Perinatal Depression: Prevalence, Risks, and the Nutrition Link—A Review of the Literature

doi:10.1016/j.jada.2009.06.368

Journal of the American Dietetic Association

Volume 109, Issue 9, September 2009, Pages 1566-1575

https://doi.org/10.1016/j.jada.2009.06.368 Get rights and content

Abstract

The purpose of this review is to examine the role of nutrition in perinatal depression. Perinatal (maternal) depression refers to major and minor episodes during pregnancy (termed antenatal) and/or within the first 12 months after delivery (termed postpartum or postnatal). Prevalence of antenatal depression can be as high as 20%, while approximately 12% to 16% of women experience postpartum depression. These are probably conservative estimates, as cases of maternal depression are underreported or underdiagnosed. Risk factors for depression include genetic predisposition and environmental factors, as well as a number of social, psychological, and biological factors. One biological factor given increasing consideration is inadequate nutrition. Credible links between nutrient deficiency and mood have been reported for folate, vitamin B-12, calcium, iron, selenium, zinc, and n-3 fatty acids. For maternal depression, the nutrient that has received the most attention from nutrition researchers has been the n-3 essential fatty acids. Numerous studies, such as randomized controlled trials, cohort studies, and ecological studies, have found a positive association between low n-3 levels and a higher incidence of maternal depression. In addition, nutrient inadequacies in pregnant women who consume a typical western diet might be much more common than researchers and clinicians realize. A number of studies have reported inadequate intakes of n-3, folate, B vitamins, iron, and calcium in pregnant women. Depletion of nutrient reserves throughout pregnancy can increase a woman's risk for maternal depression.

Section snippets

Perinatal Depression

Perinatal depression refers to major and minor episodes during pregnancy (termed antenatal) or within the first 12 months after delivery (termed postpartum or postnatal) (10). The term maternal depression has also been used interchangeably with perinatal depression. Signs and symptoms for perinatal depression are the same as those for depression in the general population: depressed mood, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy,

Antenatal Depression

Antenatal depression is a major health problem, but is less well-studied than postpartum depression (11). It has been estimated that prevalence of antenatal depression might be as high as 20% (12). For example, a cross-sectional study of 432 women seen in a private Brazilian clinic used the Beck Depression Inventory as a screening tool and reported a prevalence of 19.6% for antenatal depression (13). Previously, in a larger sample of >3,000 pregnant women in the United States, 20% scored above

Postpartum Depression

Postpartum depression (PPD) has received more attention in the medical and scientific literature than antenatal depression. Published estimates indicate that approximately 12% to 16% of women experience PPD (16). Like antenatal depression, this is probably a conservative estimate, as cases of PPD are underreported or underdiagnosed. In fact, a review by Gavin and colleagues estimated that as many as 19% of new mothers might suffer from depression within the first 3 months after giving birth (10

Effects of Maternal Depression

Maternal depression is a serious mental health problem that can negatively affect the lives of women, children, and their families (4, 19, 20). The impact of PPD and antenatal depression must be considered in terms of both the women's own lives and their children's. Deleterious effects of maternal depression on a child's functioning in cognitive, social, and developmental areas are well-documented in the literature (20, 21, 22). For the woman, depression during pregnancy has been linked to poor

Risk Factors for Maternal Depression

Symptoms of general depression are variable among patients and, consequently, depression has been viewed not as a single disease, but as a syndrome encompassing a spectrum of mood symptoms with multiple causes and possibly multiple pathophysiologies (32). These multifactorial causes of depression likely involve both genetic and environmental factors (33). The genetic basis of mood disorders has been studied extensively. Craddock and Forty reviewed linkage, genetic, family, and twin studies and

Pathophysiology of Maternal Depression

A number of mechanisms have been proposed for the pathophysiology of maternal depression, including the hypothalamic-pituitary-adrenal (HPA) axis and the role of cortisol (49, 50). Findings from studies on cortisol and the HPA axis have been contradictory. For example, Jolley and colleagues reported that there was no relationship between adrenocorticotropic hormone and cortisol levels in subjects with PPD (50). In contrast, the normal reaction of higher adrenocorticotropic hormone and lower

Nutrition and Mood

Research on the relationship between nutrition and brain function is remarkably large and reaches back almost 90 years (56, 57, 58). Credible links between nutrition and mood have been reported for folate (59), vitamin B-12 (4, 60), calcium (60, 61), iron (4, 60, 62), selenium (4, 63), zinc (4, 64, 65), and polyunsaturated fatty acids (PUFAs) (4, 66, 67, 68, 69, 70, 71, 72, 73). A review of correlational and intervention studies by Kaplan and colleagues found potentially beneficial effects of

Nutrition and Maternal Mood

While specific nutrients associated with depression in the general population have been demonstrated, little is known about low nutrient levels and maternal depression. Most studies on specific nutrients (eg, vitamins and minerals) and mood have excluded pregnant women. However, it is known that pregnant women are especially susceptible to the effects of low nutrient intakes (4). During pregnancy and lactation, nutritional requirements are increased so that fetal and infant growth are

Essential Fatty Acids and Maternal Mood

Essential fatty acids are PUFAs, categorized into two main groups: linoleic acid (n-6) and α-linolenic acid (n-3). These fatty acids are termed essential, as the body does not produce them and they must be obtained through our diet (82). The two n-3 fatty acids most relevant for brain development and function are eicosapentanoic acid (EPA) and docosahexaenoic acid (DHA), of which the latter is the most prominent in the brain. EPA and DHA can be synthesized in the body from α-linolenic acid. The

Vitamins/Minerals and Maternal Mood

Outside the PUFA literature, a thorough search of the peer-reviewed journal databases found limited research on vitamin/mineral deficiency and maternal depression. Beard and colleagues reported a strong relationship between maternal iron status and depression in a study that followed mothers of full-term normal birth weight babies from 10 weeks to 9 months postpartum (89). In another example, results from a study by Wójcik and colleagues showed a relationship between decreased serum zinc

Limitations of Studies

A review of the literature showed that studies have been both correlational (eg, finding that depressed patients suffer from poor nutrition) and interventional (eg, demonstrating improved mood following supplementation). However, the evidence on how nutrition affects women's mental health during pregnancy or in the postpartum period is limited. The strengths of some of the studies cited here have been in the identification and correlation of specific nutrients with depression. However, with the

Dietary Inadequacy in Pregnant Women

The link between nutrient deficiency and maternal depression in developed countries might not seem obvious. However, nutrient deficiencies among those who consume a typical western diet might be more common than people realize. A study of pregnant adolescents and adults living in the United States found mean intake for energy, iron, zinc, calcium, magnesium, folate, and vitamins D and E to be below recommended standards in both groups (8). Another study also found pregnant women did not consume

Conclusion

The literature reviewed here suggests that nutrient intake can be a key factor in a woman's vulnerability to perinatal depression. There is a compelling argument for longitudinal research that targets this important topic as its primary focus: determining whether nutrient status is associated with maternal mental health in pregnant women.

B. M. Y. Leung is a PhD candidate, Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada.

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Effects of ketamine and esketamine on preventing postpartum depression after cesarean delivery: A meta-analysis
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Ketamine and esketamine has been suggested to have potential efficacy in preventing postpartum depression (PPD) recent years. The aim of this meta-analysis was to evaluate the effectiveness of ketamine and esketamine on PPD after cesarean delivery.
We systematically searched PubMed, Embase, and the Cochrane Library for studies investigating the efficacy of ketamine and esketamine in preventing PPD. The primary outcomes of this study were risk ratios (RRs) and EPDS scores (Edinburgh Postnatal Depression Scale) in relation to PPD after ketamine and esketamine. The second outcomes were the postoperative adverse events.
Thirteen randomized controlled trials (RCTs) and one retrospective study including 2916 patients were analyzed, including six on the use of ketamine and eight on the use of esketamine. The risk ratios and EPDS scores of PPD were significantly decreased in the ketamine/esketamine group compared to those in the control group in one week and four weeks postoperative periods. Subgroup analyses showed that high dosage, administrated in patient controlled intravenous analgesia (PCIA) method and only esketamine exhibited a significant reduction in the incidence and EPDS scores of PPD in one week and four week postoperative. However, the incidences of postoperative adverse events, such as dizziness, diplopia, hallucination, and headache were significantly higher in the ketamine/esketamine group than that in the control group.
Ketamine and esketamine appear to be effective in preventing PPD in the one week and four week postoperative periods after cesarean delivery with moderate certainty of evidence. But they can also lead to some short-term complications too. Future high-quality studies are needed to confirm the efficacy of ketamine and esketamine in different countries.
Postpartum depression: aetiology, pathogenesis and the role of nutrients and dietary supplements in prevention and management
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Postpartum depression (PPD) is a challenging psychological disorder faced by 10–30% of mothers across the globe. In India, it occurs among 22% of mothers. Its aetiology and pathophysiology aren’t fully understood as of today but multiple theories on the interplay of hormones, neurotransmitters, genetics, epigenetics, nutrients, socio-environmental factors, etc. exist. Nutrients are not only essential for the synthesis of neurotransmitters, but they may also indirectly influence genomic pathways that methylate DNA, and there is evidence for molecular associations between nutritional quality and psychological well-being. Increased behavioural disorders have been attributed to macro- and micronutrient deficiencies, and dietary supplementation has been effective in treating several neuropsychiatric illnesses. Nutritional deficiencies occur frequently in women, especially during pregnancy and breastfeeding. The aim of this study was to perform a comprehensive literature review of evidence-based research in order to identify, gather and summarize existing knowledge on PPD’s aetiology, pathophysiology, and the role of nutrients in its prevention as well as management. The possible mechanisms of action of nutrients are also presented here. Study findings show that the risk of depression increases when omega-3 fatty acid levels are low. Both fish oil and folic acid supplements have been used to effectively treat depression. Antidepressant efficacy is lowered by folate insufficiency. Folate, vitamin B12, iron, etc. deficiencies are more prevalent in depressed people than in non-depressed people. Serum cholesterol levels and plasma tryptophan levels are found to be inversely correlated with PPD. Serum vitamin D levels were associated inversely with perinatal depression. These findings highlight the importance of adequate nutrition in the antepartum period. Given that nutritional therapies can be affordable, safe, simple to use, and are typically well-accepted by patients, more focus should be placed on dietary variables in PPD.
Increased Brain-Derived Neurotrophic Factor and Hippocampal Dendritic Spine Density Are Associated with the Rapid Antidepressant-like Effect of Iron-citalopram and Iron-Imipramine Combinations in Mice
2023, Neuroscience
Iron supplementation previously demonstrated antidepressant-like effects in post-partum rats. The present study evaluates the possible synergistic antidepressant effect of sub-therapeutic dose of iron co-administered with citalopram or imipramine in female Institute of Cancer Research mice. Depression-like symptoms were induced in the forced swim (FST), tail suspension (TST), and open space swim (OSST) tests while open field test (OFT) was used to assess locomotor activity. Mice (n = 8) received iron (0.8–7.2 mg/kg), citalopram (3–30 mg/kg), imipramine (3–30 mg/kg), desferrioxamine (50 mg/kg) or saline in the single treatment phase of each model and subsequently a sub-therapeutic dose of iron co-administered with citalopram or imipramine. Assessment of serum brain derived neurotrophic factor (BDNF) and dendritic spine density was done using ELISA and Golgi staining techniques respectively. Iron, citalopram and imipramine, unlike desferrioxamine, reduced immobility score in the TST, FST and OSST without affecting locomotor activity, suggesting antidepressant-like effect. Sub-therapeutic dose of iron in combination with citalopram or imipramine further enhanced the antidepressant-like effect, producing a more rapid effect when compared to the iron, citalopram or imipramine alone. Iron, citalopram and imipramine or their combinations increased serum BDNF concentration, hippocampal neuronal count and dendritic spine densities. Our study provides experimental evidence that iron has antidepressant-like effect and sub-therapeutic dose of iron combined with citalopram or imipramine produces more rapid antidepressant-like effect. We further show that iron alone or its combination with citalopram or imipramine attenuates the neuronal loss associated with depressive conditions, increases dendritic spines density and BDNF levels. These finding suggest iron-induced neuronal plasticity in the mice brain.
Early pregnancy essential and non-essential metal mixtures and maternal antepartum and postpartum depressive symptoms
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Mood disorders are common during and after pregnancy, and environmental metals may contribute to increased risk. Antepartum metal exposures have not been well characterized in relation to maternal depression. We evaluated the extent to which early pregnancy erythrocyte concentrations of essential and non-essential metals were prospectively associated with antepartum and postpartum depressive symptoms.
Participants were 1226 women in Project Viva, a longitudinal cohort recruited during pregnancy (1999–2002). We measured concentrations of 11 metals in maternal first trimester erythrocytes (arsenic, barium, cadmium, cesium, copper, mercury, magnesium, manganese, lead, selenium, zinc). Using the Edinburgh Postnatal Depression Scale (EPDS), we assessed elevated depressive symptoms ( $\geq$ 13; 0–30 scale) at mid-pregnancy and at 6 and 12 months postpartum. We applied latent class mixed modeling to identify symptom trajectories. Adjusting for maternal sociodemographics and co-exposures, we examined associations between the metal mixture and depressive symptoms using logistic (for EPDS $\geq$ 13)/multinomial (for symptom trajectories) regression and quantile g-computation.
In this cohort of moderately high socioeconomic status participants (e.g., 72 % college graduate), low-level metal concentrations were weakly to moderately correlated (Spearman: ˗0.24 to 0.59); the prevalence of depressive symptoms ranged from 9 % (mid-pregnancy) to 6 % (12 months postpartum); and three trajectories (stable low; elevated mid-pregnancy, then decreasing; moderate mid-pregnancy, then increasing) best fit the EPDS data. The early pregnancy erythrocyte metal mixture was not associated with maternal depressive symptoms in logistic, multinomial, or mixture models. For individual metals, most confidence intervals (CI) included the null. There was weak evidence that arsenic, lead, and selenium were moderately associated with elevated odds of depressive symptoms and/or trajectories. However, the odds ratios (95 % CI) per doubling of these three metals were imprecise [e.g., arsenic: 1.13 (0.94, 1.40) for EPDS $\geq$ 13 at six months postpartum; lead: 1.19 (0.80, 1.77) for EPDS $\geq$ 13 at mid-pregnancy; selenium: 2.35 (0.84, 6.57) for elevated mid-pregnancy, then decreasing versus stable low trajectory].
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B. M. Y. Leung is a PhD candidate, Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada.

B. J. Kaplan is a professor, Department of Paediatrics, Alberta Children's Hospital, and Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada.

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ResearchReviewPerinatal Depression: Prevalence, Risks, and the Nutrition Link—A Review of the Literature

Abstract

Section snippets

Perinatal Depression

Antenatal Depression

Postpartum Depression

Effects of Maternal Depression

Risk Factors for Maternal Depression

Pathophysiology of Maternal Depression

Nutrition and Mood

Nutrition and Maternal Mood

Essential Fatty Acids and Maternal Mood

Vitamins/Minerals and Maternal Mood

Limitations of Studies

Dietary Inadequacy in Pregnant Women

Conclusion

Lancet

Biol Psychiatry

Nutrition

J Am Diet Assoc.

Nutrition

Best Pract Res Clin Obstet Gynaecol.

J Obstet Gynecol Neonatal Nurs.

J Obstet Gynecol Neonatal Nurs.

J Obstet Gynecol Neonatal Nurs.

J Affect Disord.

Neuron

Clin Psychol Rev.

J Affect Disord.

J Affect Disord

Gen Hosp Psychiatry

Compr Psychiatry

Psychoneuroendocrinology

J Psychosom Res.

J Am Diet Assoc.

J Nutr.

Life Sci.

Eur Neuropsychopharmacol.

Biol Psychiatry

J Affect Disord.

Psychiatr Clin North Am.

Trends Endocrinol Metab.

J Nutr.

Am Soc Nutr.J Nutr.

Prostaglandins Leukot Essent Fatty Acids

Prostaglandins Leukot Essent Fatty Acids

Prev Med.

J Nutr.

J Affect Disord.

J Affect Disord.

Int J Gynaecol Obstet.

J Nutr.

J Nutr.

J Am Diet Assoc.

J Am Diet Assoc.

Depression

Awareness, diagnosis, and treatment of depression

J Gen Intern Med.

The effects of nutrients on mood

Public Health Nutr.

Dietary omega-3 fatty acids and psychiatry: Mood, behaviour, stress, depression, dementia and aging

J Nutr Health Aging

Perinatal depression: A systematic review of prevalence and incidence

Obstet Gynecol.

Antenatal depression

Can Nurse

Prevalence of anxiety and depression during pregnancy in a private setting sample

Arch Womens Ment Health

Depressive symptoms among pregnant women screened in obstetrics settings

J Women's Health (Larchmt.)

Prevalence of depression during pregnancy: Systematic review

Obstet Gynecol.

Postpartum emotional disorders

A longitudinal study of maternal postpartum depression symptoms

Res Theory Nurs Pract.

Research
Review
Perinatal Depression: Prevalence, Risks, and the Nutrition Link—A Review of the Literature