Some of us or someone close to us might have experienced a depressive episode at some point after pregnancy and at various degrees, but could not at the time give a name to the symptoms being experienced, because oftentimes the episodes are not usually made reference to as an illness.

Postpartum depression, also known as postnatal depression (PPD) refers to a major depressive episode that occurs after birth characterized by a prolonged period of emotional disturbance. This occurs in about 20% of child-bearing women.

PPD tend to have a negative impact on the cognitive and psychological development of infants born to mothers with PPD. The duration and onset of PPD can be as early as 4 weeks after child-birth and can last several months, especially in women who have had the symptoms in previous pregnancies.

What are the symptoms of Postpartum Depression?

Despite its high prevalence, PPD frequently goes unrecognized or unreported due to the similarity between the vegetative symptoms of depression and the physical symptoms commonly experienced by women in late pregnancy and/or after birth, such as fatigue, insomnia, loss of appetite and low libido.

The common symptoms to look out for are:

1. Loss of interest in life and usual daily activities
2. Inability to function in everyday activities
3. Feelings of irritability, anxiety, fear, self-blame guilt
4. Increased crying spells, sleep disturbance
5. Withdrawing from family and friends

It is important to note that these symptoms can be on and off for a long duration of time.

What causes Postpartum Depression?

The causes of postpartum depression are not clearly defined. However, here are some known contributing factors:

1. Genetic vulnerabilities: A family or personal history of depression or previous experience of depression and anxiety.
2. Hormonal changes: Fluctuation and/or fall in reproductive hormone levels.
3. Psychological stressors: Stressful events (e.g. death of a loved one), marital dysfunction, child care stressors as well as the unreasonableness between the expectations and reality of motherhood.
4. Insufficient social support
5. Nutritional deficits/Poor diet
6. Changes in sleep and circadian rhythm and low physical activity
7. Exposure to toxins: Air pollution, crowding
8. Low socioeconomic status
   

You may be familiar with the use of omega-3 fatty acids for the prevention of heart disease and for cholesterol control, however, over the past decade, there have been several studies investigating the benefits of Omega-3 fatty acids for the prevention and treatment of postpartum depression either used alone  or in combination with antidepressants.

What are Omega-3 Fatty Acids?

Omega-3 fatty acids are polyunsaturated fatty acids (PUFA) derived mainly from food sources like eggs, beans, vegetables, fish (especially oily fish like Mackerel, Sardines, Tuna, Salmon) and nuts (Peanuts, Cashews, Walnuts, Almonds).

Examples of Omega-3 fatty acids include Eicosapentaenoic acid (EPA), Docosahexaenoic acid (DHA) and Alpha-linolenic acid (ALA), these can be found as the active ingredients in most over-the-counter Fish oil.

Studies have shown that PUFAs are necessary for normal neurologic and structural development of the fetus. They are the integral building block of the CNS in infants.

Benefits of Omega-3 Fatty acids in the prevention of PPD?

Omega-3 faty acid is transferred from the mother to the fetus during pregnancy and breastfeeding, leading to the decrease of the maternal omega-3 fatty acid levels during pregnancy which can remain low at least 6 weeks after child birth.

There is a link between pregnancy, omega-3, and the chemical reaction that helps serotonin (a mood regulator) to be released into our brains. Evidently, high intake of Omega-3 fatty acid is associated with increased gray matter volume in the brain region controlling mood and depression.

The omega-3 fatty acid subcommittee of the American Psychiatry Association (APA) supports the American Heart Association (AHA) guidelines regarding fish consumption and further recommends that patients with mood, impulse control or psychotic disorders consume more than 1g/day of combined EPA and DHA; this is because there are indications that psychiatric illness and cardiovascular disease may be comorbid.

According to a study by Su et al, a dose of 4 g /day was most effective in improving depressive symptoms during pregnancy. Some prenatal vitamins contain just 0.6g/dosage form, so 6 tablets of an over-the-counter product may be needed to achieve the benefits the study observed. However, most popular fish oil supplements like cod liver oil, contain up to 1.0- 2.0 g of EPA/DHA per dosage form, so only 3 capsules /day may be needed.

Some common side effects include loose stool, nausea (mostly because of the fish smell and diarrhea (mainly due to high dosage). These side effects can be minimized by taking small doses with every meal instead of one high dose on an empty stomach.

So, Should I take Fish Oil?

Women already taking antidepressants should not discontinue treatment/therapy in place of omega-3 fatty acids supplements. However, omega-3 fatty acids may be used in combination with antidepressants, if approved by your treating health care provider.

My recommendations are:

1. Omega-3 acids should become part of pre-natal and post-natal vitamin supplementation in all women, whether predisposed to depression or not. This is because there is evidence that tissue level fatty acid tend to diminish during pregnancy due to demand by the fetus.
2. It is recommended that patients start at 1g of EPA and/or DHA per day, especially for people who consume fish frequently   and have a high tissue level of omega-3 fatty acids, however for people who do not eat fish regularly, an initial dose of 2 to 4g daily may be required. It is a challenge to get enough omega-3 FAs from food only.
3. Take time to read the labels of the over-the-counter fish oil supplements. The main active ingredients needed are DHA, EPA and ALA. Some brands contain as high as 92% omega-3, while others contain as low as 30 %.
4. Do not take fish oil supplementation if you are on blood thinners (like warfarin or high-dose aspirin) or any other medication without consulting your doctor. This is because omega-3 fatty acids can temporarily prevent blood clot.

In general, omega-3 fatty acids may be considered an option for the prevention of PPD, based on the possibility of their antidepressant effects and as well as other health benefits in pregnancy. It is still premature to use omega-3 fatty acids alone for the treatment of depression, since studies are not conclusive on its use as monotherapy.