally undertaken at the end of the 20th century with the arrival of recombinant DNA technology, when biologists were able to start to explore how development was actually controlled.

Contents

The body of a trilobite is made of many similar modules (body segments with pairs of appendages). These could be made by repeated use of the same toolkit genes.

Part I The Making of Animals

1. Animal Architecture: Modern Forms, Ancient Designs

Carroll argues that many animals have a modular design with repeated parts, as in trilobites with repeated segments, or the repeated fingers of a human hand.

2. Monsters, Mutants, and Master Genes

Embryologists study how bodies develop, and the abnormalities when things go wrong, such as homeotic variants when one body part is changed into another (for instance, a fruit fly antenna becomes a leg with the Antennapedia mutant).

3. From E. coli to Elephants

This chapter tells the tale of the genetic code, and the lac operon, showing that the environment and genetic switches together control gene expression. He introduces the evo-devo gene toolkit.

4. Making Babies: 25,000 Genes, Some Assembly Required

Carroll looks at how a fruit fly's embryonic development is controlled and describes his own discoveries (back in 1994).

5. The Dark Matter of the Genome: Operating Instructions for the Tool Kit

The chapter describes how genes are switched on and off in a precisely choreographed time sequence and 3-dimensional pattern in the developing embryo and how the logic can be modified by evolution to create different animal bodies.

Crayfish limbs are highly specialised, adapted by evo-devo gene toolkit changes from the simple appendages of their trilobite-like ancestors.

This fruit fly embryo is stained to show the expression of some of the genes (named) that control its development.

Part II Fossils, Genes, and the Making of Animal Diversity

6. The Big Bang of Animal Evolution

The Cambrian radiation saw an explosion in the variety of animal body plans, from flatworms and molluscs to arthropods and vertebrates. Carroll explains how shifting the pattern of Hox gene expression shaped the bodies of different types of arthropods and different types of vertebrates.

7. Little Bangs: Wings and Other Revolutionary Inventions

This chapter explains how evolution goes to work within a lineage, specialising arthropod limbs from all being alike to "all of the different implements a humble crayfish carries", with (he writes) more gizmos than a Swiss Army knife.

8. How the Butterfly Got Its Spots

Echoing the titles of Rudyard Kipling's Just So Stories, Carroll shows how butterfly wing patterns evolved, including his discovery of the role of the Distal-less gene there, until then known in limb development. Evidently, a genetic switch could be reused for different purposes.

9. Paint It Black

Carroll looks at zebra stripes, industrial melanism in the peppered moth and the spots of big cats, all examples of the control of pattern in animals, down to molecular level.

10. A Beautiful Mind: The Making of Homo sapiens.

This chapter discusses how humans differ from other apes and why there are not many structural genes for the differences. Most of the changes are in genetic control, not in proteins.

11. Endless Forms Most Beautiful

Carroll concludes by revisiting Darwin's Origin of Species, starting with how Darwin evolved the final paragraph of his book, leaving only these four words "completely untouched throughout all versions and editions". He shows that evo-devo is a cornerstone of a synthesis of evolution, genetics, and embryology, replacing the "Modern synthesis" of 20th century biology.

Illustrations

The book is illustrated with photographs, such as of developing fruit fly embryos dyed to show the effects of toolkit genes, and with line drawings by Jamie W. Carroll, Josh P. Klaiss and Leanne M. Olds.

Awards

• Discover magazine's Top Science Books of the Year, 2005
• USA Today's Top Science Books of the Year, 2005
• Banta Prize, Wisconsin Library Association, 2006
• Finalist, 2005 Los Angeles Times Book Prize (Science and Technology)
• Finalist, 2006 National Academy of Sciences Communication Award

Reception

"Kipling would be riveted": the book explains how animals actually acquired the features that Rudyard Kipling wrote about in his 1902 Just So Stories, such as "How the Elephant got his Trunk".

The evolutionary biologist Lewis Wolpert, writing in American Scientist, called Endless Forms Most Beautiful "a beautiful and very important book." He summarized the message of the book with the words "As Darwin's theory made clear, these multitudinous forms developed as a result of small changes in offspring and natural selection of those that were better adapted to their environment. Such variation is brought about by alterations in genes that control how cells in the developing embryo behave. Thus one cannot understand evolution without understanding its fundamental relation to development of the embryo." Wolpert noted that Carroll intended to explain evo-devo, and "has brilliantly achieved what he set out to do."

The evolutionary biologist Jerry Coyne, writing in Nature, described the book as for the interested lay reader, and called it "a paean to recent advances in developmental genetics, and what they may tell us about the evolutionary process." For him, the centrepiece was "the unexpected discovery that the genes that control the body plans of all bilateral animals, including worms, insects, frogs and humans, are largely identical. These are the 'homeobox' (Hox) genes". He called Carroll a leader in the field and an "adept communicator", but admits to "feeling uncomfortable" when Carroll sets out his personal vision of the field "without admitting that large parts of that vision remain controversial." Coyne pointed out that the idea that the "'regulatory gene' is the locus of evolution" dates back to Roy Britten and colleagues around 1970, but was still weakly supported by observation or experiment. He granted that chimps and humans are almost 99% identical at DNA level, but points out that "humans and chimps have different amino-acid sequences in at least 55% of their proteins, a figure that rises to 95% for humans and mice. Thus we can't exclude protein-sequence evolution as an important reason why we lack whiskers and tails." He also noted that nearly half of human protein-coding genes do not have homologues in fruit flies, so one could argue the opposite of Carroll's thesis and claim that "evolution of form is very much a matter of teaching old genes to make new genes."

The review in BioScience noted that the book serves as a new Just So Stories, explaining the "spots, stripes, and bumps" that had attracted Rudyard Kipling's attention in his children's stories. The review praised Carroll for tackling human evolution and covering the key concepts of what Charles Darwin called the grandeur of [the evolutionary view of] life, suggesting that "Kipling would be riveted."

The science writer Peter Forbes, writing in The Guardian, called it an "essential book" and its author "both a distinguished scientist ... and one of our great science writers." The journalist Dick Pountain, writing in PC Pro magazine, argued that Endless Forms Most Beautiful was the most important popular science book since Richard Dawkins's The Blind Watchmaker, "and in effect a sequel [to it]."

The paleobiologist Douglas H. Erwin, reviewing the book for Artificial Life, noted that life forms from fruit flies to humans have far fewer genes than many biologists expected – human beings have only some 20,000. "How could humans, in all our diversity of cell types and complexity of neurons, require essentially the same number of genes as a fly, or worse, a worm (the nematode Caenorhabditis elegans)?" asks Erwin. He answered his own question about the "astonishing morphological diversity" of animals coming from "such a limited number of genes", praising Carroll's "insightful and enthusiastic" style, writing in a "witty and engaging" way, pulling the reader into the complexities of Hox and PAX-6, as well as celebrating the Cambrian explosion of life forms and much else.

Postpartum depression

From Wikipedia, the free encyclopedia

Not to be confused with Postpartum blues.

 

Postpartum depression
Other names	Postnatal depression, perinatal depression
Specialty	Psychiatry
Symptoms	Extreme sadness, low energy, anxiety, changes in sleeping or eating patterns, crying episodes, irritability
Complications	self harm, suicide
Usual onset	A week to a month after childbirth
Causes	Unclear
Risk factors	Prior postpartum depression, bipolar disorder, family history of depression, psychological stress, complications of childbirth, lack of support, drug use disorder
Diagnostic method	Based on symptoms
Differential diagnosis	Baby blues
Treatment	Counselling, medications
Frequency	~15% of births

Postpartum depression (PPD), also called perinatal depression, is a mood disorder which may be experienced by pregnant or postpartum women. Symptoms include extreme sadness, low energy, anxiety, crying episodes, irritability, and extreme changes in sleeping or eating patterns. PPD can also negatively affect the newborn child.

Although the exact cause of PPD is unclear, it is believed to be due to a combination of physical, emotional, genetic, and social factors such as hormone imbalances and sleep deprivation. Risk factors include prior episodes of postpartum depression, bipolar disorder, a family history of depression, psychological stress, complications of childbirth, lack of support, or a drug use disorder. Diagnosis is based on a person's symptoms. While most women experience a brief period of worry or unhappiness after delivery, postpartum depression should be suspected when symptoms are severe and last over two weeks.

Among those at risk, providing psychosocial support may be protective in preventing PPD. This may include community support such as food, household chores, mother care, and companionship. Treatment for PPD may include counseling or medications. Types of counseling that are effective include interpersonal psychotherapy (IPT), cognitive behavioral therapy (CBT), and psychodynamic therapy. Tentative evidence supports the use of selective serotonin reuptake inhibitors (SSRIs).

Depression occurs in roughly 10 to 20% of postpartum women. Postpartum depression commonly affects mothers who have experienced stillbirth, live in urban areas and adolescent mothers. Moreover, this mood disorder is estimated to affect 1% to 26% of new fathers. A different kind of postpartum mood disorder is postpartum psychosis, which is more severe and occurs in about 1 to 2 per 1,000 women following childbirth. Postpartum psychosis is one of the leading causes of the murder of children less than one year of age, which occurs in about 8 per 100,000 births in the United States.

Signs and symptoms

Symptoms of PPD can occur at any time in the first year postpartum. Typically, a diagnosis of postpartum depression is considered after signs and symptoms persist for at least two weeks.

Emotional

• Persistent sadness, anxiousness, or "empty" mood
• Severe mood swings
• Frustration, irritability, restlessness, anger
• Feelings of hopelessness or helplessness
• Guilt, shame, worthlessness
• Low self-esteem
• Numbness, emptiness
• Exhaustion
• Inability to be comforted
• Trouble bonding with the baby
• Feeling inadequate in taking care of the baby
• Thoughts of self-harm or suicide

Behavioral

• Lack of interest or pleasure in usual activities
• Low libido
• Changes in appetite
• Fatigue, decreased energy and motivation
• Poor self-care
• Social withdrawal
• Insomnia or excessive sleep
• Worry about harming self, baby, or partner

Neurobiology

fMRI studies indicate differences in brain activity between mothers with postpartum depression and those without. Mothers diagnosed with PPD tend to have less activity in the left frontal lobe and increased activity in the right frontal lobe when compared with healthy controls. They also exhibit decreased connectivity between vital brain structures, including the anterior cingulate cortex, dorsal lateral prefrontal cortex, amygdala, and hippocampus. Brain activation differences between depressed and nondepressed mothers are more pronounced when stimulated by non-infant emotional cues. Depressed mothers show greater neural activity in the right amygdala toward non-infant emotional cues as well as reduced connectivity between the amygdala and right insular cortex. Recent findings have also identified blunted activity in the anterior cingulate cortex, striatum, orbitofrontal cortex, and insula in mothers with PPD when viewing images of their infants.

More robust studies on neural activation regarding PPD have been conducted with rodents than humans. These studies have allowed for greater isolation of specific brain regions, neurotransmitters, hormones, and steroids.

Onset and duration

Postpartum depression onset usually begins between two weeks to a month after delivery. A study done at an inner-city mental health clinic has shown that 50% of postpartum depressive episodes began before delivery. In the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) PPD is not recognized as a distinct condition but rather a specific type of a major depressive episode. In the DSM-5, the specifier "with peripartum onset" can be applied to a major depressive episode if the onset occurred either during pregnancy or within the four weeks following delivery. The prevalence of postpartum depression differs across different months after childbirth. Studies done on postpartum depression amongst women in the Middle East show that the prevalence in the first three months of postpartum was 31%, while the prevalence from the fourth to twelfth months of postpartum was 19%. PPD may last several months or even a year.

Consequences on maternal and child health

Postpartum depression can interfere with normal maternal-infant bonding and adversely affect acute and long-term child development. Infants of mothers with PPD have higher incidences of excess crying, temperamental symptoms, and sleeping difficulties. Probems with sleeping in infants may exacerbate or be exacerbated by concurrent PPD in mothers. Maternal outcomes of PPD include withdrawal, disengagement, and hostility. Additional patterns observed in mothers with PPD include lower rates of initiation and maintenance of breastfeeding.

Children and infants of PPD-affected mothers experience negative long-term impacts on their cognitive functioning, inhibitory control, and emotional regulation. In cases of untreated PPD, violent behaviors and psychiatric and medical conditions in adolescence have been observed.

Suicide rates of women with PPD are lower than those outside of the perinatal period. Fetal or infant death in the first year postpartum has been associated with a higher risk of suicide attempt and higher inpatient psychiatric admissions.

Postpartum depression in fathers

Paternal postpartum depression is a poorly understood concept with a limited evidence-base. However, postpartum depression affects 8 to 10% of fathers. There are no set criteria for men to have postpartum depression. The cause may be distinct in males. Causes of paternal postpartum depression include hormonal changes during pregnancy, which can be indicative of father-child relationships. For instance, male depressive symptoms have been associated with low testosterone levels in men. Low prolactin, estrogen, and vasopressin levels have been associated with struggles with father-infant attachment, which can lead to depression in first-time fathers. Symptoms of postpartum depression in men are extreme sadness, fatigue, anxiety, irritability, and suicidal thoughts. Postpartum depression in men is most likely to occur 3–6 months after delivery and is correlated with maternal depression, meaning that if the mother is experiencing postpartum depression, then the father is at a higher risk of developing the illness as well. Postpartum depression in men leads to an increased risk of suicide, while also limiting healthy infant-father attachment. Men who experience PPD can exhibit poor parenting behaviors, and distress, and reduce infant interaction.

Reduced paternal interaction can later lead to cognitive and behavioral problems in children. Children as young as 3.5 years old may experience problems with internalizing and externalizing behaviors, indicating that paternal postpartum depression can have long-term consequences. Furthermore, if children as young as two are not frequently read to, this negative parent-child interaction can harm their expressive vocabulary. A study focusing on low-income fathers found that increased involvement in their child's first year was linked to lower rates of postpartum depression.

Adoptive parents

Postpartum depression may also be experienced by non-biological parents. While not much research has been done regarding post-adoption depression, difficulties associated with parenting post-partum are similar between biological and adoptive parents. Women who adopt children undergo significant stress and life changes during the postpartum period, similar to biological mothers. This may raise their chance of developing depressive symptoms and anxious tendencies. Postpartum depression presents in adoptive mothers via sleep deprivation similar to birth mothers, but adoptive parents may have added risk factors such as a history of infertility.

Issues for LGBTQ people

Additionally, preliminary research has shown that childbearing individuals who are part of the LGBTQ community may be more susceptible to prenatal depression and anxiety than cisgender and heterosexual people.

According to two other studies, LGBTQ people were discouraged from accessing postpartum mental health services due to societal stigma adding a social barrier that heteronormative mothers do not have. Lesbian participants expressed apprehension about receiving a mental health diagnosis because of worries about social stigma and employment opportunities. Concerns were also raised about possible child removal and a parent's diagnosis including mental illness. From the studies conducted thus far, although limited, it is evident that there is a much larger population that experiences depression associated with childbirth than just biological mothers.

Causes

The cause of PPD is unknown. Hormonal and physical changes, personal and family history of depression, and the stress of caring for a new baby all may contribute to the development of postpartum depression.

Evidence suggests that hormonal changes may play a role. Understanding the neuroendocrinology characteristic of PPD has proven to be particularly challenging given the erratic changes to the brain and biological systems during pregnancy and postpartum. A review of exploratory studies in PPD has observed that women with PPD have more dramatic changes in HPA axis activity, however, the directionality of specific hormone increases or decreases remain mixed. Hormones that have been studied include estrogen, progesterone, thyroid hormone, testosterone, corticotropin releasing hormone, endorphins, and cortisol. Estrogen and progesterone levels drop back to pre-pregnancy levels within 24 hours of giving birth, and that sudden change may cause it. Aberrant steroid hormone-dependent regulation of neuronal calcium influx via extracellular matrix proteins and membrane receptors involved in responding to the cell's microenvironment might be important in conferring biological risk. The use of synthetic oxytocin, a birth-inducing drug, has been linked to increased rates of postpartum depression and anxiety.

Estradiol, which helps the uterus thicken and grow, is thought to contribute to the development of PPD. This is due to its relationship with serotonin. Estradiol levels increase during pregnancy, then drastically decrease following childbirth. When estradiol levels drop postpartum, the levels of serotonin decline as well. Serotonin is a neurotransmitter that helps regulate mood. Low serotonin levels cause feelings of depression and anxiety. Thus, when estradiol levels are low, serotonin can be low, suggesting that estradiol plays a role in the development of PPD.

Profound lifestyle changes that are brought about by caring for the infant are also frequently hypothesized to cause PPD. However, little evidence supports this hypothesis. Mothers who have had several previous children without experiencing PPD can nonetheless experience it with their latest child. Despite the biological and psychosocial changes that may accompany pregnancy and the postpartum period, most women are not diagnosed with PPD. Many mothers are unable to get the rest they need to fully recover from giving birth. Sleep deprivation can lead to physical discomfort and exhaustion, which can contribute to the symptoms of postpartum depression.

Risk factors

While the causes of PPD are not understood, several factors have been suggested to increase the risk. These risks can be broken down into two categories, biological and psychosocial:

Biological

• Administration of labor-inducing medication synthetic oxytocin
• Chronic illnesses caused by neuroendocrine irregularities
• Genetic history of PPD
• Hormone irregularities
• Inflammatory illnesses (irritable bowel syndrome, fibromyalgia)
• Cigarette smoking
• Gut microbiome

The risk factors for postpartum depression can be broken down into two categories as listed above, biological and psychosocial. Certain biological risk factors include the administration of oxytocin to induce labor. Chronic illnesses such as diabetes, or Addison's disease, as well as issues with hypothalamic-pituitary-adrenal dysregulation (which controls hormonal responses), inflammatory processes like asthma or celiac disease, and genetic vulnerabilities such as a family history of depression or PPD. Chronic illnesses caused by neuroendocrine irregularities including irritable bowel syndrome and fibromyalgia typically put individuals at risk for further health complications. However, it has been found that these diseases do not increase the risk for postpartum depression, these factors are known to correlate with PPD. This correlation does not mean these factors are causal. Cigarette smoking has been known to have additive effects. Some studies have found a link between PPD and low levels of DHA (an omega-3 fatty acid) in the mother. A correlation between postpartum thyroiditis and postpartum depression has been proposed but remains controversial. There may also be a link between postpartum depression and anti-thyroid antibodies.

Psychosocial

• Prenatal depression or anxiety
• A personal or family history of depression
• Moderate to severe premenstrual symptoms
• Stressful life events experienced during pregnancy
• Postpartum blues
• Birth-related psychological trauma
• Birth-related physical trauma
• History of sexual abuse
• Childhood trauma
• Previous stillbirth or miscarriage
• Formula-feeding rather than breast-feeding
• Low self-esteem
• Childcare or life stress
• Low social support
• Poor marital relationship or single marital status
• Low socioeconomic status
• A lack of strong emotional support from spouse, partner, family, or friends
• Infant temperament problems/colic
• Unplanned/unwanted pregnancy
• Breastfeeding difficulties
• Maternal age, family food insecurity, and violence against women

The psychosocial risk factors for postpartum depression include severe life events, some forms of chronic strain, relationship quality, and support from partner and mother. There is a need for more research regarding the link between psychosocial risk factors and postpartum depression. Some psychosocial risk factors can be linked to the social determinants of health. Women with fewer resources indicate a higher level of postpartum depression and stress than those women with more resources, such as financial.

Rates of PPD have been shown to decrease as income increases. Women with fewer resources may be more likely to have an unintended or unwanted pregnancy, increasing the risk of PPD. Women with fewer resources may also include single mothers of low income. Single mothers of low income may have more limited access to resources while transitioning into motherhood. These women already have fewer spending options, and having a child may spread those options even further. Low-income women are frequently trapped in a cycle of poverty, unable to advance, affecting their ability to access and receive quality healthcare to diagnose and treat postpartum depression.

Studies in the US have also shown a correlation between a mother's race and postpartum depression. African American mothers have been shown to have the highest risk of PPD at 25%, while Asian mothers had the lowest at 11.5%, after controlling for social factors such as age, income, education, marital status, and baby's health. The PPD rates for First Nations, Caucasian, and Hispanic women fell in between.

Migration away from a cultural community of support can be a factor in PPD. Traditional cultures around the world prioritize organized support during postpartum care to ensure the mother's mental and physical health, well-being, and recovery.

One of the strongest predictors of paternal PPD is having a partner who has PPD, with fathers developing PPD 50% of the time when their female partner has PPD.

Sexual orientation has also been studied as a risk factor for PPD. In a 2007 study conducted by Ross and colleagues, lesbian and bisexual mothers were tested for PPD and then compared with a heterosexual sample group. It was found that lesbian and bisexual biological mothers had significantly higher Edinburgh Postnatal Depression Scale scores than the heterosexual women in the sample. Postpartum depression is more common among lesbian women than heterosexual women, which can be attributed to lesbian women's higher depression prevalence. Lesbian women have a higher risk of depression because they are more likely to have been treated for depression and to have attempted or contemplated suicide than heterosexual women. These higher rates of PPD in lesbian/bisexual mothers may reflect less social support, particularly from their families of origin, and additional stress due to homophobic discrimination in society.

Different risk variables linked to postpartum depression (PPD) among Arabic women emphasize regional influences.  Risk factors that have been identified include the gender of the infant and polygamy. According to three studies conducted in Egypt and one in Jordan, mothers of female babies had a two-to-four-fold increased risk of postpartum depression (PPD) compared to mothers of male babies. Four studies found that conflicts with the mother-in-law are associated with PPD, with risk ratios of 1.8 and 2.7.

Studies have also shown a correlation between postpartum depression in mothers living within areas of conflicts, crises, and wars in the Middle East. Studies in Qatar have found a correlation between lower education levels and higher PPD prevalence.

According to research done in Egypt and Lebanon, rural residential living is linked to an increased risk. It was found that rural Lebanese women who had Caesarean births had greater PPD rates. On the other hand, Lebanese women in urban areas showed an opposite pattern.

Research conducted in the Middle East has demonstrated a link between PPD risk and mothers who were not informed and who are not given due consideration when decisions are made during childbirth.

There is a call to integrate both a consideration of biological and psychosocial risk factors for PPD when treating and researching the illness.

Violence

A meta-analysis reviewing research on the association of violence and postpartum depression showed that violence against women increases the incidence of postpartum depression. About one-third of women throughout the world will experience physical or sexual violence at some point in their lives. Violence against women occurs in conflict, post-conflict, and non-conflict areas. The research reviewed only looked at violence experienced by women from male perpetrators. Studies from the Middle East suggest that individuals who have experienced family violence are 2.5 times more likely to develop PPD. Further, violence against women was defined as "any act of gender-based violence that results in, or is likely to result in, physical, sexual, or psychological harm or suffering to women". Psychological and cultural factors associated with increased incidence of postpartum depression include family history of depression, stressful life events during early puberty or pregnancy, anxiety or depression during pregnancy, and low social support. Violence against women is a chronic stressor, so depression may occur when someone is no longer able to respond to the violence.

Diagnosis

Criteria

Postpartum depression in the DSM-5 is known as "depressive disorder with peripartum onset". Peripartum onset is defined as starting anytime during pregnancy or within the four weeks following delivery. There is no longer a distinction made between depressive episodes that occur during pregnancy or those that occur after delivery. Nevertheless, the majority of experts continue to diagnose postpartum depression as depression with onset anytime within the first year after delivery.

The criteria required for the diagnosis of postpartum depression are the same as those required to make a diagnosis of non-childbirth-related major depression or minor depression. The criteria include at least five of the following nine symptoms, within two weeks:

• Feelings of sadness, emptiness, or hopelessness, nearly every day, for most of the day, or the observation of a depressed mood made by others
• Loss of interest or pleasure in activities
• Weight loss or decreased appetite
• Changes in sleep patterns
• Feelings of restlessness
• Loss of energy
• Feelings of worthlessness or guilt
• Loss of concentration or increased indecisiveness
• Recurrent thoughts of death, with or without plans of suicide

Differential diagnosis

Postpartum blues

Main article: Postpartum blues

Postpartum blues, commonly known as "baby blues," is a transient postpartum mood disorder characterized by milder depressive symptoms than postpartum depression. This type of depression can occur in up to 80% of all mothers following delivery. Symptoms typically resolve within two weeks. Symptoms lasting longer than two weeks are a sign of a more serious type of depression. Women who experience "baby blues" may have a higher risk of experiencing a more serious episode of depression later on.

Psychosis

Postpartum psychosis is not a formal diagnosis, but is widely used to describe a psychiatric emergency that appears to occur in about 1 in 1000 pregnancies, in which symptoms of high mood and racing thoughts (mania), depression, severe confusion, loss of inhibition, paranoia, hallucinations, and delusions begin suddenly in the first two weeks after delivery; the symptoms vary and can change quickly. It is different from postpartum depression and maternity blues. It may be a form of bipolar disorder. It is important not to confuse psychosis with other symptoms that may occur after delivery, such as delirium. Delirium typically includes a loss of awareness or inability to pay attention.

About half of women who experience postpartum psychosis have no risk factors; but a prior history of mental illness, especially bipolar disorder, a history of prior episodes of postpartum psychosis, or a family history put some at a higher risk.

Postpartum psychosis often requires hospitalization, where treatment is antipsychotic medications, mood stabilizers, and in cases of strong risk for suicide, electroconvulsive therapy.

The most severe symptoms last from 2 to 12 weeks, and recovery takes 6 months to a year. Women who have been hospitalized for a psychiatric condition immediately after delivery are at a much higher risk of suicide during the first year after delivery.

Childbirth-Related/Postpartum Posttraumatic Stress Disorder

Parents may suffer from post-traumatic stress disorder (PTSD), or suffer post-traumatic stress disorder symptoms, following childbirth. While there has been debate in the medical community as to whether childbirth should be considered a traumatic event, the current consensus is childbirth can be a traumatic event. The DSM-IV and DSM-5 (standard classifications of mental disorders used by medical professionals) do not explicitly recognize childbirth-related PTSD, but both allow childbirth to be considered as a potential cause of PTSD. Childbirth-related PTSD is closely related to postpartum depression. Research indicates mothers who have childbirth-related PTSD also commonly have postpartum depression. Childbirth-related PTSD and postpartum depression have some common symptoms. Although both diagnoses overlap in their signs and symptoms, some symptoms specific to postpartum PTSD include being easily startled, recurring nightmares and flashbacks, avoiding the baby or anything that reminds one of birth, aggression, irritability, and panic attacks. Real or perceived trauma before, during, or after childbirth is a crucial element in diagnosing childbirth-related PTSD.

Currently, there are no widely recognized assessments that measure postpartum post-traumatic stress disorder in medical settings. Existing PTSD assessments (such as the DSM-IV) have been used to measure childbirth-related PTSD. Some surveys exist to measure childbirth-related PTSD specifically, however, these are not widely used outside of research settings.

Approximately 3–6% of mothers in the postpartum period have childbirth-related PTSD. The percentage of individuals with childbirth-related PTSD is approximately 15–18% in high-risk samples (women who experience severe birth complications, have a history of sexual/physical violence, or have other risk factors). Research has identified several factors that increase the chance of developing childbirth-related PTSD. These include a negative subjective experience of childbirth, maternal mental health (prenatal depression, perinatal anxiety, acute postpartum depression, and history of psychological problems), history of trauma, complications with delivery and baby (for example emergency cesarean section or NICU admittance), and a low level of social support.

Childbirth-related PTSD has several negative health effects. Research suggests that childbirth-related PTSD may negatively affect the emotional attachment between mother and child. However, maternal depression or other factors may also explain this negative effect. Childbirth-related PTSD in the postpartum period may also lead to issues with the child's social-emotional development. Current research suggests childbirth-related PTSD results in lower breastfeeding rates and may prevent parents from breastfeeding for the desired amount of time.

Screening

Screening for postpartum depression is critical as up to 50% of cases go undiagnosed in the US, emphasizing the significance of comprehensive screening measures. In the US, the American College of Obstetricians and Gynecologists suggests healthcare providers consider depression screening for perinatal women. Additionally, the American Academy of Pediatrics recommends pediatricians screen mothers for PPD at 1-month, 2-month, and 4-month visits. However, many providers do not consistently provide screening and appropriate follow-up. For example, in Canada, Alberta is the only province with universal PPD screening. This screening is carried out by Public Health nurses with the baby's immunization schedule. In Sweden, Child Health Services offers a free program for new parents that includes screening mothers for PPD at 2 months postpartum. However, there are concerns about adherence to screening guidelines regarding maternal mental health.

The Edinburgh Postnatal Depression Scale, a standardized self-reported questionnaire, may be used to identify women who have postpartum depression. If the new mother scores 13 or more, she likely has PPD and further assessment should follow.

Healthcare providers may take a blood sample to test if another disorder is contributing to depression during the screening.

The Edinburgh Postnatal Depression Scale is used within the first week of the newborn being admitted. If mothers receive a score less than 12 they are told to be reassessed because of the depression testing protocol. It is also advised that mothers in the NICU get screened every four to six weeks as their infant remains in the neonatal intensive care unit. Mothers who score between twelve and nineteen on the EPDS are offered two types of support. The mothers are offered LV treatment provided by a nurse in the NICU and they can be referred to the mental health professional services. If a mother receives a three on item number ten of the EPDS they are immediately referred to the social work team as they may be suicidal.

It is critical to acknowledge the diversity of patient populations diagnosed with postpartum depression and how this may impact the reliability of the screening tools used. There are cultural differences in how patients express symptoms of postpartum depression; those in non-western countries exhibit more physical symptoms, whereas those in Western countries have more feelings of sadness. Depending on one's cultural background, symptoms of postpartum depression may manifest differently, and non-Westerners being screened in Western countries may be misdiagnosed because their screening tools do not account for cultural diversity. Aside from culture, it is also important to consider one's social context, as women with low socioeconomic status may have additional stressors that affect their postpartum depression screening scores.

Prevention

A 2013 Cochrane review found evidence that psychosocial or psychological intervention after childbirth helped reduce the risk of postnatal depression. These interventions included home visits, telephone-based peer support, and interpersonal psychotherapy. Support is an important aspect of prevention, as depressed mothers commonly state that their feelings of depression were brought on by "lack of support" and "feeling isolated."

Across different cultures, traditional rituals for postpartum care may be preventative for PPD but are more effective when the support is welcomed by the mother.

In couples, emotional closeness and global support by the partner protect against both perinatal depression and anxiety. In 2014, Alasoom and Koura found that compared to 42.9 percent of women who did not get spousal support, only 14.7 percent of women who got spousal assistance had PPD. Further factors such as communication between the couple and relationship satisfaction have a protective effect against anxiety alone.

In those who are at risk counseling is recommended. The US Preventative Services Task Force (USPSTF) conducted a review of evidence which supported the use of counseling interventions such as therapy for the prevention of PPD in high-risk groups. Women who are considered to be high-risk include those with a past or present history of depression, or with certain socioeconomic factors such as low income or young age.

Preventative treatment with antidepressants may be considered for those who have had PPD previously. However, as of 2017, the evidence supporting such use is weak.

Community perinatal mental health teams were launched in England in 2016 to improve access to mental healthcare for pregnant women. They aim to prevent and treat episodes of mental illness during pregnancy and after birth. Researchers found that in areas of the country where teams were available, women who had previous contact with psychiatric services (many of whom had a previous diagnosis of anxiety or depression) were more likely to access mental health support and had a lower risk of relapse requiring hospital admission in the year after giving birth.

Treatments

Treatment for mild to moderate PPD includes psychological interventions or antidepressants. Women with moderate to severe PPD would likely experience a greater benefit with a combination of psychological and medical interventions. Light aerobic exercise is useful for mild and moderate cases.

Therapy

Both individual social and psychological interventions appear equally effective in the treatment of PPD. Social interventions include individual counseling and peer support, while psychological interventions include cognitive behavioral therapy (CBT) and interpersonal therapy (IPT). Support groups and group therapy options focused on psychoeducation around postpartum depression have been shown to enhance the understanding of postpartum symptoms and often assist in finding further treatment options. Other forms of therapy, such as group therapy, home visits, counseling, and ensuring greater sleep for the mother may also have a benefit. While specialists trained in providing counseling interventions often serve this population in need, results from a 2021 systematic review and meta-analysis found that nonspecialist providers, including lay counselors, nurses, midwives, and teachers without formal training in counseling interventions, often provide effective services related to perinatal depression and anxiety which promotes task-sharing and telemedicine.

Psychotherapy

Psychotherapy is the use of psychological methods, particularly when based on regular personal interaction, to help a person change behavior, increase happiness, and overcome problems. Psychotherapy can be super beneficial for mothers or fathers that are dealing with PPD. It allows individuals to talk with someone, maybe even someone who specializes in working with people who are dealing with PPD, and share their emotions and feelings to get help to become more emotionally stable. Psychotherapy proves to show efficacy of psychodynamic interventions for postpartum depression, both in home and clinical settings and both in group and individual format.

Cognitive behavioral therapy

Internet-based cognitive behavioral therapy (CBT) has shown promising results with lower negative parenting behavior scores and lower rates of anxiety, stress, and depression. CBT  may be beneficial for mothers who have limitations in accessing in-person CBT. However, the long-term benefits have not been determined. The implementation of cognitive behavioral therapy happens to be one of the most successful and well-known forms of therapy regarding PPD. In simple terms, cognitive behavioral therapy is a psycho-social intervention that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders. While being a wide branch of therapy, it remains very beneficial when tackling specific emotional distress, which is the foundation of PPD. Thus, CBT manages to further reduce or limit the frequency and intensity of emotional outbreaks in the mothers or fathers.

Interpersonal therapy

Interpersonal therapy (IPT) has shown to be effective in focusing specifically on the mother and infant bond. Psychosocial interventions are effective for the treatment of postpartum depression. Interpersonal therapy otherwise known as IPT is a wonderfully intuitive fit for many women with PPD as they typically experience a multitude of biopsychosocial stressors that are associated with their depression, including several disrupted interpersonal relationships.

Medication

A 2010 review found few studies of medications for treating PPD noting small sample sizes and generally weak evidence. Some evidence suggests that mothers with PPD will respond similarly to people with major depressive disorder. There is low-certainty evidence which suggests that selective serotonin reuptake inhibitors (SSRIs) are an effective treatment for PPD. The first-line anti-depressant medication of choice is sertraline, an SSRI, as very little of it passes into the breast milk and, as a result, to the child. However, a recent study has found that adding sertraline to psychotherapy does not appear to confer any additional benefit. Therefore, it is not completely clear which antidepressants, if any, are most effective for the treatment of PPD, and for whom antidepressants would be a better option than non-pharmacotherapy.

Some studies show that hormone therapy may be effective in women with PPD, supported by the idea that the drop in estrogen and progesterone levels post-delivery contributes to depressive symptoms. However, there is some controversy with this form of treatment because estrogen should not be given to people who are at higher risk of blood clots, which include women up to 12 weeks after delivery. Additionally, none of the existing studies included women who were breastfeeding. However, there is some evidence that the use of estradiol patches might help with PPD symptoms.

Oxytocin is an effective anxiolytic and in some cases antidepressant treatment in men and women. Exogenous oxytocin has only been explored as a PPD treatment with rodents, but results are encouraging for potential application in humans.

In 2019, the FDA approved brexanolone, a synthetic analog of the neurosteroid allopregnanolone, for use intravenously in postpartum depression. Allopregnanolone levels drop after giving birth, which may lead to women becoming depressed and anxious. Some trials have demonstrated an effect on PPD within 48 hours from the start of infusion. Other new allopregnanolone analogs under evaluation for use in the treatment of PPD include zuranolone and ganaxolone.

Brexanolone has risks that can occur during administration, including excessive sedation and sudden loss of consciousness, and therefore has been approved under the Risk Evaluation and Mitigation Strategy (REMS) program. The mother is to be enrolled before receiving the medication. It is only available to those at certified healthcare facilities with a healthcare provider who can continually monitor the patient. The infusion itself is a 60-hour, or 2.5-day, process. People's oxygen levels are to be monitored with a pulse oximeter. Side effects of the medication include dry mouth, sleepiness, somnolence, flushing, and loss of consciousness. It is also important to monitor for early signs of suicidal thoughts or behaviors.

In 2023, the FDA approved zuranolone, sold under the brand name Zurzuvae for treatment of postpartum depression. Zuranolone is administered through a pill, which is more convenient than brexanolone, which is administered through an intravenous injection.

Breastfeeding

The use of SSRIs for the treatment of PPD is not a contraindication for breastfeeding. While antidepressants are excreted in breastmilk, the concentrations recorded in breastmilk are very low. Extensive research has shown that the use of SSRI's by women who are lactating is safe for the breastfeeding infant/child. Regarding allopregnanolone, very limited data did not indicate a risk for the infant.

Other

Electroconvulsive therapy (ECT) has shown efficacy in women with severe PPD who have either failed multiple trials of medication-based treatment or cannot tolerate the available antidepressants. Tentative evidence supports the use of repetitive transcranial magnetic stimulation (rTMS).

As of 2013, it is unclear if acupuncture, massage, bright lights, or taking omega-3 fatty acids are useful.

Further information: Oxytocin treatment for postpartum depression

Resources

International

Postpartum Support International is the most recognized international resource for those with PPD as well as healthcare providers. It brings together those experiencing PPD, volunteers, and professionals to share information, referrals, and support networks. Services offered by PSI include the website (with support, education, and local resource info), coordinators for support and local resources, online weekly video support groups in English and Spanish, free weekly phone conferences with chats with experts, educational videos, closed Facebook groups for support, and professional training of healthcare workers.

United States

Educational interventions

Educational interventions can help women struggling with postpartum depression (PPD) to cultivate coping strategies and develop resiliency. The phenomenon of "scientific motherhood" represents the origin of women's education on perinatal care with publications like Ms. circulating some of the first press articles on PPD that helped to normalize the symptoms that women experienced. Feminist writings on PPD from the early seventies shed light on the darker realities of motherhood and amplified the lived experiences of mothers with PPD.

Instructional videos have been popular among women who turn to the internet for PPD treatment, especially when the videos are interactive and get patients involved in their treatment plans. Since the early 2000s, video tutorials on PPD have been integrated into many web-based training programs for individuals with PPD and are often considered a type of evidence-based management strategy for individuals. This can take the form of objective-based learning, detailed exploration of case studies, resource guides for additional support and information, etc.

Government-funded programs

The National Child and Maternal Health Education Program functions as a larger education and outreach program supported by the National Institute of Child Health and Human Development (NICHD) and the National Institute of Health. The NICHD has worked alongside organizations like the World Health Organization to conduct research on the psychosocial development of children with part of their efforts going towards the support of mothers' health and safety. Training and education services are offered through the NICHD to equip women and their healthcare providers with evidence-based knowledge of PPD.

Other initiatives include the Substance Abuse and Mental Health Services Administration (SAMHSA) whose disaster relief program provides medical assistance at both the national and local level. The disaster relief fund not only helps to raise awareness of the benefits of having healthcare professionals screen for PPD but also helps childhood professionals (home visitors and early care providers) develop the skills to diagnose and prevent PPD. The Infant and Early Childhood Mental Health Consultation (IECMH) center is a related technical assistance program that utilizes evidence-based treatment services to address issues of PPD. The IECMH facilitates parenting and home visit programs, early care site interventions with parents and children, and a variety of other consultation-based services. The IECMH's initiatives seek to educate home visitors on screening protocols for PPD as well as ways to refer depressed mothers to professional help.

Links to government-funded programs

• www.nichd.nih.gov/ncmhep
• www.nichd.nih.gov
• www.samhsa.gov
• www.samhsa.gov/iecmhc

Psychotherapy

Therapeutic methods of intervention can begin as early as a few days post-birth when most mothers are discharged from hospitals. Research surveys have revealed a paucity of professional, and emotional support for women struggling in the weeks following delivery despite there being a heightened risk for PPD for new mothers during this transitional period.

Community-based support

A lack of social support has been identified as a barrier to seeking help for postpartum depression. Peer support programs have been identified as an effective intervention for women experiencing symptoms of postpartum depression. In-person, online, and telephone support groups are available to both women and men throughout the United States. Peer support models are appealing to many women because they are offered in a group and outside of the mental health setting. The website Postpartum Progress provides a comprehensive list of support groups separated by state and includes the contact information for each group. The National Alliance on Mental Illness lists a virtual support group titled "The Shades of Blue Project," which is available to all women via the submission of a name and email address. Additionally, NAMI recommends the website "National Association of Professional and Peer Lactation Supports of Color" for mothers in need of a lactation supporter. Lactation assistance is available either online or in-person if there is support nearby.

Personal narratives & memoirs

Postpartum Progress is a blog focused on being a community of mothers talking openly about postpartum depression and other mental health conditions associated. Story-telling and online communities reduce the stigma around PPD and promote peer-based care. Postpartum Progress is specifically relevant to people of color and queer folks due to an emphasis on cultural competency.

Hotlines & telephone interviews

Hotlines, chat lines, and telephone interviews offer immediate, emergency support for those experiencing PPD. Telephone-based peer support can be effective in the prevention and treatment of postpartum depression among women at high risk. Established examples of telephone hotlines include the National Alliance on Mental Illness: 800-950-NAMI (6264), National Suicide Prevention Lifeline: 800-273-TALK (8255), Postpartum Support International: 800-944-4PPD (4773), and SAMHSA's National Hotline: 1-800-662-HELP (4357). Postpartum Health Alliance has an immediate, 24/7 support line in San Diego/San Diego Access and Crisis Line at (888) 724–7240, in which you can talk with mothers who have recovered from PPD and trained providers.

However, hotlines can lack cultural competency which is crucial in quality healthcare, specifically for people of color. Calling the police or 911, specifically for mental health crises, is dangerous for many people of color. Culturally and structurally competent emergency hotlines are a huge need in PPD care.

• National Alliance on Mental Illness: 800-950-NAMI (6264)
• National Suicide Prevention Lifeline: 800-273-TALK (8255)
• Postpartum Support International: 800-944-4PPD (4773)
• SAMHSA's National Hotline: 1-800-662-HELP (4357)

Self-care & well-being activities

Women demonstrated an interest in self-care and well-being in an online PPD prevention program. Self-care activities, specifically music therapy, are accessible to most communities and valued among women as a way to connect with their children and manage symptoms of depression. Well-being activities associated with being outdoors, including walking and running, were noted amongst women as a way to help manage mood.

Accessibility to care

Those with PPD come across many help-seeking barriers, including lack of knowledge, stigma about symptoms, as well as health service barriers. There are also attitudinal barriers to seeking treatment, including stigma. Interpersonal relationships with friends and family, as well as institutional and financial obstacles, serve as help-seeking barriers. A history of mistrust within the United States healthcare system or negative health experiences can influence one's willingness and adherence to seek postpartum depression treatment. Cultural responses must be adequate in PPD healthcare and resources. Representation and cultural competency are crucial to equitable healthcare for PPD. Different ethnic groups may believe that healthcare providers will not respect their cultural values or religious practices, which influences their willingness to use mental health services or be prescribed antidepressant medications. Additionally, resources for PPD are limited and often don't incorporate what mothers would prefer. The use of technology can be a beneficial way to provide mothers with resources because it is accessible and convenient.

Epidemiology

North America

United States

Within the United States, the prevalence of postpartum depression was lower than the global approximation at 11.5% but varied between states from as low as 8% to as high as 20.1%. The highest prevalence in the US is found among women who are American Indian/Alaska Natives or Asian/Pacific Islanders, possess less than 12 years of education, are unmarried, smoke during pregnancy, experience over two stressful life events, or have full-term infant is low-birthweight or was admitted to a NICU. While US prevalence decreased from 2004 to 2012, it did not decrease among American Indian/Alaska Native women or those with full term, low-birthweight infants.

Even with the variety of studies, it is difficult to find the exact rate as approximately 60% of US women are not diagnosed and of those diagnosed, approximately 50% are not treated for PPD. Cesarean section rates did not affect the rates of PPD. While there is discussion of postpartum depression in fathers, there is no formal diagnosis for postpartum depression in fathers.

Canada

Canada has one of the largest refugee resettlement in the world with an equal percentage of women to men. This means that Canada has a disproportionate percentage of women who develop postpartum depression since there is an increased risk among the refugee population. In a blind study, where women had to reach out and participate, around 27% of the sample population had symptoms consistent with postpartum depression without even knowing. Also found that on average 8.46 women had minor and major PPDS was found to be 8.46 and 8.69% respectively. The main factors that were found to contribute to this study were the stress during pregnancy, the availability of support after, and a prior diagnosis of depression were all found to be factors. Canada has specific population demographics that also involve a large amount of immigrant and indigenous women which creates a specific cultural demographic localized to Canada. In this study, researchers found that these two populations were at significantly higher risk compared to "Canadian-born non-indigenous mothers". This study found that risk factors such as low education, low-income cut-off, taking antidepressants, and low social support are all factors that contribute to the higher percentage of these populations developing PPDS. Specifically, indigenous mothers had the most risk factors than immigrant mothers with non-indigenous Canadian women being closer to the overall population.

South America

A main issue surrounding PPD is the lack of study and the lack of reported prevalence that is based on studies developed in Western economically developed countries. In countries such as Brazil, Guyana, Costa Rica, Italy, Chile, and South Africa reports are prevalent, around 60%. An itemized research analysis put a mean prevalence at 10–15% percent but explicitly stated that cultural factors such as perception of mental health and stigma could be preventing accurate reporting. The analysis for South America shows that PPD occurs at a high rate looking comparatively at Brazil (42%) Chile (4.6-48%) Guyana and Colombia (57%) and Venezuela (22%). In most of these countries, PPD is not considered a serious condition for women and therefore there is an absence of support programs for prevention and treatment in health systems. Specifically, in Brazil PPD is identified through the family environment whereas in Chile PPD manifests itself through suicidal ideation and emotional instability. In both cases, most women feel regret and refuse to take care of the child showing that this illness is serious for both the mother and child.

Asia

From a selected group of studies found from a literature search, researchers discovered many demographic factors of Asian populations that showed significant association with PPD. Some of these include the age of the mother at the time of childbirth as well as the older age at marriage. Being a migrant and giving birth to a child overseas has also been identified as a risk factor for PPD. Specifically for Japanese women who were born and raised in Japan but who gave birth to their child in Hawaii, USA, about 50% of them experienced emotional dysfunction during their pregnancy. All women who gave birth for the first time and were included in the study experienced PPD. In immigrant Asian Indian women, the researchers found a minor depressive symptomatology rate of 28% and an additional major depressive symptomatology rate of 24% likely due to different healthcare attitudes in different cultures and distance from family leading to homesickness.

In the context of Asian countries, premarital pregnancy is an important risk factor for PPD. This is because it is considered highly unacceptable in most Asian cultures as there is a highly conservative attitude toward sex among Asian people than people in the West. In addition, conflicts between mother and daughter-in-law are notoriously common in Asian societies as traditionally for them, marriage means the daughter-in-law joining and adjusting to the groom's family completely. These conflicts may be responsible for the emergence of PPD. Regarding the gender of the child, many studies have suggested dissatisfaction with an infant's gender (birth of a baby girl) is a risk factor for PPD. This is because, in some Asian cultures, married couples are expected by the family to have at least one son to maintain the continuity of the bloodline which might lead a woman to experience PPD if she cannot give birth to a baby boy.

The Middle East

With a prevalence of 27%, postpartum depression amongst mothers in the Middle East is higher than in the Western world and other regions of the world. Despite the high number of postpartum depression cases in the region in comparison to other areas, there is a large literature gap in correlation with the Arab region, and no studies have been conducted in the Middle East studying interventions and prevention to tackle postpartum depression in Arab mothers. Countries within the Arab region had a postpartum depression prevalence ranging from 10% to 40%, with a PPD prevalence in Qatar at 18.6%, UAE between 18% and 24%, Jordan between 21.2 and 22.1, Lebanon at 21%, Saudi Arabia between 10.1 and 10.3, and Tunisia between 13.2% and 19.2%, according to studies carried out in these countries.

There are also examples of nations with noticeably higher rates, such as Iran at 40.2%, Bahrain at 37.1%, and Turkey at 27%. The high prevalence of postpartum depression in the region may be attributed to socio-economic and cultural factors involving social and partner support, poverty, and prevailing societal views on pregnancy and motherhood. Another factor is related to the region's women's lack of access to care services because many societies within the region do not prioritize mental health and do not perceive it as a serious issue. The prevailing crises and wars within some countries of the region, lack of education, polygamy, and early childbearing are additional factors. Fertility rates in Palestine are noticeably high; higher fertility rates have been connected to a possible pattern where birth rates increase after violent episodes. Research conducted on Arab women indicates that more cases of postpartum depression are associated with increased parity. A study found that the most common pregnancy and birth variable reported to be associated with PPD in the Middle East was an unplanned or unwanted pregnancy while having a female baby instead of a male baby is also discussed as a factor with 2 to 4 times higher risk.

Europe

There is a general assumption that Western cultures are homogenous and that there are no significant differences in psychiatric disorders across Europe and the USA. However, in reality, factors associated with maternal depression, including work and environmental demands, access to universal maternity leave, healthcare, and financial security, are regulated and influenced by local policies that differ across countries. For example, European social policies differ from country to country contrary to the US, all countries provide some form of paid universal maternity leave and free healthcare. Studies also found differences in symptomatic manifestations of PPD between European and American women. Women from Europe reported higher scores of anhedonia, self-blaming, and anxiety, while women from the US disclosed more severe insomnia, depressive feelings, and thoughts of self-harming. Additionally, there are differences in prescribing patterns and attitudes towards certain medications between the US and Europe which are indicative of how different countries approach treatment, and their different stigmas.

Africa

Africa, like all other parts of the world, struggles with the burden of postpartum depression. Current studies estimate the prevalence to be 15–25% but this is likely higher due to a lack of data and recorded cases. The magnitude of postpartum depression in South Africa is between 31.7% and 39.6%, in Morocco between 6.9% and 14%, in Nigeria between 10.7% and 22.9%, in Uganda 43%, in Tanzania 12%, in Zimbabwe 33%, in Sudan 9.2%, in Kenya between 13% and 18.7% and, 19.9% for participants in Ethiopia according to studies carried out in these countries among postpartum mothers between the ages of 17–49. This demonstrates the gravity of this problem in Africa and the need for postpartum depression to be taken seriously as a public health concern in the continent. Additionally, each of these studies was conducted using Western-developed assessment tools. Cultural factors can affect diagnosis and can be a barrier to assessing the burden of disease. Some recommendations to combat postpartum depression in Africa include considering postpartum depression as a public health problem that is neglected among postpartum mothers. Investing in research to assess the actual prevalence of postpartum depression, and encourage early screening, diagnosis, and treatment of postpartum depression as an essential aspect of maternal care throughout Africa.

Issues in reporting prevalence

Most studies regarding PPD are done using self-report screenings which are less reliable than clinical interviews. This use of self-reporting may have results that underreport symptoms and thus postpartum depression rates.

Furthermore, the prevalence of postpartum depression in Arab countries exhibits significant variability, often due to diverse assessment methodologies. In a review of twenty-five studies examining PPD, differences in assessment methods, recruitment locations, and timing of evaluations complicate prevalence measurement. For instance, the studies varied in their approach, with some using a longitudinal panel method tracking PPD at multiple points during pregnancy and postpartum periods, while others employed cross-sectional approaches to estimate point or period prevalences. The Edinburgh Postnatal Depression Scale (EPDS) was commonly used across these studies, yet variations in cutoff scores further determined the results of prevalence.

For example, a study in Kom Ombo, Egypt, reported a rate of 73.7% for PPD, but the small sample size of 57 mothers and the broad measurement timeframe spanning from two weeks to one year postpartum contributes to the challenge of making definitive prevalence conclusions (2). This wide array of assessment methods and timing significantly impacts the reported rates of postpartum depression.

History

Prior to the 19th century

Western medical science's understanding and construction of postpartum depression have evolved over the centuries. Ideas surrounding women's moods and states have been around for a long time, typically recorded by men. In 460 B.C., Hippocrates wrote about puerperal fever, agitation, delirium, and mania experienced by women after childbirth. Hippocrates' ideas still linger in how postpartum depression is seen today.

A woman who lived in the 14th century, Margery Kempe, was a Christian mystic. She was a pilgrim known as "Madwoman" after having a tough labor and delivery. There was a long physical recovery period during which she started descending into "madness" and became suicidal. Based on her descriptions of visions of demons and conversations she wrote about that she had with religious figures like God and the Virgin Mary, historians have identified what Margery Kempe was experiencing as "postnatal psychosis" and not postpartum depression. This distinction became important to emphasize the difference between postpartum depression and postpartum psychosis. A 16th-century physician, Castello Branco, documented a case of postpartum depression without the formal title as a relatively healthy woman with melancholy after childbirth, remained insane for a month, and recovered with treatment. Although this treatment was not described, experimental treatments began to be implemented for postpartum depression for the centuries that followed. Connections between female reproductive function and mental illness would continue to center around reproductive organs from this time through to the modern age, with a slowly evolving discussion around "female madness".

19th century and after

With the 19th century came a new attitude about the relationship between female mental illness and pregnancy, childbirth, or menstruation. The famous short story, "The Yellow Wallpaper", was published by Charlotte Perkins Gilman in this period. In the story, an unnamed woman journals her life when she is treated by her physician husband, John, for hysterical and depressive tendencies after the birth of their baby. Gilman wrote the story to protest the societal oppression of women as the result of her own experience as a patient.

Also during the 19th century, gynecologists embraced the idea that female reproductive organs, and the natural processes they were involved in, were at fault for "female insanity." Approximately 10% of asylum admissions during this period are connected to "puerperal insanity," the named intersection between pregnancy or childbirth and female mental illness. It wasn't until the onset of the twentieth century that the attitude of the scientific community shifted once again: the consensus amongst gynecologists and other medical experts was to turn away from the idea of diseased reproductive organs and instead towards more "scientific theories" that encompassed a broadening medical perspective on mental illness.

20th century and beyond

The inseparability of the structural and the biological, the medical and the political, the exaltations and challenges of motherhood, all point to not just a history of suffering and treatment, but one of advocacy. The history of groundbreaking women health's activism between the 1970s and 2020s, in addition to the story of upholding the idealization of motherhood, is a poignant story of pushing against the status quo and also pragmatically embracing the legitimizing power of medicalization and political neutrality. The phenomenon of baby blues was first named amid the surge of births following World War II. Baby blues or postpartum blues during the time following World War II hold an evolved understanding in the 21st century, and is understood as emotional distress of fluctuations that begin a couple days postpartum and can last up to two weeks. Baby blues is considered to affect perhaps 80% of new moms. While women experiences baby blues in the 1940s, 1950s and 1960s were often counseled to treat themselves with a new hat from the milliner or some other pick-me-up, in the 2020s, women are reminded about the role of hormones and are often encouraged to prioritize self care, and to rest as they adjust. Between the 1970s and 1990s, psychological professionals more frequently distinguished between subclinical baby blues, and the more serious medical issues of postpartum depression. The 1980s was a decade of depression in America, with huge increases in general depression diagnoses and in antidepressant availability.

Though there have been attempts at defining postpartum depression, doctors now consider it amongst a host of different illnesses, and refer to call the issues postpartum, Postpartum Mood and Anxiety Disorders (PMAD) rather than postpartum depression. There is still no standalone diagnosis in the American Psychological Associations Bible, Diagnostic and Statistical Manual. Rather there is an umbrella of conditions. Advocates and clinicians mention PMADs as including mental distress during pregnancy in addition to the postpartum and around lactation, as well as an array of disorders beyond just depression. PMADs include postpartum obsessive-compulsive disorder, often with moms counting ounces of pumped milk, and obsessing over if it was enough and how to heal aching breast and chapped and blistered nipples, and postpartum anxiety, such as an excess of worries, like dropping the baby. A very rare percentage will show signs of postpartum psychosis that has led to issues such as infanticide. PMADs help to create an overarching recognition of many issues new parents, especially new mothers worry about, beyond the extent of exhaustion and sleep deprivation, the overwhelm of physical pain after birth, the vast changes in hormones and body conformation, the need to keep watch on the size of blood clots, the possibility of birth trauma, the social stresses and pressures, massive changes in relationship status with your husband, partner, and family, if you have one, and a constraint and limitation on familial and community resources for support, and lessons and guidance, leaving a new mother alone and vulnerable. On top of that, for wage-earning mothers, there is additional stress navigating working or not working, how much leave you have and how you will atone for taking that leave if you are lucky enough to have it, how to survive you do not take leave, if your leave is unpaid, or you have social opinions and naysayers to you taking leave. Then there is the stress of feeding an infant, including balancing feeding needs with paid work. Some of the difficulties of defining postpartum mood disorders comes from the long list of some of these examples, but also include an incomplete list of other challenges and contributing factors. Doctors are wary to clinically diagnosis, but there exists a fine line between, for instance mild obsession with counting ounces of milk, and postpartum obsessive-compulsive disorder. There is a fine line between worrying occasionally that you might drop your baby, or hold your baby incorrectly, and the feelings of some parents that veers into intrusive thoughts, or all-consuming panic attacks, and chronic anxiety. There is a fine line between an exhausted lethargic parent simply needing a very long nap or many long naps, and there also being the presence of clinical depression, testable with the Edinburgh Postnatal Depression Scale (EPDS).

In the 1990s, the largest advocacy organization of postpartum advocates, Postpartum Support International, began addressed postpartum politics arguing that postpartum depression is not just an illness, but the most common complication of pregnancy.

There are other health measures monitored for in pregnancy as more screenings and health concerns have been introduced with advanced research in obstetrics and gynecology, perinatal, maternal-fetal medicine, neonatology, and pediatrics. A long list of these monitored complications follows.

There are the additional screenings that pregnant women have to worry, such as general screenings with a Pap smear, complete blood count, HIV screening, urine culture, rubella titer, ABO, Rh typing, hepatitis B screening, testing for all sexually transmitted diseases, gestational diabetes, and group B streptococcus.

Then there is other monitoring, include regular blood pressure to monitor for preeclampsia, ultrasounds to help monitor the position of the placenta and for placenta previa, monitoring and screening chorionic villus sampling (CVS), preeclampsia, eclampsia, and sampling of amniotic fluid via amniocentesis for health and maturity of the fetus, monitoring the change in the pelvic organs especially for intrauterine growth restriction (IUGR) in, and general monitoring of changes in a mother's pelvic organs via various testing including Goodell sign, Chadwick sign, Hegar sign, McDonald sign, uterine enlargement, Braun von Fernwald sign, uterine souffle, chloasma or melasma, linea nigra, changes in nipples, abdominal striae, ballottement, monitoring hormone levels and changes.

Continuing, there is the monitoring of the fetus for quickening, fetal heart tones (FHT), fetal heart rate (FHR), fetal blood sampling (FBS), fetal altitude, fetal lie, fetal breathing movements (FBM), fetal movement record (FMR)/fetal movement count (FMC) fetal growth and movement, fetal position, and fetal positioning.

Then mothers have to worry about screenings each trimester, including first-trimester screenings for defects of trisomies through testing such as nuchal translucency testing (NTT), and serum testing for PAPP-A and beta-hCG, and later trimester monitoring for any pre-labor ruptures of membranes (PROM) that can lead to an abortion or if a premature pre-labor rupture of membrane (PPROM) before 37 weeks can lead to a preterm birth, if it occurs when the fetus is viable.

Thus, there is a lot of stress on the mother and non-credit given to what her body goes through; hence starting after the 1940s, 1950s, and 1960s, and with headway made in the 1970s and 1980s, even more activism in the 1990s, promoted greater advocacy by postpartum groups, political advocates, medical clinicians, that emphasized how necessary and important it is for emotional and mental health screening, during pregnancy and in postpartum that can run anywhere from the first two weeks to the first 18 months. Mothers goes through often inconceivable changes in their bodies to bring a life into the world, and that can be overwhelming and stressful especially to any first time mom. This is why it is critical to continue to advocate for more screenings, support services, and self-care opportunities, that help alleviate the burden of motherhood.

The 21st century

The first quarter of the 21st century has brought about regression in many women's health gains of the 20th century. As 21st-century legislation has led to deep divides and debate in regard to abortion politics and who makes decisions over a woman's body and in regard to a woman's health. There needs to be more advocacy for universal parental paid leave, more equality and increases in women's pay where discrimination continues to persist, and additional opportunities for paid time off for family needs, medical needs, and mental health needs. For new parents, better health insurance plans and leeway and lenience for parents need to be tolerated and respected, especially during the first five years, until a child enters school systems. With this, there also need to be better options for childcare—a program that often ends mid-day—and more flexibility from employers on employees to decrease the stress of working obligations and the need to pick up a child from childcare, which can exacerbate postpartum mental health conditions (PMHCs). Additional after-school care programs that do not leave parents feeling like they are neglecting their children simply in financially supporting the family would also help alleviate PMHCs, especially for working women who are the primary financial provider and/or go from previously one full-time job to two full-time jobs, with only one being paid and financially compensated.

In a visual timeline by the Maternal Mental Health Leadership Alliance (MMHLA), a 501(c)(3) nonpartisan nonprofit organization leading national efforts to improve maternal mental health in the United States by advocating for policies, building partnerships, and curating information, there have been numerous advancements in services and legislation, including the 21st Century Cures Act signed into law in December 2016. And, as of 2024, family and medical leave has been cleared for use of PMHCs, including postpartum depression. This is a start, but there is still much progress to be made, given the consideration that of 41 countries, only the United States lacks paid parental leave, though it offers unpaid leave under the Family and Medical Leave Act (FMLA). There is currently no federal law providing or guaranteeing access to paid family and medical leave for workers in the private sector, especially during the postpartum period. However, some states have their own paid leave programs and requirements for companies to provide paid parental leave. Paid leave advocates realize that paid leave, as opposed to unpaid leave, helps to alleviate some of the stress and overwhelming burden tacked on to the postpartum period that can exacerbate PMHCs and can inhibit or make it more difficult to return to work after maternity leave.

Society and culture

Legal recognition

Recently, postpartum depression has become more widely recognized in society. In the US, the Patient Protection and Affordable Care Act included a section focusing on research into postpartum conditions including postpartum depression. Some argue that more resources in the form of policies, programs, and health objectives need to be directed to the care of those with PPD.

Role of stigma

When stigma occurs, a person is labeled by their illness and viewed as part of a stereotyped group. There are three main elements of stigmas, 1) problems of knowledge (ignorance or misinformation), 2) problems of attitudes (prejudice), and 3) problems of behavior (discrimination). Specifically regarding PPD, it is often left untreated as women frequently report feeling ashamed about seeking help and are concerned about being labeled as a "bad mother" if they acknowledge that they are experiencing depression. Although there has been previous research interest in depression-related stigma, few studies have addressed PPD stigma. One study studied PPD stigma by examining how an education intervention would impact it. They hypothesized that an education intervention would significantly influence PPD stigma scores. Although they found some consistency with previous mental health stigma studies, for example, that males had higher levels of personal PPD stigma than females, most of the PPD results were inconsistent with other mental health studies. For example, they hypothesized that education intervention would lower PPD stigma scores, but in reality, there was no significant impact, and also familiarity with PPD was not associated with one's stigma towards people with PPD. This study was a strong starting point for further PPD research but indicates more needs to be done to learn what the most effective anti-stigma strategies are specifically for PPD.

Postpartum depression is still linked to significant stigma. This can also be difficult when trying to determine the true prevalence of postpartum depression. Participants in studies about PPD carry their beliefs, perceptions, cultural context, and stigma of mental health in their cultures with them which can affect data. The stigma of mental health - with or without support from family members and health professionals - often deters women from seeking help for their PPD. When medical help is achieved, some women find the diagnosis helpful and encourage a higher profile for PPD amongst the health professional community.

Cultural beliefs

Postpartum depression can be influenced by sociocultural factors. There are many examples of particular cultures and societies that hold specific beliefs about PPD.

Malay culture holds a belief in Hantu Meroyan; a spirit that resides in the placenta and amniotic fluid. When this spirit is unsatisfied and venting resentment, it causes the mother to experience frequent crying, loss of appetite, and trouble sleeping, known collectively as "sakit meroyan". The mother can be cured with the help of a shaman, who performs a séance to force the spirits to leave.

Some cultures believe that the symptoms of postpartum depression or similar illnesses can be avoided through protective rituals in the period after birth. These may include offering structures of organized support, hygiene care, diet, rest, infant care, and breastfeeding instruction. The rituals appear to be most effective when the support is welcomed by the mother.

Some Chinese women participate in a ritual that is known as "doing the month" (confinement) in which they spend the first 30 days after giving birth resting in bed, while the mother or mother-in-law takes care of domestic duties and childcare. In addition, the new mother is not allowed to bathe or shower, wash her hair, clean her teeth, leave the house, or be blown by the wind.

The relationship with the mother-in-law has been identified as a significant risk factor for postpartum depression in many Arab regions. Based on cultural beliefs that place importance on mothers, mothers-in-law have significant influences on daughters-in-law and grandchildren's lives in such societies as the husbands frequently have close relationships with their family of origin, including living together.

Furthermore, cultural factors influence how Middle Eastern women are screened for PPD. The traditional Edinburgh Postnatal Depression Scale, or EPDS, has come under criticism for emphasizing depression symptoms that may not be consistent with Muslim cultural standards. Thoughts of self-harm are strictly prohibited in Islam, yet it is a major symptom within the EPDS. Words like "depression screen" or "mental health" are considered disrespectful to some Arab cultures. Furthermore, women may under report symptoms to put the needs of the family before their own because these countries have collectivist cultures.

Additionally, research showed that mothers of female babies had a considerably higher risk of PPD, ranging from 2-4 times higher than those of mothers of male babies, due to the value certain cultures in the Middle East place on female babies compared to male babies.

Media

Certain cases of postpartum mental health concerns received attention in the media and brought about dialogue on ways to address and understand more about postpartum mental health. Andrea Yates, a former nurse, became pregnant for the first time in 1993. After giving birth to five children in the coming years, she had severe depression and many depressive episodes. This led to her believing that her children needed to be saved and that by killing them, she could rescue their eternal souls. She drowned her children one by one over the course of an hour, by holding their heads underwater in their family bathtub. When called into trial, she felt that she had saved her children rather than harming them and that this action would contribute to defeating Satan.

This was one of the first public and notable cases of postpartum psychosis, which helped create a dialogue on women's mental health after childbirth. The court found that Yates was experiencing mental illness concerns, and the trial started the conversation of mental illness in cases of murder and whether or not it would lessen the sentence or not. It also started a dialogue on women going against "maternal instinct" after childbirth and what maternal instinct was truly defined by.

Yates' case brought wide media attention to the problem of filicide, or the murder of children by their parents. Throughout history, both men and women have perpetrated this act, but the study of maternal filicide is more extensive.