|Classification and external resources|
Postpartum depression (PPD), also called postnatal depression, is a type of clinical depression which can affect women after childbirth. Symptoms may include sadness, low energy, changes in sleeping and eating patterns, reduced desire for sex, crying episodes, anxiety and irritability.
Although a number of risk factors have been identified, the causes of PPD are not well understood. Many women recover with a treatment consisting of a support group or counseling. The Edinburgh Postnatal Depression Scale, a standardised 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.
Studies report prevalence rates among women from 5% to 25%, but methodological differences among the studies make the actual prevalence rate unclear. Among men, in particular new fathers, the incidence of postpartum depression has been estimated to be between 1% and 25.5%.
Signs and symptoms
Symptoms of PPD can occur any time in the first year postpartum. These include, but are not limited to:
- Low self-esteem
- A feeling of being overwhelmed
- Sleep and eating disturbances
- Inability to be comforted
- Inability to experience pleasure from activities usually found enjoyable
- Social withdrawal
- Low or no energy
- Becoming easily frustrated
- Feeling inadequate in taking care of the baby
- Decreased sex drive
Onset and duration
Postpartum depression usually begins in the first few months after childbirth. In Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, it is defined as depression with onset within four weeks after childbirth. Postpartum depression can also affect women who have suffered a miscarriage. It usually begins around two weeks after delivery. It may last several months or even a year. The common term, Postpartum depression, does not exist as a diagnosis in the DSM-4 nor the DSM-5. In the DSM-5, "PPD" would be diagnosed as a depressive disorder with peripartum onset. "With peripartum onset" can occur during pregnancy or in the 4 weeks following delivery. There is no longer a distinction made between depressive episodes that occur during pregnancy or that occur after delivery.
Postpartum psychosis is a separate mental health disorder which is sometimes erroneously referred to as postpartum depression. It is less common than PPD, and it involves the onset of psychotic symptoms that may include thought disturbances, hallucinations, delusions and/or disorganised speech or behaviour. The prevalence of postpartum psychosis in the general population is 1–2 per 1,000 childbirths, but the rate is 100 times higher in women with bipolar disorder or a previous history of postpartum psychosis. Bipolar disorder and, to a lesser extent, schizophrenia, have elevated prevalences in postpartum psychosis. Previous research looked at the relationship between childbirth and postpartum psychosis. Using data on 54,000 births over a 12-year period, researchers found that psychiatric admissions were seven times more likely in the first 30 days after childbirth than in the prepregnancy period, and among women who developed postpartum psychosis after childbirth, 72%–80% had bipolar disorder or schizoaffective disorder and 12% had schizophrenia. Indicators of a possible bipolar diagnosis include a history of missed or misdiagnosed mood episodes, any previous mania or hypomania, and a family history of bipolar disorder or postpartum psychosis.
Treatment for postnatal psychosis is essential; it will not go away without medical attention.
Effects on the parent-infant relationship
Postpartum depression may lead mothers to be inconsistent with childcare. Women diagnosed with postpartum depression often focus more on the negative events of childcare, resulting in poor coping strategies. The four groups of coping methods are divided into different styles of coping subgroups. Avoidance coping is one of the most common strategies used. It consists of denial and behavioral disengagement subgroups (for example, an avoidant mother might not respond to her baby crying). This strategy, however, does not resolve any problems and ends up negatively affecting the mother’s mood, similarly of the other coping strategies used.
- Avoidance coping: denial, behavioral disengagement
- Problem-focused coping: active coping, planning, positive reframing
- Support seeking coping: emotional support, instrumental support
- Venting coping: venting, self-blame
Multiple factors must be considered when evaluating the capacity of a seriously depressed mother to provide a safe-enough caregiving environment that can support the healthy development of her baby and her relationship with that baby. Such factors, including maternal attachment history, present social supports, insight and ability to accept help, are often best considered by an interdisciplinary professional treatment team that includes infant mental health specialists or other mental health practitioners with experience in working with children and families.
The etiology of PPD is not well understood. It is sometimes assumed to be caused by a lack of vitamins. Other studies tend to show the more likely causes are the significant changes in a woman's hormones during pregnancy. Yet other studies have suggested no known correlation between hormones and postpartum mood disorders, and hormonal treatment has not helped postpartum depression victims. Further, fathers, who are not undergoing profound hormonal changes, suffer PPD at relatively high rates. Finally, all mothers experience these hormonal changes, yet only about 10–15% suffer PPD. This does not mean, however, that hormones do not play a role in PPD. For example, in women with a history of PPD, a hormone treatment simulating pregnancy and parturition caused these women to suffer mood symptoms. The same treatment, however, did not cause mood symptoms in women with no history of PPD. One interpretation of these results is that a subgroup of women are vulnerable to hormone changes during pregnancy. Another interpretation is that simulating a pregnancy will trigger PPD in women who are vulnerable to PPD for any of the reasons indicated by Beck's meta-analysis as summarised above.
Profound lifestyle changes brought about by caring for the infant are also frequently claimed to cause PPD, but, again, little evidence supports this hypothesis. Mothers who have had several previous children without suffering PPD can nonetheless suffer it with their latest child. Plus, most women experience profound lifestyle changes with their first pregnancy, yet most do not suffer PPD.
In 2009, researchers at the University of California, Irvine, reported the levels of placental corticotropin-releasing hormone (CRH) during the 25th week of pregnancy may help predict a woman's chances of developing postpartum depression.
While the causes of PPD are not understood, a number of factors have been suggested to increase the risk:
- Birth-related psychological trauma
- Birth-related physiological trauma
- Elevated prolactin levels
- Oxytocin depletion
- Formula-feeding rather than breast-feeding
- A history of depression
- Cigarette smoking
- Low self-esteem
- Childcare stress
- Prenatal depression during pregnancy
- Prenatal anxiety
- Low social support
- Life stress
- Poor marital relationship
- Infant temperament problems/colic
- Maternity blues
- Single marital status
- Low socioeconomic status
- Unplanned/unwanted pregnancy
Of these, formula-feeding, a history of depression, and cigarette smoking have been shown to be additive effects.
These factors are known to correlate with PPD. "Correlation" in this case means, for example, high levels of prenatal depression are associated with high levels of postnatal depression, and low levels of prenatal depression are associated with low levels of postnatal depression. But this does not mean prenatal depression causes postnatal depression—they might both be caused by some third factor. In contrast, some factors, such as lack of social support, almost certainly cause postpartum depression. Anthropologists Kruckman and Stern tested the idea cross culturally, and their pioneering study determined six ways in which postpartum rituals, including the use of the postpartum ritual, la cuarentena, in Chicago Latina mothers, to protect or cushion the expression of mood disorders.
In addition to Beck’s meta-analysis cited above, other academic studies have shown a correlation between a mother’s race, social class and/or sexual orientation and postpartum depression. In 2006, Segre et al. conducted a study "on the extent to which race/ethnicity is a risk factor" for PPD. Studying 26,877 postpartum women, they found that 15.7% were depressed. Of the women who suffered from PPD, African American women suffered at a rate of 25.2%, American Indian/Native Alaskan women at 22.9%, Caucasian women at 15.5%, Hispanic women at 15.3%, and 11.5% for those reporting Asian/Pacific Islander. Even when "important social factors such as age, income, education, marital status, and baby’s health were controlled, African American women still emerged with significantly increased risk for…PPD".
Segre et al. also found a correlation between a mother’s social class and PPD. Not surprisingly, women with fewer resources indicate a higher level of postpartum depression and stress than those with more financial resources. Rates of PPD decreased as income increased as follows: Women with fewer resources are also more likely to have an unintended or unwanted pregnancy, further increasing risk of PPD. Beck (2001) concurs with this, stating that these women are at risk for PPD because they may experience stressors such as financial difficulties. Single mothers of low income may have fewer resources to which they have access while transitioning into motherhood.
Likewise, a study conducted by Howell et al. in 2006 confirms Segre’s findings that women who are not Caucasian and in lower socioeconomic categories have more symptoms of PPD.
In a 2007 study conducted by Ross et al., lesbian and bisexual mothers were tested for PPD and then compared with a heterosexual sample. Ross et al. found that "lesbian and bisexual biological mothers had significantly higher Edinburgh Postnatal Depression Scale (EPDS) scores than the…sample of heterosexual women." The Ross study suggests that PPD may be more common among lesbian and bisexual mothers. From a study conducted in 2005 by Ross, the higher rates of PPD in lesbian/bisexual mothers than heterosexual mothers may be due to less "social support, particularly from their families of origin and…additional stress due to homophobic discrimination" in society.
Research suggests that PPD is a functional component of human reproductive decision-making, research supports the notion that PPD caused mothers to decline investment in their offspring.
Human infants require an extraordinary degree of care. Lack of support and insufficient investment from fathers and/or other family members will increase the costs borne by mothers, whereas infant health problems will reduce the evolutionary benefits to be gained. If ancestral mothers did not receive enough support from fathers or other family members, they may not have been able to afford raising the new infant without harming any existing children, or damaging their own health (nursing depletes mothers' nutritional stores, placing the health of poorly nourished women in jeopardy).
For mothers suffering inadequate social support or other costly and stressful circumstances, negative emotions directed towards a new infant could serve an important evolved function by causing the mother to reduce her investment in an unaffordable infant, thereby reducing her costs. Numerous studies support the correlation between postpartum depression and lack of social support or other childcare stressors. Kruckman, using observations from anthropological field work, suggests that supportive rituals and knowledge, if projected to the mother in a meaningful and sincere fashion, can affect the hypothalamus, pituitary and adrenal function and the production of endocrine signal molecules, and reduce the expression of anxiety or panic in postpartum women.
Mothers with postpartum depression can unconsciously exhibit fewer positive emotions and more negative emotions toward their children, are less responsive and less sensitive to infant cues, less emotionally available, have a less successful maternal role attainment, and have infants that are less securely attached; and in more extreme cases, some women may have thoughts of harming their children. In other words, most mothers with PPD are suffering some kind of cost, like inadequate social support, and consequently are mothering less.[improper synthesis?]
In this view, mothers with PPD do not have a mental illness, but instead cannot afford to take care of the new infant without more social support, more resources, etc. Treatment should therefore focus on helping mothers get what they need.
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.
A major part of prevention is being informed about the risk factors, and the medical community can play a key role in identifying and treating postpartum depression. Women should be screened by their physician to determine their risk for acquiring postpartum depression. Also, proper exercise and nutrition appears to play a role in preventing postpartum, and depressed mood in general.
In the US, the American College of Obstetricians and Gynecologists recommends that the first prenatal visit include screening for depression, stress, support, and whether the pregnancy was planned. However providers do not consistently provide screening and appropriate follow-up. Currently, Alberta is the only province in Canada with universal PPD screening which has been in place since 2003. The PPD screening is carried out by Public Health nurses in conjunction with the baby's immunization schedule.
Various treatment options include the following: medical evaluation to rule out physiological problems, cognitive behavioural therapy, medication, support groups among others. If the cause of PPD can be identified, treatment should be aimed at the root cause of the problem, including increased partner support, additional help with childcare, etc. A plan may include any combination of the above options, and might include some discussion or feedback from/with a partner. If a woman with PPD does not feel she is being taken seriously or is being recommended a treatment plan she does not feel comfortable with, she will want to seek a second opinion.
There is poor quality evidence that selective serotonin reuptake inhibitors (SSRIs) are effective. It is unclear if acupuncture, massage, bright lights or taking omega-3 fatty acids are useful.
Postpartum depression are found across the globe, with rates varying from 11% to 42%. According to the National Institutes of Mental Health, studies show that the childbearing years are when a woman is most likely to experience depression in her lifetime. Approximately 15% of all women will experience postpartum depression following the birth of a child.
Society and culture
The Malay culture holds a belief in a spirit known as Hantu Meroyan 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. Chinese women participate in a ritual known as "doing the month" 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, wash her hair, leave the house, or be blown by the wind.
In the past, developmentalists have frequently underestimated the importance of fathers and their interactions with the child in early development. However, researchers have conducted more studies that analyzes the impact of early experiences with fathers on child development, proving that fathers' involvement in early life has significant effects on later development. These studies include infants' exposure to paternal depression and its repercussions on the child's development.
Research on postpartum depression have mostly focused on mothers, but studies have shown that fathers also pose a risk of experiencing postpartum depression, though a lower prevalence than in mothers. Compared to mothers, fathers face lower levels of anxiety towards fatherhood and typically take part less in direct care for the child, reducing their susceptibility to PPD. In addition, researchers have depicted a positive correlation between maternal postnatal depression and paternal depression, most likely due to factors such as marital satisfaction, a strong predictor for PPD. Some studies propose that maternal depression plays a causal role in the development of postnatal depression in fathers.
Furthermore, the prevalence of PPD in fathers inversely correlate with socioeconomic status, in which the PPD in fathers increased as socioeconomic status declined. Similarly, unemployed fathers also demonstrated greater vulnerability to developing PPD.
Several negative development outcomes in children have been associated with paternal depression. In a cross-sectional study, pre-school children, three to five years of age, who faced paternal depression as infants developed increased behavioral problems relating to conduct and hyperactivity. In other words, paternal depression in early life places the child at a higher risk for developing behavioral issues, especially in early childhood. The results of the study also indicated a higher incidence of behavioral problems, as a result of paternal postpartum depression, in boys than in girls. Generally, boys more sensitively responded to the father's parenting, explaining the increased tendency of the boys to develop behavioral issues.
The study proposes several explanations for the development of behavioral issues. Similar to maternal depression, fathers experiencing depression find it more difficult to care for their children and to fulfill their roles and responsibilities in the family. As a result, early interaction between the father and the child may decrease. Also, indirect causes of depression, such as marital stress and tension, could also be a factor in the increase in behavior problems.
Prevention and treatment for parental postnatal depression follow the same guidelines as in maternal depression. Awareness through consulting services by doctors and nurses of postpartum depression, baby care, and the attachment and relationship between the parents and the child will provide fathers with the necessary information to avoid depression.
- Kinnaman, Gary & Jacobs, Richard. Seeing in the Dark. Michigan: Baker Publing Group, 2006.[page needed]
- "Perinatal Depression: Prevalence, Screening Accuracy, and Screening Outcomes". Agency for Health Care Research and Quality.
- Cox JL, Holden JM, Sagovsky R (June 1987). "Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale". Br J Psychiatry 150 (6): 782–6. doi:10.1192/bjp.150.6.782. PMID 3651732.
- Paulson, James F. (2010). "Focusing on depression in expectant and new fathers: prenatal and postpartum depression not limited to mothers". Psychiatry Times 27 (2).
- The Boston Women's Health Book Collective: Our Bodies Ourselves, pages 489–491, New York: Touchstone Book, 2005
- Morof D, Barrett G, Peacock J, Victor CR, Manyonda I (December 2003). "Postnatal depression and sexual health after childbirth". Obstet Gynecol 102 (6): 1318–25. doi:10.1016/j.obstetgynecol.2003.08.020. PMID 14662221.
- Miller LJ (February 2002). "Postpartum depression". JAMA 287 (6): 762–5. doi:10.1001/jama.287.6.762. PMID 11851544.
- Postpartum Depression from Pregnancy Guide, by Peter J. Chen, at Hospital of the University of Pennsylvania. Reviewed last on: 10/22/2008
- Canadian Mental Health Association > Post Partum Depression Retrieved on June 13, 2010
- Spinelli MG (April 2009). "Postpartum psychosis: detection of risk and management". Am J Psychiatry 166 (4): 405–8. doi:10.1176/appi.ajp.2008.08121899. PMID 19339365.
- Field, T (Feb 2010). "Postpartum depression effects on early interactions, parenting, and safety practices: A review". Infant Behavior and Development. 33, 1-6.
- Almeida A, Merminod G, Schechter DS (2009). "Mothers with severe psychiatric illness and their newborns: a hospital-based model of perinatal consultation". Journal of ZERO-TO-THREE: National Center for Infants, Toddlers, and Families 29 (5): 40–46.
- Beard JL, Hendricks MK, Perez EM, et al. (February 2005). "Maternal iron deficiency anemia affects postpartum emotions and cognition". J. Nutr. 135 (2): 267–72. PMID 15671224.
- Soares CN, Zitek B (July 2008). "Reproductive hormone sensitivity and risk for depression across the female life cycle: a continuum of vulnerability?". J Psychiatry Neurosci 33 (4): 331–43. PMC 2440795. PMID 18592034.
- Goodman JH (January 2004). "Paternal postpartum depression, its relationship to maternal postpartum depression, and implications for family health". J Adv Nurs 45 (1): 26–35. doi:10.1046/j.1365-2648.2003.02857.x. PMID 14675298.
- Block et al. (2000).[dead link]
- Nielsen Forman D, Videbech P, Hedegaard M, Dalby Salvig J, Secher NJ (October 2000). "Postpartum depression: identification of women at risk". BJOG 107 (10): 1210–7. doi:10.1111/j.1471-0528.2000.tb11609.x. PMID 11028570.
- Rich-Edwards JW, Mohllajee AP, Kleinman K, et al. (May 2008). "Elevated midpregnancy corticotropin-releasing hormone is associated with prenatal, but not postpartum, maternal depression". J. Clin. Endocrinol. Metab. 93 (5): 1946–51. doi:10.1210/jc.2007-2535. PMC 2386278. PMID 18303075.
- McCoy SJ, Beal JM, Shipman SB, Payton ME, Watson GH (April 2006). "Risk factors for postpartum depression: a retrospective investigation at 4-weeks postnatal and a review of the literature". J Am Osteopath Assoc 106 (4): 193–8. PMID 16627773.
- Beck CT (1996). "A meta-analysis of the relationship between postpartum depression and infant temperament". Nurs Res 45 (4): 225–30. doi:10.1097/00006199-199607000-00006. PMID 8700656.
- The causal role of lack of social support in PPD is strongly suggested by several studies, including O'Hara 1985, Field et al. 1985; and Gotlib et al. 1991.
- Stern G, Kruckman L (1983). "Multi-disciplinary perspectives on post-partum depression: an anthropological critique". Soc Sci Med 17 (15): 1027–41. doi:10.1016/0277-9536(83)90408-2. PMID 6623110.
- Segre, Lisa S.; O'Hara, Michael W.; Losch, Mary E. (2006). "Race/ethnicity and perinatal depressed mood". Journal of Reproductive and Infant Psychology 24 (2): 99–106. doi:10.1080/02646830600643908.
- Howell EA, Mora P, Leventhal H (March 2006). "Correlates of early postpartum depressive symptoms". Matern Child Health J 10 (2): 149–57. doi:10.1007/s10995-005-0048-9. PMC 1592250. PMID 16341910.
- Ross LE, Steele L, Goldfinger C, Strike C (2007). "Perinatal depressive symptomatology among lesbian and bisexual women". Arch Womens Ment Health 10 (2): 53–9. doi:10.1007/s00737-007-0168-x. PMID 17262172.
- Ross LE (2005). "Perinatal mental health in lesbian mothers: a review of potential risk and protective factors". Women Health 41 (3): 113–28. doi:10.1300/J013v41n03_07. PMID 15970579.
- Hagen, Edward H (1999). "The Functions of Postpartum Depression". Evolution and Human Behavior 20 (5): 325–59. doi:10.1016/S1090-5138(99)00016-1.
- Kruckman, Laurence (1999). "Rituals as Prevention: The Case of Postpartum Depression". In Heinze, Ruth-Inge. The Nature and Function of Rituals: Fire from Heaven. Greenwood Publishing. pp. 213–28. ISBN 978-0-89789-663-4.
- Kruckman, L. "A Renewed Call for a Biocultural Understanding of Postpartum Depression Etiology," paper presented at the Max Planck Institute International Symposium, "Postpartum Dysphoria & Depression: Anthropological, Ethnopsychiatric & Evolutionary Dimensions" Reimers Stiftung, Bad Homburg, Germany, 2000.
- Beck 1995[verification needed]
- Cohn, Jeffrey F.; Campbell, Susan B.; Matias, Reinaldo; Hopkins, Joyce (1990). "Face-to-face interactions of postpartum depressed and nondepressed mother-infant pairs at 2 months". Developmental Psychology 26: 15–23. doi:10.1037/0012-1622.214.171.124.
- Cohn, Jeffrey F.; Campbell, Susan B.; Ross, Shelley (2009). "Infant response in the still-face paradigm at 6 months predicts avoidant and secure attachment at 12 months". Development and Psychopathology 3 (4): 367–76. doi:10.1017/S0954579400007574.
- Field, Tiffany; Sandberg, David; Garcia, Robert; Vega-Lahr, Nitza; Goldstein, Sheri; Guy, Lisa (1985). "Pregnancy problems, postpartum depression, and early motherinfant interactions". Developmental Psychology 21 (6): 1152–6. doi:10.1037/0012-16126.96.36.1992.
- Fowles, Eileen R. (1998). "The Relationship Between Maternal Role Attainment and Postpartum Depression". Health Care for Women International 19 (1): 83–94. doi:10.1080/073993398246601. PMID 9479097.
- Hoffman, Yonit; Drotar, Dennis (1991). "The impact of postpartum depressed mood on mother-infant interaction: Like mother like baby?". Infant Mental Health Journal 12: 65–80. doi:10.1002/1097-0355(199121)12:1<65::AID-IMHJ2280120107>3.0.CO;2-T.
- Jennings et al. 1999[verification needed]
- Murray, Lynne (1991). "Intersubjectivity, object relations theory, and empirical evidence from mother-infant interactions". Infant Mental Health Journal 12 (3): 219–32. doi:10.1002/1097-0355(199123)12:3<219::AID-IMHJ2280120308>3.0.CO;2-G.
- Murray, Lynne; Cooper, Peter J. (1996). "The impact of postpartum depression on child development". International Review of Psychiatry 8: 55–63. doi:10.3109/09540269609037817.
- Hagen EH, Barrett HC (March 2007). "Perinatal sadness among Shuar women: support for an evolutionary theory of psychic pain". Med Anthropol Q 21 (1): 22–40. doi:10.1525/maq.2007.21.1.22. PMID 17405696.
- Dennis CL, Dowswell T (2013). Dennis, Cindy-Lee, ed. "Psychosocial and psychological interventions for preventing postpartum depression". Cochrane Database Syst Rev 2: CD001134. doi:10.1002/14651858.CD001134.pub3. PMID 23450532.
- PubMed Health. "Preventing postnatal depression". National Center for Biotechnology Information. Retrieved 30 May 2013.
- "Providers miss opportunities to prevent depression in and discuss birth control with women with unplanned pregnancies". Research Activities (Agency for Healthcare Research and Quality) (372): 15. August 2011.
- Dennis, CL; Hodnett, E (Oct 17, 2007). "Psychosocial and psychological interventions for treating postpartum depression.". The Cochrane database of systematic reviews (4): CD006116. PMID 17943888.
- Molyneaux, E; Howard, LM; McGeown, HR; Karia, AM; Trevillion, K (Sep 11, 2014). "Antidepressant treatment for postnatal depression.". The Cochrane database of systematic reviews 9: CD002018. PMID 25211400.
- Dennis, CL; Dowswell, T (Jul 31, 2013). "Interventions (other than pharmacological, psychosocial or psychological) for treating antenatal depression.". The Cochrane database of systematic reviews 7: CD006795. PMID 23904069.
- Ali NS, Ali BS, Azam IS (2009). "Post partum anxiety and depression in peri-urban communities of Karachi, Pakistan: a quasi-experimental study". BMC Public Health 9: 384. doi:10.1186/1471-2458-9-384. PMC 2768706. PMID 19821971.
- Chasse, J[verification needed]
- McElroy, Ann; Townsend, Patricia K., eds. (2009). "Culture, Ecology, and Reproduction". Medical Anthropology in Ecological Perspective. pp. 217–66. ISBN 978-0-7867-2740-7.
- Klainin P, Arthur DG (October 2009). "Postpartum depression in Asian cultures: a literature review". Int J Nurs Stud 46 (10): 1355–73. doi:10.1016/j.ijnurstu.2009.02.012. PMID 19327773.
- Ramchandani, Paul; Stein, Alan; Evans, Jonathan; O'Connor, Thomas G. (2005). "Paternal depression in the postnatal period and child development: a prospective population study". The Lancet.
- Paulson, James F.; Bazemore, Sharnail D. (May 19, 2010). "Prenatal and Postpartum Depression in Fathers and Its Association With Maternal Depression: A Meta-analysis". Journal of the American Medical Association.
- Sehran, Nilufer; Ege, Emel; Ayranci, Unal; Kosgeroglu, Nedime (2011). "Prevalence of postpartum depression in mothers and fathers and its correlates". Journal of Clinical Nursing.
- Postpartum depression at DMOZ
- Postpartum depressive illness at GPnotebook
- "Depression during and after pregnancy fact sheet". Womenshealth.gov. 6 March 2009.
- Postnatal Depression, information from the mental health charity The Royal College of Psychiatrists
- NHS Choices Health A-Z: Postnatal depression
- NHS Choices Pregnancy Care Planner: The baby blues and postnatal depression
- NHS Choices Live Well: Postnatal depression