Postpartum depression (PPD) is a complex psychiatric condition that affects one in seven mothers within the first year after childbirth, impacting not only the individual but also their families. While clinical evaluation remains essential in diagnosing PPD, relying solely on symptomatology may overlook underlying physiological factors contributing to the disorder.
Comprehensive laboratory testing within an integrative medicine framework can uncover hormonal imbalances, nutritional deficiencies, and other physiological contributors, enabling a more tailored and effective treatment plan.
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What Is Postpartum Depression?
PPD is a mood disorder that affects women during the postpartum period (the first year after giving birth). It is a type of depression characterized by persistent feelings of sadness that can interfere with a woman's ability to care for herself or her family after childbirth. PPD can impair mother-infant bonding, disrupt family dynamics, and increase the risk of developmental issues in children (48).
Types of Postpartum Depression
About 85% of women experience some type of mood disturbance during the postpartum period. Postpartum mood disorders are generally divided into these three categories:
Postpartum Blues
Up to 80% of people experience postpartum blues, or "baby blues," after childbirth. This mild form of worry, sadness, and fatigue typically begins within five days after giving birth and self-resolves within two weeks.
Postpartum Depression
PPD is a more severe form of depression that can manifest within the first year of giving birth. While most affected people begin to experience symptoms within the first month after childbirth, symptoms can arise as late as 30 weeks postpartum. Unlike postpartum blues, PPD usually requires some form of treatment to improve. (1)
Postpartum Psychosis
Postpartum psychosis is a rare but severe mental health disorder that affects between 0.089 and 2.6 people out of every 1,000 births. Psychosis affects a person's sense of reality and how they understand the world, causing symptoms like mood changes, disorganized thinking, hallucinations, delusions, and thoughts of self-harm or harming others. (36)
Causes of Postpartum Depression
The exact cause of postpartum depression is not fully understood, but it is believed to result from a combination of hormonal, psychological, and social factors.
Biological Factors
The postpartum period is marked by significant shifts in hormones, neurotransmitters, metabolism, and immune function, all of which can affect mood.
Hormonal Fluctuations: Dramatic drops in estrogen and progesterone levels, dysregulated cortisol, and low levels of oxytocin and prolactin have been linked to PPD (29). Additionally, postpartum thyroiditis – a transient inflammation of the thyroid gland – can lead to either hyperthyroidism or hypothyroidism, both of which are associated with mood disturbances.
Neurotransmitter Imbalances: Dysregulated neurotransmitter signaling pathways, particularly related to GABA, serotonin, glutamate, and dopamine, have been implicated in the development of PPD.
Genetics: Individuals with a family history of depression or other mental health disorders are at a higher risk for developing PPD, highlighting the interplay between genetic predisposition and mood regulation. Genetic variations (polymorphisms) in specific genes, such as 5HTT, COMT, TPH2, and MAOA, have been linked to PPD. (14)
Social Factors
Social factors also significantly influence the onset of PPD. Social risk factors for PPD include:
- Inadequate social support
- Low socioeconomic status
- Domestic violence
- Smoking
- Young maternal age
Psychological Factors
Women with a personal or family history of depression, PPD, or premenstrual dysphoric disorder (PMDD) are at a higher risk of developing PPD. Having a history of PPD increases your risk to 30% of developing it again in a subsequent pregnancy. (33)
Additional psychological risk factors for PPD include (29, 34):
- Having a negative attitude towards the baby
- Reluctance to accept the baby's sex
- Having a baby that is hard to comfort or has needs that are difficult to predict
- Emotional stressors
- History of sexual abuse
- Traumatic events during childbirth
Symptoms of Postpartum Depression
PPD manifests through a variety of emotional and physical symptoms, including:
- Persistent sadness, emptiness, hopelessness, or lack of motivation
- Feelings of worthlessness or excessive guilt
- Loss of interest or pleasure in activities
- Irritability or anger
- Changes in appetite
- Trouble sleeping (insomnia) or sleeping more often (hypersomnia)
- Frequent crying
- Fatigue or loss of energy
- Difficulty concentrating or making decisions
- Lack of interest in your baby
- Recurrent thoughts of death or suicide
- Physical symptoms such as headaches, digestive issues, or changes in weight without a clear cause
Diagnosing Postpartum Depression
According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), PPD is diagnosed when depressive symptoms occur within four weeks following childbirth. Many experts extend this window up to one year postpartum. At least five of the following symptoms, one of which must be depressed mood or anhedonia, must be present for at least two weeks and impair normal function:
- Depressed mood
- Decreased interest in pleasurable activities (anhedonia)
- Decreased energy
- Changes in sleep pattern
- Weight change
- Decreased concentration or indecisiveness
- Feelings of guilt or worthlessness
- Psychomotor retardation or agitation
- Suicidal ideation
Sadly, up to 50% of cases go undiagnosed due to patients' reluctance to seek medical help because of the stigma regarding the condition. This highlights the importance of routine screening during postpartum care visits. The most commonly used validated screening tool is the Edinburgh Postnatal Depression Scale.
Top 8 Labs to Order for Patients with Postpartum Depression
Comprehensive laboratory testing can identify underlying physiological contributors to PPD, facilitating a more effective and personalized treatment approach.
1. Thyroid Function Tests
Thyroid hormones play a critical role in regulating metabolism, energy levels, and mood. Depression is a common symptom of hypothyroidism.
Evidence suggests that among pregnant women with thyroid disorders, the prevalence of PPD ranges from 8.3-36%, while follow-up studies in urban settings have reported a cumulative incidence of self-reported depression of 6.3% within the first postpartum year.
Postpartum thyroiditis is autoimmune-mediated inflammation of the thyroid gland that affects approximately 5% of women after childbirth. It can present with transient hyperthyroidism followed by hypothyroidism, both of which can mimic or exacerbate depressive symptoms. Women with thyroid peroxidase (TPO) antibodies in the third trimester may be at higher risk for PPD symptoms after giving birth.
Recommended Thyroid Tests:
2. Complete Blood Count (CBC)
Anemia, particularly iron deficiency anemia, is common in the postpartum period, affecting up to half of women in developed countries, and can contribute to fatigue, weakness, and depressive symptoms.
Low red blood cell counts, hemoglobin, and hematocrit measured on a CBC are diagnostic for anemia.
Recommended Tests:
- CBC by Access Med Labs
- Complete Blood Count with Differential by Empire City Laboratories Inc.
3. Comprehensive Metabolic Panel (CMP)
A CMP is a panel that includes the following components:
- Glucose (blood sugar)
- Electrolytes
- Protein levels
- Kidney function markers
- Liver enzymes
Blood sugar imbalances can exacerbate mood disturbances.
The liver is involved in the metabolism of reproductive hormones and the conversion of thyroid hormones (40).
Recommended Tests:
- Comprehensive Metabolic Panel by Access Med Labs
- Comprehensive Metabolic Panel by Boston Heart Diagnostics
4. Micronutrient Panel
Over 20 different nutrient deficiencies have been associated with depression. Studies have specifically linked the following vitamin and mineral deficiencies to PPD:
- Iron
- Vitamin D
- Zinc
- Omega-3 fatty acids
- Selenium
- B vitamins (e.g., folate and vitamin B12)
A micronutrient test is an in-depth analysis of these micronutrients, among others, to comprehensively measure nutritional status and screen for imbalances that could increase the risk and severity of depression in new mothers.
Recommended Micronutrient Tests:
- Cellular Micronutrient Assay by Cell Science Systems
- Micronutrient Test by SpectraCell Laboratories
5. Cortisol and Adrenal Function Tests
The hypothalamic-pituitary-adrenal (HPA) axis is a central signaling network that orchestrates the body's response to stress by regulating the release of various hormones:
- Upon encountering a stressor, the hypothalamus secretes corticotropin-releasing hormone (CRH), which stimulates the pituitary gland to release adrenocorticotropic hormone (ACTH).
- ACTH then prompts the adrenal glands to produce cortisol, an important hormone that coordinates various physiological processes that allow the body to adapt to stress.
Hormonal shifts related to the HPA axis occur during the postpartum period, predisposing individuals to HPA axis dysfunction and cortisol dysregulation. Abnormal cortisol patterns, such as elevated baseline cortisol levels or an altered diurnal cortisol slope, have been correlated with the onset of PPD. (18)
Recommended Tests to Assess the HPA Axis:
- HPA Panel by Sanesco
- Adrenocortex Stress Profile by Genova Diagnostics
- Diurnal Cortisol Profile by Doctor's Data
6. Sex Hormones
Estrogen augments the function of neurotransmitter systems, including serotonin, acetylcholine, dopamine, and norepinephrine. The rapid drop in estrogen after childbirth can disrupt the balance of these mood-regulating neurotransmitters, leading to mood disturbances and depressive symptoms.
As a hormone that can cross the blood-brain barrier, progesterone and its metabolite allopregnanolone influence neurotransmitter levels and specific brain regions involved in emotional regulation, culminating in a calming effect. The dramatic decrease in progesterone after childbirth (that persists until a woman begins ovulating again) is linked to increased irritability and rates of depression. (46)
Sex hormones can be measured in blood, urine, or saliva.
Recommended Female Hormone Panels:
- Female Hormone Panel by Precision Point
- DUTCH Complete by Precision Analytical (DUTCH)
- Saliva Female Hormones by Ayumetrix
7. Neurotransmitters
The monoamine theory posits that deficiencies in serotonin, dopamine, and norepinephrine are central contributors to clinical depression. Additionally, autopsy studies of severely depressed patients have revealed elevated glutamate levels in the frontal cortex. (15)
Genetic polymorphisms, nutrient deficiencies, and dramatic hormonal changes influence the production, signaling systems, and metabolism of neurotransmitters, potentially exacerbating imbalances playing into PPD.
Neurotransmitters, their amino acid building blocks, and their metabolites can be measured in urine to provide insights into neurotransmitter levels in the body.
Recommended Neurotransmitter Tests:
- Neurotransmitters by ZRT Laboratory
- Comprehensive Neurotransmitter Profile - Random by Doctor's Data
8. Gut Health Markers
The gut-brain axis is a bidirectional communication network that links the central nervous system (CNS) with the enteric nervous system (ENS) in the gastrointestinal tract. This intricate system involves multiple pathways, including neural (vagus nerve), hormonal, and immunological mechanisms, facilitating constant interaction between the gut and the brain.
The gut is often referred to as the "second brain" due to the presence of the ENS, which contains more than 500 million neurons, and its ability to operate independently of the CNS to regulate digestive processes.
Dysbiosis, or imbalance in gut microbiota, has been linked to depression through inflammatory and metabolic mechanisms.
Recommended Comprehensive Stool Tests:
- GI Effects® Comprehensive Profile - 3 day by Genova Diagnostics
- GI-MAP by Diagnostic Solutions
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Key Takeaways
- Implementing a comprehensive lab testing protocol for patients with PPD allows healthcare providers to identify and address physiological contributors, facilitating a more effective and individualized treatment plan. This approach not only alleviates depressive symptoms but also promotes overall health and well-being in the postpartum period.
- While current evidence supports the role of various physiological factors in PPD, further research is needed to elucidate the complex interplay between these factors and their collective impact on mood disorders. Longitudinal studies and randomized controlled trials will enhance our understanding and inform evidence-based clinical practices for managing PPD.
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