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This essay discusses depression in length and further on postnatal depression and depression after cancer, its implications and public health responses. Improper diagnosis and consequent prognosis on patients who otherwise are suffering from depression has been commonplace as people tend to ignore depression as a major health issue and should be viewed as an illness. This essay also extensively expounds on postnatal depression normally suffered by mothers after childbirth and depression in relation to cancer.

Depression, therefore, is a state whereby a person experiences low mood and an aversion to any activity be it physical or mental. Depressed people usually feel sad, anxious, helpless, hopeless, worthless, full- of-guilt, irritated and at times restless. This comes along with loss of interest in once pleasurable activities, poor concentration, contemplation of suicide and loss of appetite or the extreme opposite: overeating. Patients may also experience fatigue, aches and pains, insomnia and digestive problems.

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Depression can lead to various disorders classified either as Psychiatric syndromes or non-psychiatric. Psychiatric disorders are mainly due to moods. This include Major Depressive Disorder where a person experiences at least two weeks of depression, or loss of interest in all activities; chronic depressed mood condition normally referred to as Dysthymia; Bipolar disorder whereby the state of depression may not be major and Adjustment disorder where a person experiences depressed moods as a psychological response to a particular event or stressing factor, in which resultant emotional or behavioral symptoms are significant but not critical. On-psychiatric illnesses are a result of depressed moods bringing about physiological and infectious disorders such as mononucleosis, a viral disorder, and contributes as an early sign of hypothyroidism.

Depression was determined in U.S by Centre for disease control in 2010 under an analysis termed as Behavioral Risk Factor Surveillance System (BRFSS). The BRFSS carried its survey for 235067 adults and found 9.0% as currently depressed inclusive of 3.4% of major depression. Under a clinical context, depression results in production changes of neurotransmitters in the brain that aid in communication such as dopamine and norepinephrine. Levels of these substances, when varied, bring about hormonal changes, physical illnesses, aging, brain damage and changes in genetics.

A complete medical check-up and a thorough study of explicit symptoms helps determine the root-cause of depression. Standardized questionnaires for depression quantifier such as Beck Depression Inventory and Hamilton Rating Scale provide insights to the actual cause of a patient's depression state. Various tests are necessary to rule out other causes such as blood tests to measure levels of thyroxine to exclude hypothyroidism; ruling out metabolic disturbance by basic electrolytes and calcium tests; ESR and blood counts to rule systemic infection or chronic disease; hypogodanism is ruled out by testerone tests in men and finally side effects as a reaction to drugs previously administered or alcohol should also be done. Elderly people exhibit more cognitive complaints but this could be misread as depression but may rather be dementia which can only be distinguished by cognitive testing and brain scanning. Such as CT scans.

This essay also focuses on Postpartum or postnatal depression (PPD) is a state of illness under clinical depression which mainly affects women rather than men normally after childbirth. Research has indicated prevalence rates between 5% and 25% and lasts either for a few months or up to a year. Fathers experiencing paternity for the first time have been found to be between 1.2% and 25.5%.

Symptoms may vary from feeling sad, fatigued, loss or gain in appetite, reduced libido, crying at various times of day, anxiety, extensive or minimal sleep and irritability. In women, it is said to be caused by hormonal changes therefore necessitating support groups or counseling rather than hormonal treatment. Postpartum exhaustion is a subtype of postnatal depression caused by extreme fatigue and it normally lasts for a few days up to a maximum of 20 days. Another type of postnatal depression is baby or maternity blues which are normally mild and suffered by a large proportion of mothers. Symptoms include crying episodes, irritability, sleeplessness, hypochondrias, impaired concentration, headache and feelings of emptiness and loneliness.

There several major Symptoms of Postnatal Depression a include: Sadness, feelings of guilt, low self-esteem, changes in sleeping and eating patterns, fatigue, inability to feel comforted, anhedonia, emptiness, non-energetic, socially withdrawn, frustrations, anxiety and restlessness, decreased libido, easily angered and impaired writing skills and speech. Postpartum depression can be determined by Edinburgh Postnatal Depression Scale. A score greater than 13 indicates a high likelihood of development of this condition.

Various risk factors or causes have been identified and assigned a scale rating under the above method where a high value increases probability.

"Formula feeding rather than breast feeding  (2.04), A history of depression (1.87) (.38 to.39), Cigarette smoking (1.58), Low self esteem (.45 to. 47), Childcare stress (.45 to .46), Prenatal depression during pregnancy (.44 to .46), Prenatal anxiety (.41 to .45), Life stress (.38 to .40), Low social support (.36 to .41), Poor marital relationship (.38 to .39), Infant temperament problems (.33 to .34), Baby blues(.25 to .31), Single parent (.21 to .35) Low socioeconomic status (.19 to .22) Beck (2001), Unplanned/unwanted pregnancy (.14 to .17)"  (Beck, 2001)

Additive effects have been found to be: feeding formula, a history of depression and smoking and are directly correlated to PND such as high levels of prenatal depression are interlink with high levels of postnatal depression, hence implying low levels of prenatal depression consequently lead to low levels of postnatal depression. A third factor may come into play to interlink the two such as lack of social support. (O'Hara, 1985) ( Field et al., 1985) (Gotlib et al., 1991.) There is also a correlation between race, social class and sexual orientation with respect to postpartum depression.

In 2006, a study on "the extent to which ethnicity and ethnicity is a risk factor for PPD carried on 26,877 postpartum women  found  15.7% were depressed. 25.2% of PPD cases were African American, 22.9% were either American Indian or Native Alaskan, 15.5% of them were Whites, 15.3% Hispanic and 11.5% Asian or of Pacific Islander. Under a controlled environment such as age, income, education, marital status, and baby's health, African American women still emerged with significantly increased risk for...PPD". (Segre et al, 2006).  Likewise, a study conducted by Howell et al. in 2006 confirms Segre's findings that "women who are nonwhite and in lower socioeconomic categories have more symptoms of PPD."

Lack of support from father's will increase burden to mothers be it emotional or financial while "infant health problems will reduce the evolutionary benefits to be gained." (Hagen 2007). Mothers under postnatal depression may fail in raising their infants without resultant harm to other exiting kids or exhausting their nutritional stores consequently harming their own health. Inadequate social support may lead to the mother directing stressful and emotional conditions towards the child. Studies have shown high correlation between postpartum depression and insufficient social support and other childcare stress factors.

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Mothers with postpartum depression unconsciously display negative emotions and lesser positive ones towards their children and display irresponsive and insensitive behavior to cues expressed at infancy once the mothers are more emotionally withdrawn. (Fowles, 1996)  Hence, their maternal role is highly compromised hence their infants grow to be insecure. Extremities show women who failed to experience social support may harm their infants. (Hoffman and Drotar 1991) Therefore social support in order to ensure mothers overcome postnatal depression is vital in order to ensure infants are well brought up. (Jennings et al. 1999)

Postpartum depression may affect parent-infant relationship such that mothers may be inconsistent with child needs. This is usually evidenced by mothers focusing on the negativity of childcare hence poor coping strategy (Murray and Cooper 1996). Murray lists down four coping strategies and further insists on avoidance coping whereby it encompasses denial and behavioral disengagement of the mother such that "an avoidant mother might not respond to her baby crying" This however does not save the situation since the baby normally goes on crying.

The four coping strategies are: avoidance coping entailing denial and behavioral disconnection from child problem-focused coping such as actively coping, planning and positive reframing, Support seeking coping whereby a mother seeks emotional support and societal support and Venting coping: whereby a mother is highly regretful and blame oneself.

Mothers who resort to avoidance coping don't respond to their infants' requirements and consequently, the infant feels insecure. This may lead to infant stress and avoidance as proposed by Edhborg.  The baby tends not to interact with adults especially the mother. This is high concern especially in the first two to six months whereby interactive and cognitive skills are developed. Therefore, if a child is poorly handle by mother experiencing postnatal depression, possible onset of depression in the child may occur. Lack of interaction may lead to minimal or no parent-infant communication hence poor infant performance. Therefore, to establish a safe care giving environment, factors such as maternal history, current social supports, insight and acceptance of help should be considered by a professional and experienced help team that should be inclusive of mental health practitioners.

A study on mother-child attachment that looked at forty-five randomly selected mother-child pairs by Edhborg chosen under the Edinburgh Postnatal Depression Scale (EPDS) form used to measure postpartum depression in the society indicates 326 women filled the form, of 24 scored above twelve which is considered as potentially depressed and 21 women scoring less than nine, who were considered not depressed at all, were recruited. The 45 mother-child pairs were recorded on video at home for a session of five minutes at different times.  The mother and kid were put in a control represented by a standard set of toys. They were then allowed to play freely in a standard toy room. Finally, the mother left the room ordinarily just like in a home environment under pretence she was going to check on something then return.  Psychologists then recorded the score which was a representative of the degree of relationship between mother and child. The first two scenarios were represented on a five point scale ranging from one being the area of most concern to five being an area of strength. In the other scenario, the attachment behavior was classified into three categories based the child's reaction to the mother's return. These were: Secure and joyful attachment: whereby a child joyfully greets the mother with joy and feels comforted by the mother's presence; Secure attachment but restricted expression of joy and pleasure: the child acknowledges the mother's presence, but is less joyful than the case is normally is; and Insecure attachment: child shows signs of avoidance and resistance whereby the child would continuously pull away from the mother.

When the mother and child were subjected to the free play scenario, mothers with high EPDS scores kids had little interest in such pleasures as exploration and playing with their mothers and were rather socially withdrawn. Their mothers too showed minimal maternal emotions. A cluster analysis was therefore carried out by Edhborg, which showed at times there was no correlation between EPDS scores and some depressed kids. However, the research was able to establish that high EPDS scores in mothers could be directly linked to the insecure state of the child. It also showed that these mothers were "aware of their unavailability for the child in the early postpartum period and thus tried harder... to help their children succeed in the task" (Edhborg, 2001). This therefore proves that a lot of mother- child interaction could also hinder mother-to-child communication hence insecurity. Child attachment issues, due to exposure to their mother's depressed state in infancy, led to impairment of cognitive and emotional developments. The lack thereof of attachment can lead to poor social interaction and long-term poor personal esteem and independence. Honey states that these kids could be highly diagnosed with depression at later life stages.

John Bowlby's attachment theory expounds on how "infants learn about their environment while keeping their caregiver close." Bowlby bases his theories on principles of  heredity, variety and natural selection. Kids need space in order to learn about their outside environment while keeping a balance with their parents' ties. Bowlby concentrates on instinct and humane nature displayed by children unlike Locke who believes that "a newborn has no instinct to direct him or her." (Murray, 1992)

Postpartum depression should therefore be identified early enough to ensure proper intervention and at times pre-emptive techniques to ensure a lasting solution for a long-term prognosis. Women need to be properly informed about the social risk factors, time-to-time screening of mothers by physician in order to identify any postpartum depression early signs such as the universal PPD in Alberta, Canada. Finally, regular exercising and proper nutrition shall go a long way in keeping depression at bay. Pregnant, nursing and postpartum women should seek the medical advice of their dietitian, obstetrician and physician regarding nutrition and balanced diet.

The essentials are:Omega-3 fatty acids: Some professionals infer that postpartum depression is caused by minimal omega-3 fatty acids in the mother's brain to support fetus brain development or breast-feed an infant hence a high intake during pregnancy should be ensured such as intake of edible linseed oil, fish, eggs from flax-fed chicken and meat from grass-fed cattle or purchased in capsule supplements. Proteins are contained in meat whereby 3 ounces contain 25 grams of proteins, eggs contain 19grams for every 3 and Swiss cheese whereby 3 ounces contain 15 grams.  Mothers should also take in large volumes of water to ensure hydration. It is recommended that ten eight ounce glasses should be consumed daily during pregnancy, nursing and breastfeeding. Caffeine and alcohol consumption should be regulated by a physician. Prenatal and postnatal vitamin consumption supplement should also be prescribed. Riboflavin, commonly referred to as Vitamin B is water-soluble hence should be replenished daily. Loss of appetite or any eating disorder should be addressed since this may be a sign of onset of postpartum depression. If postpartum depression is identified under social risk factors, cognitive therapy and additional childcare support should be addressed.

Postpartum treatment can be carried out through psychotherapy, and in particular cognitive behavioral therapy, probable medication, support groups, home by home visits, healthy intakes in dieting and consistent resting and sleeping patterns. Medical tests to rule out any physiological problems should be carried out.

Physicians should work closely with the mother to come up with a treatment that suits her. If a postpartum mother feels that her needs are not being aptly addressed, she will seek a second opinion. A 1997 study carried out by Appleby et al., confirms that postpartum depression in mothers is alleviated at similar rates as applying it with cognitive behavioral therapy or treatment with fluoxetine antidepressant.

"A group of 61 depressed mothers completed a 12-week treatment program with or without the antidepressant plus one session versus six sessions of counseling." Improvement was noted after "one to four weeks of either treatment."(Ross et al, 1997)

The findings go a step further to demonstrate that combining counseling with drug therapy was not at all beneficial but rather one technique could be applied to effectively and successfully solve postpartum depression.

Therefore, "the choice of treatment [psychotherapy vs. medication] may...be made by the women themselves". Other ways such as group therapy and home visitations are also effective in treating PPD. Postnatal measures, such as during breastfeeding, can only be implemented after extensive talks and agreement with the mother.Treating PPD reduces the period of suffering and its associated severity. Untreated, the Baby Blues may end by itself but would take a longer period. When symptoms occur, prompt reporting to the physician is necessary to ensure swift treatment.

Research shows that the childbearing years are the most probable times postpartum depression can occur based on The National Institute of Mental Health findings. Approximately 15% of the world's women experience this kind of depression after child-bearing. (Chasse, J). When the mother's mental health is at risk, so is the entire family's.

In the section, depression resultant from a patient's knowledge that he may be carrying a life-threatening disease and its implications such as cancer may be overwhelming. Depression affects 15% to 25% of cancer patients and affects both men and women living with cancer equally. A cancer diagnosis brings about stress and emotional depression. Issues that are of high concern to the patient are fear of death, self-esteem and body image, interrupted life plans, changes in the person's lifestyle and financial security. Reaction to these concerns determines the individual's level of anxiety.

After treatment, a patient may have the following symptom: anger, tense and anxious or very sad. One must learn to live with his or her condition to ease depression otherwise the case may b very severe. This leads to depression that would potentially impair the brain. Therefore, a cancer patient needs to see a therapist or the patient's personal doctor for lessons on stress management in order to avoid depression.

On completing active treatment, a patient may feel either relieved or worried. According to Lina Chase, Social Worker for the Survivorship Clinic, survivors are mainly worried about recurrence. Talking to a counselor often validates a patients thoughts an eases stress or anxiety. Some people are more likely to feel depressed more than others. These are people who have been under severe depression before, introverts such that they are not ready to share and those under drugs that cause depression.

Signs exhibited by patients after treatment are classified into emotional signs or bodily changes. Emotional signs include but not limited to: Feeling of worried, anxious, or sad which don't go away, emotional numbness, overwhelmed, shaky and not in control, continuous guilt feeling and a sense of unworthy, helpless or hopeless feeling, short-tempered, easily angered and moody, poor concentration, crying episodes throughout the day, continuously worrying about a patient's particular problem, loss of interest in everyday's pleasures, avoiding any situations that are harmless yet the patient feels they are risky and thoughts of personal pain inflictment or suicide. Body changes symptoms are weight loss or gain due to medication, lack of sleep and may include hallucinations and nightmares, high adrenaline such that the patient experiences a racing heart, dry mouth, high perspiration, stomach upsets and may include diarrhea, fatigue, headaches and myalgia.

Most cancer patients feel hopeless and that life is not worth living. This is due to the understanding of their condition as terminal and that they feel that they are a financial burden and an emotional wreck and their families may be better off without them which is not always the case. These thoughts may culminate into suicidal thoughts whereby the patient feels that he or she can escape from the pressure. When this bottom low is experienced, patients should talk to their doctor though this should be pre-emptied by family and social support groups. 24- Hour calling groups are also available which one can call before contemplating death. Symptoms of continuous advancement to this stage are: suicidal plans, feelings and thoughts, hallucinations, delusions and self-harm. This is treated by talking therapies at hospital followed by home visits. The psychiatrist may also recommend drug treatment.

Some cancer patients are put under antidepressant therapy in order to lift their moods. They normally work after three to four weeks since they continuously build slowly. There are various drugs in the market that work well with different people. To avoid recurrence, doctors recommend that patients take antidepressants for at least three months after which dosage is slowly reduced. However, antidepressants have side effects such as drowsiness, dry mouth, nausea, reduced sexual drive, sleeplessness and headaches. Therefore, the choice of an appropriate antidepressant is based on benefits versus effects analysis.

Herbal treatment has been shown to be effective by research carried out and mat actually cause minimal side-effects in comparison to chemical off-the-shelf antidepressants. St John's Wort is such a herbal treatment that is usually taken on its own rather than in combination with other drugs. However, a doctor must be consulted before medication begins since it alters how various drugs such as those used in chemotherapy and hormonal treatment work like tamoxifen. This herbal treatment also contains hypericin which reacts to sunlight; hence proper measures should be taken when under direct sunlight to avoid sun burns. Critical cancer cases should be aptly referred to a psychiatrist who then establishes the root-cause of the depression and carries out a diagnosis and consequent prognosis. A visit to a counselor may also be of great help to the patient.

Therefore, a patient should seek emotional support from nurses and doctors or the entire health team in order to curb loneliness, joining online support groups, family, talking to friends, other survivors and the clergy and joining a cancer support group where they hold round-table discussions on experiences and share feelings and concern. Close friends and family should ensure a depressed person continues with medication even after improvement and keep reassuring the affected party.