User:Mlshulk/sandbox

 To do [week of 10/14/19]: 

[x] move article to postpartum depression

- find relevant images

[x] epidemiology

[x] add info about cross-cultural prevalence

[x] causes

- add info about predominance of positive symptoms in blues

[x] add info about specific scales being used for blues in research (e.g. MBS)

[x] differential

- rewrite differential section for readability and add content

[x] prevention

- add info about global screening recs

[x] outcomes

- add info about link between blues and PPD

- history/culture

- add info about cultural practices that may affect blues/PPD

[x] postpartum blues in men

- add references to infobox - not necessary if cited in main article. use citations if main article is incomplete

[x] reassessment on wiki project womens health - posted on discussion page

[x] assessment on wikiproject medicine - posted request

- look into thought leaders on this topic around the country, questions about the article

[x] citation re-formatting throughout article after periods

= Postpartum Blues Sandbox 10/12/19 = Postpartum blues, also known as baby blues and maternity blues, is a very common but self-limited condition that begins shortly after childbirth and can present with a variety of symptoms such as mood swings, irritability, and tearfulness.

While postpartum blues is often thought of as a benign condition, its association with postpartum depression underscores the importance of further research to better understand its etiology.

The early postpartum period may represent a critical opportunity to identify and evaluate

may have therapeutic implications

Postpartum blues appears to delineate from a non-specific affective response to a major stress. 'ohara

Epidemiology
Postpartum blues is a very common condition, affecting up to 80% of new mothers. Estimates of prevalence vary greatly, from 26-84%, depending on the criteria used. Precise rates are difficult to obtain given lack of standardized diagnostic criteria and inconsistency of symptom reporting. Retrospective reporting of postpartum blues symptoms has methodological limitations.

Evidence demonstrates that postpartum blues exists across a variety of countries and cultures, however there is considerable heterogeneity in reported prevalence rates. For instance, reports of prevalence of postpartum blues in the literature vary from 15% in Japan to 60% in Iran. Underreporting of symptoms based on cultural norms and expectations may be one explanation for this heterogeneity.

Speculation depends on what you believe the mechanism to be - entirely physiological, or related to PPD. On PPD, data is mixed whether prevalence varies across cultures (global maternal health paper - yes, WHO paper - no).

Signs and Symptoms
Symptoms of postpartum blues can vary significantly from one individual to another, and from one pregnancy to the next. Many of the symptoms of postpartum blues overlap both with normal symptoms experienced by new parents and with postpartum depression. Individuals with postpartum blues have symptoms that are milder and less disruptive to their daily functioning compared to those with postpartum depression. Symptoms of postpartum blues include, but are not limited to :


 * Tearfulness or crying "for no reason"
 * Mood swings
 * Irritability
 * Anxiety
 * Feeling overwhelmed
 * Questioning one's ability to care for the baby
 * Difficulty making choices
 * Loss of appetite
 * Fatigue
 * Difficulty sleeping
 * Difficulty concentrating
 * Negative mood symptoms interspersed with positive symptoms

The term blues is a misnomer, since the predominant mood of most women with this condition is happiness.

Onset
Symptoms of postpartum blues generally begin within a few days of childbirth.

Duration
Postpartum blues may last a few days up to two weeks. If symptoms last more than two weeks, the individual must be evaluated for postpartum depression.

Causes
The causes of postpartum blues are not fully understood. Most hypotheses regarding the etiology of postpartum blues and postpartum depression center on the intersection of the significant biological and psychosocial changes that occur with childbirth.

Biological causes
After delivery of the placenta, mothers experience an abrupt decline of gonadal hormones, namely estrogen and progesterone. Major hormonal changes in the early postpartum period may trigger mood symptoms similarly to how more minor hormonal shifts cause mood swings prior to menstrual periods.

However, studies have not detected a consistent association between hormone concentrations and development of postpartum mood disorders. Some investigators believe the discrepant results may be due to variations in sensitivity to hormonal shifts across different subgroups of women. Therefore, development of mood symptoms may be related to a woman's sensitivity, based on genetic predisposition and psychosocial stressors, to changes in hormones rather than absolute hormonal levels. There is direct evidence supporting this mechanism in women with a history of postpartum depression in a double-blind trial conducted by Bloch and colleagues. This trial simulated the abrupt hormonal withdrawal following delivery in sixteen non-pregnant euthymic women. Five of the eight women with a history of postpartum depression developed mood symptoms compared to zero of the eight without prior history.

The association between postpartum blues and a variety of other biological factors, including cortisol and the HPA axis, tryptophan, prolactin, thyroid hormone, and others have been assessed over the years with inconclusive results. Emerging research has suggested a potential association between the gut microbiome and perinatal mood and anxiety disorders.

Notes:

The emotional reactivity mediated by oxytocin which may promote the parent-child attachment soon after birth may also increase vulnerability for development of postpartum mood disorders.

Psychosocial causes
Pregnancy and postpartum are significant life events that increase a woman's vulnerability for postpartum blues. Even with a planned pregnancy, it is normal to have feelings of doubt or regret, and it takes time to adjust to having a newborn. Feelings commonly reported by new parents and lifestyle changes that may contribute to developing early postpartum mood symptoms include :


 * Fatigue after labor and delivery
 * Caring for a newborn that requires 24/7 attention
 * Sleep deprivation
 * Lack of support from family and friends
 * Marital or relationship strain
 * Changes in home and work routines
 * Financial stress
 * Unrealistic expectations of self
 * Societal or cultural pressure to "bounce back" quickly after pregnancy and childbirth
 * Overwhelmed and questioning ability to care for baby
 * Anger, loss, or guilt, especially for parents of premature or sick infants

Risk factors
Most risk factors studied have not clearly and consistently demonstrated an association with postpartum blues. These include sociodemographic factors, such as age and marital status, obstetric factors, such as delivery complications or low birth weight.

Factors most consistently shown to be predictive of postpartum blues are personal and family history of depression. This is of particular interest given of the bidirectional relationship between postpartum blues and postpartum depression: a history of postpartum depression appears to be a risk factor for developing postpartum blues, and postpartum blues confers a higher risk of developing subsequent postpartum depression.

Poor family and/or marital relations, higher levels of neuroticism

This is in contrast to postpartum depression, in which a variety of risk factors have been established.

Criteria
There are no standardized criteria for the diagnosis of postpartum blues. Unlike postpartum depression, postpartum blues is not a diagnosis included in the Diagnostic and Statistical Manual of Mental Disorders.

Investigators have employed a variety of diagnostic tools in prospective and retrospective studies of postpartum blues, including repurposing screening tools, such as the Edinburgh Postnatal Depression Scale (EPDS) and Beck Depression Index (BDI), as well as developing blues-specific scales. Examples of blues-specific scales include the Maternity Blues Questionnaire and the Stein Scale.

Differential diagnosis
Although symptoms of postpartum blues present in a majority of mothers and the condition is self-limited, it is important to keep related psychiatric conditions in mind as they all have overlap in presentation and similar period of onset.

Postpartum anxiety: Symptoms of anxiety and irritability are often predominant in the presentation of postpartum blues. However, compared to postpartum anxiety, postpartum blues are less severe, resolve on their own, and last fewer than two weeks.

Postpartum depression: Compared to postpartum depression, symptoms of postpartum blues are less severe, resolve on their own, and last fewer than two weeks.

Postpartum psychosis: Although both conditions can cause periods of high and low moods, the mood swings in postpartum psychosis are significantly more severe and may include mania, hallucinations, and delusions. Postpartum psychosis is a rare condition, affecting 1-2 per 1000 women. Postpartum psychosis is classified as a psychiatric emergency and requires hospital admission.

Additionally, a variety of medical co-morbidities can mimic or worsen psychiatric symptoms.

Given the predominance of irritability and anxiety in postpartum blues, this condition often mirrors postpartum anxiety more closely than postpartum depression, given.

Screening
There are no specific screening recommendations for postpartum blues. Nonetheless, a variety of professional organizations recommend routine screening for depression and anxiety and assessment of emotional well-being during pregnancy and/or the postpartum period. Specific recommendations are listed below:


 * American College of Obstetrics and Gynecology (ACOG): In 2018, ACOG recommended that all patients be screened for depression and anxiety using a validated tool at least once during pregnancy or postpartum, in addition to a full assessment of mood and well-being at the postpartum visit. This is in addition to existing recommendations for annual depression screening in all women
 * American Academy of Pediatrics (AAP): In 2017, the AAP recommended universal screening of mothers for postpartum depression at the 1-, 2-, 4-, and 6-month well child visits
 * United States Preventative Services Task Force (USPSTF): In 2016, the USPSTF recommended depression screening in the general adult population, including pregnant and postpartum women. Their recommendations did not include guidelines for frequency of screening

Prevention
Given the mixed evidence regarding causes of postpartum blues, it is unclear whether prevention strategies would be effective in decreasing the risk of developing this condition. However, educating women during pregnancy about postpartum blues may help to prepare them for these symptoms that are often unexpected and concerning in the setting of excitement and anticipation of a new baby. It is important to reassure the new mother, who may have feelings of guilt, that low mood symptoms after childbirth are common and transient. Obstetric providers may also recommend that patients and their families prepare ahead of time to ensure the mother will have adequate support and rest after the delivery.

Treatment
Postpartum blues is a self-limited condition. Signs and symptoms are expected to resolve within two weeks of onset without any specific treatment. Nevertheless, there are a number of recommendations to help relieve symptoms, including :


 * Getting enough sleep
 * Taking time to relax and do activities that you enjoy
 * Asking for help from family and friends
 * Reaching out to other new parents
 * Avoiding alcohol and other drugs that may worsen mood symptoms
 * Reassurance that symptoms are very common and will resolve on their own

If symptoms do not resolve within two weeks or if they interfere with functioning, individuals are encouraged to contact their healthcare provider. Early diagnosis and treatment of more severe postpartum psychiatric conditions, such as postpartum depression, postpartum anxiety, and postpartum psychosis, are critical for improved outcomes in both the parent and child.

Outcomes
Most mothers who develop postpartum blues experience complete resolution of symptoms by two weeks. However, a number of prospective studies have identified more severe postpartum blues as an independent risk factor for developing subsequent postpartum depression.

There is disagreement regarding the association between postpartum blues and postpartum depression.

Postpartum blues in men
Literature is lacking on whether new fathers also experience postpartum blues. However, given similar causes of postpartum blues and postpartum depression in women, it may be relevant to examine rates of postpartum depression in men. A 2010 meta-analysis published in JAMA with over 28,000 participants across various countries showed that prenatal and postpartum depression affects about 10% of men. This analysis was updated by an independent research team in 2016, who found the prevalence to be 8.4% in over 40,000 participants. Both were significantly higher than previously reported rates of 3-4% from two large cohort studies in the United Kingdom, which may reflect heterogeneity across countries. Both meta-analyses found higher rates in the United States (12.8-14.1%) compared to studies conducted internationally (7.1-8.2%). Furthermore, there was a moderate positive correlation between paternal and maternal depression (r = 0.308; 95% CI, 0.228-0.384).

While postpartum blues are more commonly associated with new mothers, research shows that fathers may also be at risk for this condition.

has typically been perceived as a problem limited to women

paternal prenatal and postpartum depression has received little attention from researchers and clinicians

History
early discoveries, historical figures, outdated treatments

Society and Culture
social perceptions, stigma, economics, religious aspects, awareness, legal issues, notable cases