Medicine:Antenatal depression

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Antenatal depression
SpecialtyOB/GYN psychiatry

Antenatal depression, also known as prenatal or perinatal depression, is a form of clinical depression that can affect a woman during pregnancy, and can be a precursor to postpartum depression if not properly treated.[1] It is estimated that 7% to 20% of pregnant women are affected by this condition.[2] Any form of prenatal stress felt by the mother can have negative effects on various aspects of fetal development, which can cause harm to the mother and child. Even after birth, a child born from a depressed or stressed mother feels the affects. The child is less active and can also suffer from emotional distress. Antenatal depression can be caused by the stress and worry that pregnancy can bring, but at a more severe level. Other triggers include unplanned pregnancy, difficulty becoming pregnant, history of abuse, and economic or family situations.[3]

Commonly, symptoms involve how the patient views herself, how she feels about going through such a life changing event, the restrictions on the mother's lifestyle that motherhood will place, or how the partner or family feel about the baby.[4] Pregnancy places significant strain on a woman's body, so stress, mood swings, sadness, irritability, pain, and memory changes are to be expected. Left untreated, antenatal depression can be extremely dangerous for the health of the mother and the baby. It is highly recommended that mothers who feel they are experiencing antenatal depression have a discussion about it with their health care provider. Mothers with a history of mental health issues should also talk to their doctor about it early in the pregnancy to help with possible depressive symptoms.

Signs and symptoms

Antenatal depression is classified based on a woman's symptoms. During pregnancy, a lot of changes to mood, memory, eating habits, and sleep are common. When these common traits become severe, and begin to alter one's day-to-day life, that is when it is considered to be antenatal depression. Symptoms of antenatal depression are:

  • Inability to concentrate.
  • Overwhelming anxiety and fear.
  • Difficulty remembering.
  • Feeling emotionally numb.
  • Extreme irritability.
  • Sleeping too much or not enough, or restless sleep.
  • Extreme or unending fatigue.
  • Desire to over eat, or not eat at all.
  • Weight loss/gain unrelated to pregnancy.
  • Loss of interest in sex.
  • A sense of dread about everything, including the pregnancy.
  • Feelings of failure, or guilt.
  • Persistent sadness.
  • Thoughts of suicide, or death.[5]

Other symptoms can include the inability to get excited about the pregnancy, and/or baby, a feeling of disconnection with the baby, and an inability to form/feel a bond with the developing baby.[6] This can drastically affect the relationship between the mother and the baby, and can drastically affect the mother's capacity for self-care. Such inadequacies can lead to even greater risk factors for the mother.[7] Antenatal depression can be triggered by various causes, including relationship problems, family or personal history of depression, infertility, previous pregnancy loss, complications in pregnancy, and a history of abuse or trauma.[8]

Onset and duration of symptoms

Antenatal depression can be caused by many factors. Often it is associated with the fear and stress of the pregnancy. Other factors include unintended pregnancy, hyperemesis gravidarum, financial issues, living arrangements and relationships with the father and family. Typically, depression symptoms associated with pregnancy are categorized as postnatal depression, due to the onset of symptoms occurring after childbirth has occurred. The following is a breakdown of when a group of various women began to feel the onset of symptoms associated with depression:

  • 11.8 percent at 18 weeks
  • 13.5 percent at 32 weeks
  • 9.1 percent 8 weeks after the birth
  • 8.1 percent 8 months after the birth[9]

In a recent article posted by The BabyCenter, the authors stated that "For years, experts mistakenly believed that pregnancy hormones protected against depression, leaving women more vulnerable to the illness only after the baby was born and their hormone levels plunged."[10] This is a possible explanation as to why antenatal depression has just recently been identified.

Prevalence and causes

The prevalence of antenatal depression differs slightly by region of world. In the United States, antenatal depression is experienced in as many as 16% of pregnant women, while in South Asia it is experienced in as many as 24% of pregnant women.[11][12][13] It's becoming more prevalent as more medical studies are being done. Antenatal depression was once thought to simply be the normal stress associated with any pregnancy, and was waved off as a common ailment. It can be caused by many factors, usually though involving aspects of the mothers personal life, such as family, economic standing, relationship status, etc. It can also be caused by hormonal and physical changes that are associated with pregnancy.[14] Additional risk factors include lack of social support, marital dissatisfaction, discriminatory work environments, history of domestic abuse, and unplanned or unwanted pregnancy.[15] Studies have determined that there may be a connection between antenatal and postpartum depression in women with lower vitamin D levels.[16] There is a higher risk of antenatal depression in woman living in low-income countries who deal with less access to quality healthcare, have economic issues, and don't have a good support system.[17]

Screening

Perinatal mental health screenings are important in detecting and diagnosing antenatal and postpartum depression early. The American College of Obstetricians and Gynecologists is one of the many maternal health organizations that strongly encourage universal screening for expectant and postpartum women for depression as part of routine obstetric care.[18] In fact, many states, including California have already legislated laws that require providers to screen patients during visits because they recognize that early screenings can expedite the process in receiving effective treatment. The Patient Health Questionnaire 9 (PHQ-9) is a screening tool typically used to detect depression.[19]

PHQ-9 is a reliable depression severity scale that was formulated in accordance with DSM-IV criteria for depression, consisting of 9 items correlating to the 9 criteria listed in DSM-IV.[20] It is a shortened version of the PHQ and has been assessed for comparable sensitivity and specificity.[20] The screening test is self-administered to patients and are usually performed at the primary care clinic.[20]

However, it is not enough to just provide mental health screenings to at risk patients. Interventions such as referrals to treatment and mental health monitoring should be implemented in health care systems in order to ensure these women are helped consistently throughout their recovery journey.[18]

Studies suggest that obese woman tend to suffer more frequently from mental health issues and should discuss any symptoms with their doctor at the first prenatal appointment.[21]

Treatment

Treatment for antenatal depression poses many challenges because the baby is also affected by any treatment given to the mother.[22] There are both non-pharmacological and pharmacological treatment options which can be considered by women with antenatal depression.

Non-pharmacological Therapy

Psychotherapy

Psychotherapy is recommended for any woman suffering from antenatal depression,[23] as it is an effective way for the mother to express her feelings in her own words. Specifically, Cognitive Behavioral Therapy effectively helps decrease symptoms of antenatal depression.[24] In addition to psychotherapy, being seen by a psychiatrist is recommended as they can assess if medications will be beneficial and make specific medication recommendations, if warranted. Familial support may also play a role in helping with the emotional aspects of antenatal depression.[25]

While mental health specialists are trained in providing counseling interventions, results from a recent systematic review and meta-analysis of the literature found that nonspecialist providers, such as lay counselors, nurses, midwives, and teachers with no formal training in counseling interventions, often fill a gap in providing effective services related to depression and anxiety treatments.[26]

Exercise Therapy

Studies suggest that forms of exercise can help with depressive symptoms both before and after birth, but not prevent it entirely.[27]

Exercise options that have been studied to help reduce symptoms:

  • Yoga[28]
  • Walking
  • Stretching
  • Aerobic exercise[29]

Medications

When discussing medication options for antenatal depression, it is important to ask the prescribing healthcare provider to share more details about all the risks and benefits of the available medications. During pregnancy, there are two main kinds of antidepressants used during pregnancy; tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs). Once prescribed, anti-depressant medication has been found to be extremely effective in treating antenatal depression. Patients can expect to feel an improvement in mood in roughly 2 to 3 weeks on average, and can begin to feel themselves truly connect with their baby. Reported benefits of medication include returned appetite, increased mood, increased energy, and better concentration. Side effects are minor, though they are reported in some cases. Currently, no abnormalities of the baby have been associated with the use of antidepressants during pregnancy.[30] It may be true that maternal SSRI use during pregnancy can lead to difficulty for their newborn adjusting to conditions outside of the womb immediately following birth. Some studies indicate that infants with exposure to SSRIs in the second and third trimester were more likely to be admitted to intensive care following their birth for respiratory, cardiac, low weight and other reasons, and that infants with prenatal SSRI exposure exhibited less motor control upon delivery than infants who were not exposed to SSRIs. Newborns who were exposed to SSRIs for five months or more prior to birth were at a greater risk for lower Apgar scores 1 and 5 minutes after delivery, indicating they were of lesser health than newborns who were not exposed to SSRIs before birth. However, prenatal SSRI exposure was not found to have a significant impact the long-term mental and physical health of the children. These results are not independent of any effects of prenatal depression on infants.[31]

Connection to postpartum depression and parenting stress

Studies have found a strong link between antenatal depression and postpartum depression in women. In other words, women who are suffering from antenatal depression are very likely to also suffer from postpartum depression. The cause of this is based on the continuation of the antenatal depression into postpartum. In a logistical light, it makes sense that women who are depressed during their pregnancy will also be depressed following the birth of their child.[32] This being said there are some factors that determine exclusively the presence of postpartum depression that are not necessarily linked with antenatal depression. These examples include variables like socioeconomic class, if a pregnancy was planned or not, and the parents' relationship prior to conception and delivery of the child.[citation needed]

In reference to a recent study by Coburn et al., the authors found that in addition to prenatal effects, higher maternal depressive symptoms during the postpartum period (12 weeks) were associated with more infant health concerns. This is consistent with other findings among low-SES Mexican-American women and their infants.[33] Women with prenatal depressive symptoms are more likely to develop postpartum depression, which can also have negative consequences on children, such as emotional and behavior problems, attachment difficulties, cognitive deficits, physical growth and development, and feeding habits and attitudes.[34] Related, maternal depression affects parenting behaviors,[35] which in turn could affect child outcomes. Thus, women’s mental health throughout the perinatal period should be a priority, not only to support women, but also to promote optimal functioning for their infants.[36]

Antenatal Depression and Infant Health

Depression during pregnancy is associated with an increased risk of spontaneous abortion. In a review by Frazier et al., acute and chronic stress during pregnancy can diminish proper immunological activity crucial during pregnancy, and can possibly induce spontaneous abortion.[37] There is still a debate on whether the miscarriage is due to the depressive disease state or the anti-depressant medication. A large study conducted in Denmark observed that there was a higher incidence of first trimester miscarriage in depressed women not exposed to SSRI compared to non-depressed women exposed to SSRI,[38] indicating that the miscarriage may be associated with the psychological state of the mother rather than the anti-depressant.

Depressive symptoms in pregnant women are linked with poor health outcomes in infants.[39] The rates of hospitalization are found increased for infants who are born to women with high depression levels during pregnancy. Reduced breastfeeding, poor physical growth, lower birth weight, early gestational age and high rates of diarrheal infection are some of the reported outcomes of poor health among infants born to depressed pregnant women.[40] In fact, positive antenatal screenings administered in the first or third trimester are found to be high risk factors for early cessation in breastfeeding.[41] Studies also report that the environmental effects of maternal depression affect the developing fetus to such an extent that the impact can be seen during adulthood of the offspring. The effects are worse for women from low socio-economic backgrounds. In a recent study by Coburn et al.,[39] maternal prenatal depressive symptoms predicted significantly higher number of infant health concerns at 12-weeks (3 months) of age. The health concerns included rash, colic, cold, fever, cough, diarrhea, ear infections, and vomiting.[39] Additional concerns for women in low-income backgrounds includes low birth rate and preterm births.[42]

An interesting and informative area of research has been done to see the role of confounding variables in relationship of maternal prenatal depression with infant health concerns. Age of mother, romantic partner, education, household income, immigrant status, and number of other children, breastfeeding, gestational age, birth weight are some of the mediating or moderating factors which are found correlated with infant health concerns.[43] The studies of post-partum depressive symptoms are relatively more than those of prenatal depression and the studies should look into the role of various factors during pregnancy that may impact the health of infants, even continuing into adulthood.[43]

Male Perspective for Antenatal Depression

Fathers can also experience depression during their partner's pregnancy, commonly displayed as fatigue or changes in sleep and eating patterns.[44] Men whose partners are women struggling with antenatal or postnatal depression often find themselves receiving less affection and intimacy from their partners.[45] If symptoms of antenatal depression arise, it is recommended for fathers to provide encouragement for their partners to discuss their condition with a healthcare provider.[45] It is also important for the father to also seek support for himself. In a research performed in Sweden observing 366,499 births, newly diagnosed paternal depression around the time of conception or during pregnancy was associated with an increased risk of preterm birth. However, a preexisting paternal depression did not show any correlation, which may be due to the mother's perception of the changes in her partner's mood.[46]

See also

References

  1. ↑ "NIMH » Depression in Women: 5 Things You Should Know". https://www.nimh.nih.gov/health/publications/depression-in-women/index.shtml. 
  2. ↑ Wilson, Pamela. "Antenatal Depression". health.ninemsn.com. http://health.ninemsn.com/pregnancy/complications/693967/antenatal-depression. 
  3. ↑ Biaggi, Alessandra; Conroy, Susan; Pawlby, Susan; Pariante, Carmine M. (Feb 2016). "Identifying the women at risk of antenatal anxiety and depression: A systematic review". Journal of Affective Disorders 191: 62–77. doi:10.1016/j.jad.2015.11.014. ISSN 0165-0327. PMID 26650969. 
  4. ↑ "Antenatal depression". www.nct.org.uk. http://www.nct.org.uk/pregnancy/antenatal-depression. 
  5. ↑ "Antenatal Depression". www.panda.org.asu. http://www.panda.org.au/practical-information/about-postnatal-depression/27-antenatal-depression. 
  6. ↑ "Antenatal Depression". www.babiesonline.com. http://www.babiesonline.com/articles/health/antenataldepression.asp. 
  7. ↑ "Risk factors for antenatal depression, postnatal depression and parenting stress". BMC Psychiatry 8: 24. April 2008. doi:10.1186/1471-244X-8-24. PMID 18412979. 
  8. ↑ "Racial/Ethnic Disparities in Antenatal Depression in the United States: A Systematic Review". Maternal and Child Health Journal 20 (9): 1780–97. September 2016. doi:10.1007/s10995-016-1989-x. PMID 27016352. 
  9. ↑ Sharps, Linda (2012-10-18). "Prenatal Depression Warning Signs: Here's What to Look For". The Huffington Post. http://www.huffingtonpost.com/the-stir/prenatal-depression_b_1967991.html. 
  10. ↑ "Is it common to suffer from depression or anxiety during pregnancy?". The Baby Center. http://www.babycenter.com/0_depression-during-pregnancy_9179.bc. 
  11. ↑ "Perinatal depression: a systematic review of prevalence and incidence" (in en). Obstetrics and Gynecology 106 (5 Pt 1): 1071–83. November 2005. doi:10.1097/01.AOG.0000183597.31630.db. PMID 16260528. http://insights.ovid.com/. 
  12. ↑ "Prevalence of antenatal depression in South Asia: a systematic review and meta-analysis". Journal of Epidemiology and Community Health 73 (8): 768–777. August 2019. doi:10.1136/jech-2018-211819. PMID 31010821. https://jech.bmj.com/content/73/8/768. 
  13. ↑ "Estimated prevalence of antenatal depression in the US population". Archives of Women's Mental Health 19 (2): 395–400. April 2016. doi:10.1007/s00737-015-0593-1. PMID 26687691. 
  14. ↑ "Prenatal (Antenatal) Depression". www.pandasfoundation.org.u. Pandas Foundation. http://www.pandasfoundation.org.uk/help-and-information/pre-ante-and-postnatal-illnesses/pre-antenatal-depression.html#.UZKT8rWkpa8. 
  15. ↑ Biaggi, Alessandra; Conroy, Susan; Pawlby, Susan; Pariante, Carmine M. (February 2016). "Identifying the women at risk of antenatal anxiety and depression: A systematic review". Journal of Affective Disorders 191: 62–77. doi:10.1016/j.jad.2015.11.014. ISSN 0165-0327. PMID 26650969. 
  16. ↑ Aghajafari, Fariba; Letourneau, Nicole; Mahinpey, Newsha; Cosic, Nela; Giesbrecht, Gerald (2018-04-12). "Vitamin D Deficiency and Antenatal and Postpartum Depression: A Systematic Review". Nutrients 10 (4): 478. doi:10.3390/nu10040478. ISSN 2072-6643. PMID 29649128. 
  17. ↑ Fekadu Dadi, Abel; Miller, Emma R.; Mwanri, Lillian (2020-01-10). "Antenatal depression and its association with adverse birth outcomes in low and middle-income countries: A systematic review and meta-analysis". PLOS ONE 15 (1): e0227323. doi:10.1371/journal.pone.0227323. ISSN 1932-6203. PMID 31923245. Bibcode: 2020PLoSO..1527323F. 
  18. ↑ 18.0 18.1 "Consensus Bundle on Maternal Mental Health: Perinatal Depression and Anxiety". Journal of Obstetric, Gynecologic, and Neonatal Nursing 46 (2): 272–281. 2017-03-01. doi:10.1016/j.jogn.2017.01.001. PMID 28190757. 
  19. ↑ "National Perinatal Association - Perinatal Mental Health". http://www.nationalperinatal.org/mental_health. 
  20. ↑ 20.0 20.1 20.2 "The PHQ-9: validity of a brief depression severity measure". Journal of General Internal Medicine 16 (9): 606–13. September 2001. doi:10.1046/j.1525-1497.2001.016009606.x. PMID 11556941. 
  21. ↑ Petursdottir Maack, Heidrun; Skalkidou, Alkistis; Sjöholm, Anna; Eurenius-Orre, Karin; Mulic-Lutvica, Ajlana; Wikström, Anna-Karin; Sundström Poromaa, Inger (2019-04-17). "Maternal body mass index moderates antenatal depression effects on infant birthweight". Scientific Reports 9 (1): 6213. doi:10.1038/s41598-019-42360-1. ISSN 2045-2322. PMID 30996270. Bibcode: 2019NatSR...9.6213P. 
  22. ↑ "Antenatal depression: a rationale for studying exercise". Depression and Anxiety 28 (3): 234–42. March 2011. doi:10.1002/da.20777. PMID 21394856. 
  23. ↑ Li, Caixia; Sun, Xiaohua; Li, Qing; Sun, Qian; Wu, Beibei; Duan, Dongyun (2020-07-02). "Role of psychotherapy on antenatal depression, anxiety, and maternal quality of life". Medicine 99 (27): e20947. doi:10.1097/MD.0000000000020947. ISSN 0025-7974. PMID 32629701. 
  24. ↑ "Selective serotonin reuptake inhibitors are tolerated better than tricyclic antidepressants". BMJ 314 (7081). 1997. doi:10.1136/bmj.314.7081.0e. ISSN 0959-8138. 
  25. ↑ Hu, Ying; Wang, Ying; Wen, Shu; Guo, Xiujing; Xu, Liangzhi; Chen, Baohong; Chen, Pengfan; Xu, Xiaoxia et al. (2019-11-19). "Association between social and family support and antenatal depression: a hospital-based study in Chengdu, China". BMC Pregnancy and Childbirth 19 (1): 420. doi:10.1186/s12884-019-2510-5. ISSN 1471-2393. PMID 31744468. 
  26. ↑ Singla, Daisy R.; Lawson, Andrea; Kohrt, Brandon A.; Jung, James W.; Meng, Zifeng; Ratjen, Clarissa; Zahedi, Nika; Dennis, Cindy-Lee et al. (2021-05-01). "Implementation and Effectiveness of Nonspecialist-Delivered Interventions for Perinatal Mental Health in High-Income Countries: A Systematic Review and Meta-analysis" (in en). JAMA Psychiatry 78 (5): 498–509. doi:10.1001/jamapsychiatry.2020.4556. ISSN 2168-622X. PMID 33533904. PMC 7859878. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2775992. 
  27. ↑ Daley, A. J.; Foster, L.; Long, G.; Palmer, C.; Robinson, O.; Walmsley, H.; Ward, R. (2015). "The effectiveness of exercise for the prevention and treatment of antenatal depression: systematic review with meta-analysis" (in en). BJOG: An International Journal of Obstetrics & Gynaecology 122 (1): 57–62. doi:10.1111/1471-0528.12909. ISSN 1471-0528. PMID 24935560. 
  28. ↑ Gong, Hong; Ni, Chenxu; Shen, Xiaoliang; Wu, Tengyun; Jiang, Chunlei (2015-02-05). "Yoga for prenatal depression: a systematic review and meta-analysis". BMC Psychiatry 15: 14. doi:10.1186/s12888-015-0393-1. ISSN 1471-244X. PMID 25652267. 
  29. ↑ El-Rafie, Mervat M; Khafagy, Ghada M; Gamal, Marwa G (2016-02-24). "Effect of aerobic exercise during pregnancy on antenatal depression". International Journal of Women's Health 8: 53–57. doi:10.2147/IJWH.S94112. ISSN 1179-1411. PMID 26955293. 
  30. ↑ "Depression in Pregnancy& Antidepressant Medication Use". www.mhcs.health.nsw.gov.au/. Division of Mental Health St George Hospital and Community Health Services. http://www.mhcs.health.nsw.gov.au/publication_pdfs/7570/AHS-7570-ENG.pdf. 
  31. ↑ "Length of prenatal exposure to selective serotonin reuptake inhibitor (SSRI) antidepressants: effects on neonatal adaptation and psychomotor development". Psychopharmacology 217 (2): 211–9. September 2011. doi:10.1007/s00213-011-2270-z. PMID 21499702. 
  32. ↑ "Antenatal depression and anxiety affect postpartum parenting stress: a longitudinal, prospective study". Canadian Journal of Psychiatry 55 (4): 222–8. April 2010. doi:10.1177/070674371005500405. PMID 20416145. 
  33. ↑ "Postpartum depression prevalence and impact on infant health, weight, and sleep in low-income and ethnic minority women and infants". Maternal and Child Health Journal 16 (4): 887–93. May 2012. doi:10.1007/s10995-011-0812-y. PMID 21559774. 
  34. ↑ "Effects of perinatal mental disorders on the fetus and child". Lancet 384 (9956): 1800–19. November 2014. doi:10.1016/S0140-6736(14)61277-0. PMID 25455250. 
  35. ↑ "Maternal personality, parenting cognitions, and parenting practices". Developmental Psychology 47 (3): 658–75. May 2011. doi:10.1037/a0023181. PMID 21443335. 
  36. ↑ "Mother's depression linked to depression in offspring" (in en). 2018-10-03. https://www.nhs.uk/news/pregnancy-and-child/mothers-depression-linked-to-depression-in-offspring/. 
  37. ↑ Frazier, Tyralynn; Hogue, Carol J. Rowland; Bonney, Elizabeth A.; Yount, Kathryn M.; Pearce, Brad D. (2018-06-01). "Weathering the storm; a review of pre-pregnancy stress and risk of spontaneous abortion". Psychoneuroendocrinology 92: 142–154. doi:10.1016/j.psyneuen.2018.03.001. ISSN 0306-4530. PMID 29628283. 
  38. ↑ Johansen, Rie Laurine Rosenthal; Mortensen, Laust Hvas; Andersen, Anne-Marie Nybo; Hansen, Anne Vinkel; Strandberg‐Larsen, Katrine (2015). "Maternal Use of Selective Serotonin Reuptake Inhibitors and Risk of Miscarriage – Assessing Potential Biases". Paediatric and Perinatal Epidemiology 29 (1): 72–81. doi:10.1111/ppe.12160. ISSN 1365-3016. PMID 25382157. 
  39. ↑ 39.0 39.1 39.2 "Prenatal Maternal Depressive Symptoms Predict Early Infant Health Concerns". Maternal and Child Health Journal 22 (6): 786–793. June 2018. doi:10.1007/s10995-018-2448-7. PMID 29427015. 
  40. ↑ "Maternal depressive symptoms and infant health practices among low-income women". Pediatrics 113 (6): e523-9. June 2004. doi:10.1542/peds.113.6.e523. PMID 15173532. 
  41. ↑ "The Association between Positive Antenatal Depression Screening and Breastfeeding Initiation and Continuation". American Journal of Perinatology 38 (2): s–0039–1695775. September 2019. doi:10.1055/s-0039-1695775. PMID 31480085. 
  42. ↑ Fekadu Dadi, Abel; Miller, Emma R.; Mwanri, Lillian (2020-01-10). "Antenatal depression and its association with adverse birth outcomes in low and middle-income countries: A systematic review and meta-analysis". PLOS ONE 15 (1): e0227323. doi:10.1371/journal.pone.0227323. ISSN 1932-6203. PMID 31923245. Bibcode: 2020PLoSO..1527323F. 
  43. ↑ 43.0 43.1 "Comments on "Prenatal Depression and Infant Health: The Importance of Inadequately Measured, Unmeasured and Unknown Confounds"". Indian Journal of Psychological Medicine 40 (6): 592–594. 2018. doi:10.4103/IJPSYM.IJPSYM_306_18. PMID 30533965. 
  44. ↑ "What Is Postpartum Depression?". https://www.psychiatry.org/patients-families/postpartum-depression/what-is-postpartum-depression. 
  45. ↑ 45.0 45.1 "Antenatal depression and postnatal depression in men". https://raisingchildren.net.au/grown-ups/looking-after-yourself/depression-before-and-after-birth/antenatal-postnatal-depression-men. 
  46. ↑ Liu, C; Cnattingius, S; Bergström, M; Östberg, V; Hjern, A (November 2016). "Prenatal parental depression and preterm birth: a national cohort study". BJOG 123 (12): 1973–1982. doi:10.1111/1471-0528.13891. ISSN 1470-0328. PMID 26786413. 

Further reading




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