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Post-natal depression

Introduction

Having a baby is a life-changing experience. Pregnancy and the first year after the birth are periods that many parents find quite stressful. The birth of a baby is an emotional experience and, for many new mothers, feeling tearful and depressed is also common. However, sometimes longer periods of depression, known as postnatal depression (PND), can occur during the first few weeks and months of the baby's life.

PND can have a variety of physical and emotional symptoms, and many women are unaware that they have the condition. It's therefore important for partners, family, friends and healthcare professionals to recognise the signs of PND as early as possible so that the appropriate treatment can be given. Following childbirth there are three different types of depression, which are outlined below.

Baby blues

Baby blues is a common cause of feeling low, and it is the least severe type of PND. It does not usually last very long, starting from around the third day after birth and until around the 10th day. During this time you may feel tearful and irritable, but no medical treatment is needed.

Postnatal depression (PND)

Postnatal depression (PND) affects about one in 10 mothers in the UK, and usually develops in the first four to six weeks after childbirth. However, in some cases it may take several months to develop. If you feel depressed for most of the time, and the feelings do not go away, you may have PND. Your GP will be able to determine whether you have the condition and, if you do, suggest an appropriate course of treatment.

Postnatal psychosis

Postnatal psychosis is a rare but severe, form of depression. It develops in about one in 1000 mothers. Symptoms can include irrational behaviour, confusion and suicidal thoughts. Women with postnatal psychosis often need specialist psychiatric treatment

Although postnatal depression is more common in women, men can be affected too. As the birth of a new baby can be a stressful time for both parents, some fathers feel unable to cope, or feel that they're not giving their parent all the support she needs. They can also find it difficult to adjust to the big changes and the demands made by a new baby.

Postnatal depression can put strain on a relationship. This can cause the break up of some relationships, which is why it's  important to recognise the symptoms of PND at an early stage and take steps to get treatment.

Myths surrounding PND

PND is often misunderstood and many myths surround the condition. These include:

  • That PND is less severe than other types of depression. In fact, PND is as serious as other types of depression.
  • That PND is entirely caused by hormonal changes. PND is actually caused by many different factors.
  • That PND will go away by itself. Unlike the baby blues, PND can only be resolved with treatment.

PND can be lonely, distressing and frightening, but you should be reassured that it's always treatable. It's very important to understand that having PND doesn't mean that you don't love or care for your baby.

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Symptoms

Postnatal depression can affect different women in different ways. The symptoms can begin soon after the birth and last for months (or in severe cases, for over a year).

The symptoms of PND usually include one or more of the following:

  • low mood for prolonged periods of time (a week or more),
  • feeling irritable for a lot of the time,
  • tearfulness,
  • lack of interest in yourself and your new baby, 
  • lack of motivation,
  • panic attacks or feeling trapped in your life,
  • difficulty concentrating,
  • feeling lonely,
  • feeling guilty, rejected, or inadequate,
  • feeling overwhelmed,
  • feeling unable to cope,
  • difficulty sleeping, and
  • physical signs of tension, such as headaches, stomach pains or blurred vision.

You may also feel constantly tired, have a lack of appetite, and a reduced sex drive. However, these symptoms normally affect most people for a while after childbirth and, on their own, may not mean that you are depressed.

PND can interfere with your day-to-day life. Some women feel unable to look after their baby, and others feel too anxious to leave the house or to keep in touch with friends. Many mothers do not recognise that they have PND, and do not talk to family and friends about how they are really feeling. So, it is important for partners, family members, and friends to recognise the signs of PND at an early stage, and to seek professional health advice as soon as possible.

Some women who have PND get thoughts about harming their baby. This is quite common, affecting about half of all women with the condition. You may also have thoughts about harming, or killing, yourself. Thoughts like these do not mean that you are a bad or unfit mother, and it is very rare for either mother or baby to be harmed. However, it is vital that you see your GP if you have these or any other symptoms of PND. Treatment will benefit both your health and the healthy development of your baby, as well as your relationship with your partner, family and friends.

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Causes

The cause of postnatal depression (PND) is not completely clear. The condition can affect any mother (or father). PND does not usually have a single cause, but is the result of a combination of factors. Depression is often caused by emotional and stressful events, such as moving house, the break up of a relationship, the death of a relative or having a baby.

In terms of PND, stressful events around the birth can increase your risk of getting the condition. This may include factors such as:

  • a difficult delivery,
  • lack of support at home,
  • money problems,
  • relationship worries,
  • having no close family or friends around you,
  • depression during the pregnancy,
  • worry and anxiety about the responsibiltiy of having a new baby,
  • mental health problems in the past, such as depression or previous postnatal depression, and
  • physical health problems following the birth, such as anaemia or urinary incontinence.

Aside from other factors, having a baby is a life-changing event in itself. It can often be extremely exhausting and a very stressful experience.

Genetics and hormones

As depression tends to run in families, genetics are thought to play a part in the PND, but the exact nature of the link between the condition and genetics is not fully understood. The huge changes in hormone levels that occur during and after pregnancy were once thought to cause PND. However, there is no evidence to suggest that this is the case. It is much more likely that the condition is related to the combination of life changes that occur after childbirth.

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Diagnosis

Your GP should be able to diagnose postnatal depression (PND) by asking you two questions:

  • "During the past month, have you often been bothered by feeling down, depressed or hopeless?", and
  • "During the past month, have you often been bothered by taking little or no pleasure in doing things that normally make you happy?"

If the answer to both of these questions is yes, then it is likely you have PND.

Some mothers, especially mothers who do not have a close support network of a partner or relatives to help with the care of their baby, are often reluctant to provide honest answers to these questions.

This is because some worry that a diagnosis of PND will mean they are seen as a bad mother and that there is a chance that their baby will be taken into care.

It should be stressed that this will only happen in the most exceptional of circumstances, as one of the prime goals of treatment of PND is to help you care for and bond with your baby. Even if the symptoms of your PND are so severe that you require treatment at a mental health clinic, specialist 'Mother and Baby' clinics are available.

Sometimes, your GP may do a blood test to make sure that there is not a physical reason for your symptoms, such as an underactive thyroid gland or anaemia. These conditions often occur after having a baby.

Types of depression

If your GP suspects that you have PND, they will want to know about associated symptoms, which will allow them to assess the severity of your PND and decide on the best course of treatment.

They will wish to know if you have:

  • been having disturbed sleep,
  • had problems concentrating or making decisions,
  • low self-confidence,
  • a loss of appetite or alternatively an increased appetite (comfort eating is often a symptom of depression),
  • been feeling anxious,
  • been feeling tired, listless and reluctant to undertake any physical activity,
  • been feeling guilty or self-critical, and
  • been experiencing suicidal thoughts.

If you have three of the above symptoms it is likely you have mild depression. People with mild depression are generally able to carry out normal activities.

If you have five or six of the above symptoms it is likely you have moderate depression. People with moderate depression will have great difficulties carrying out normal activities.

If you have all of the above symptoms it is likely you have severe depression. People with severe depression are unable to function at all, and need help from a dedicated mental health team.

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Treatment

If you think that you have postnatal depression (PND), you should see your GP, midwife or health visitor as soon as possible so that a diagnosis can be made, and an appropriate course of treatment undertaken. If you do have PND, it is important for you and your family to remember that it can sometimes take a long time to fully recover from the condition.

Common treatment methods for PND are detailed below.

Support

The most important step in treating PND is recognising the problem and then taking steps to deal with it. The support and understanding of your partner, family and friends can play a big part in your recovery. However, to benefit from this, it is important for you to talk to those who are close to you and explain how you feel, rather than keepin everything pent-up inside. This can cause tension, particularly with your partner, who may feel that they are being shut out.

The support and advice from social workers, or counsellors, can also be very helpful if you have PND. Ask your health visitor about what are available in your area. Self-help groups can also provide you with good advice about how to cope with the effects of PND, and you may find it reassuring to meet other women who feel the same as you.

Medication

Medication is sometimes used to treat PND. Antidepressants are often prescribed to treat moderate or severe cases. They work by balancing the mood-altering chemicals in your brain. Antidepressants can help ease symptoms such as low mood, irritability, lack of concentration and sleeplessness, allowing you to function normally and giving you the ability to cope better with your new baby.

A course of antidepressant medicines usually lasts for four to six months. However, if your symptoms improve, the dose may be steadily reduced by your doctor. Antidepressants take two to four weeks to start working, so it is important to keep taking them even if you do not notice an improvement straight away. It is also important to continue taking your medicine for the full length of time recommended by your doctor because if you stop taking it too early, your depression may return.

You should talk to your GP about the type of medicine that is most suitable for you, and any possible side effects that may be caused. If you do experience any side effects from the medicine that you are prescribed, you should tell your GP so that they can alter your dose or change your medicine.

In severe cases of PND, such as postnatal psychosis, where symptoms can include irrational behaviour, hallucinations and suicidal thoughts, tranquillisers may be prescribed as a possible treatment option. However, they are usually only recommended for short-term use.

Between 50% and 70% of women who have moderate to severe PND improve within a few weeks of starting treatment with antidepressants. However, they are not an effective method for everyone.

Antidepressants and breastfeeding

Not enough is known about the possible long-term risks to babies of antidepressants taken by breastfeeding mothers. This is because the normal method of assessing these risks - that is, running large scale clinical trials involving people who have given their consent - would be unethical for children.

We know that antidepressants can pass into breast milk. Therefore, women who are taking antidepressants may wish to discuss feeding options with their GP so that they can make an informed choice.

Many mothers are keen to continue breastfeeding because they feel that it helps them to bond with their child, and boosts their self-esteem and confidence in their maternal abilities. These are important factors in combating the symptoms of PND.

Your GP will be able to provide advice about the benefits and risks of the different feeding methods, but the final decision will be yours to make.

The limited evidence available suggests that the class of antidepressant known as tricyclic antidepressants (TCA) are probably the safest to take while breastfeeding.

TCAs are not suitable for some people, including:

  • people with a history of heart disease,
  • people with epilepsy, and
  • people with severe depression who have frequent suicidal thoughts (this is because an overdose of TCAs can be fatal).

In these circumstances, another type of antidepressant may be prescribed known as a selective serotonin reuptake inhibitor (SSRI). The preferred SSRIs are paroxetine or sertraline because tests have shown that the amounts of these medicines that is found in breast milk is so small that it is unlikely to be harmful.

Counselling

Counselling, or talking treatments, can be useful in treating PND. If your GP feels it may help you, you will be referred to a psychologist or other mental health specialist. There are various different types of counselling, but their availability on the NHS may vary depending where you live. Types of counselling are discussed below.

Cognitive therapy

Cognitive therapy is based on the idea that certain thoughts can 'trigger' mental health problems, such as depression. The therapist will help you to understand how your thoughts can be unhelpful or harmful to your state of mind. Sessions are usually conducted on a weekly basis over several months, and the aim is to help you to change your thought patterns in a way that is more helpful and positive.

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) combines cognitive therapy and behaviour therapy. Behaviour therapy is about changing any behaviour that is harmful or unhelpful. The aim of CBT is to help you change the way that you think, feel and behave for the better.

Other talking therapies

Other talking therapies include interpersonal therapy and problem solving therapy. Also, trained health visitors sometimes give short counselling sessions over several weeks, and these have been shown to help ease PND.

For those who have moderate PND, talking treatments such as cognitive therapy and CBT have about the same success rate as antidepressants (50-70%). However, talking treatments may not be as effective for people with severe depression because they require a certain level of motivation, and those with severe depression often find it difficult to motivate themselves.

Some research has suggested that a combination of antidepressants and counselling is better than either treatment alone.

Treating severe PND

You may be referred to a mental health team if your PND is severe, or does not respond to treatment. These teams are usually made up of psychologists, psychiatrists, specialist nurses and occupational therapists. They often provide intensive specialist talking treatments, such as cognitive therapy or psychotherapy.

If it is felt that your PND is so severe that you are at risk of harming yourself or your baby, you may be admitted to hospital or referred to a mental health clinic.

If you have support available from your partner or family, it may be recommended that they care for your baby until you are well enough to return home.

If you do not have support available to help you care for your baby, or your mental health team feel that separation from your baby would adversely affect your recovery, it may be recommended that you are transferred to a specialised 'mother and baby' mental health clinic.

Your baby may have to sleep in a separate nursery until you are well enough to look after them. Once your symptoms begin to respond to treatment, your baby will be able to sleep in your room.

Electroconvulsive therapy (ECT) may be advised if you have severe PND. ECT works for severe PND, but is only used when antidepressants and other treatments have not worked.

If ECT is recommended, you will be given a general anaesthetic and medication to relax your muscles. Electrodes are then placed on your head and a pulse of electricity is passed through your brain, which will trigger a fit or seizure (which is why you are given muscle relaxants). Most people have either six or twelve sessions of ECT, normally with two sessions a week.

For most people the treatment is effective in relieving severe depression, but the effect may not be permanent. Nobody is entirely sure how ECT works, but the generally agreed view is that the electricity changes the chemical composition of the brain in such a way as to elevate mood.

Some people experience unpleasant side effects, including headaches and both short-term and long-term memory loss. Because of the risk of memory loss, your memory will be assessed at the end of each ECT session. If it looks like memory loss is occurring, or you experience any other adverse side effects then the ECT sessions will be stopped.

St John's wort

St John's wort is a herbal supplement that some people take for depression. Though there is some evidence may be of benefit in treating mild or moderate depression, its use is not recommended. This is because it is not tested as rigorously as a medicine. Also, the quantity of its active ingredients vary among individual brands and batches, so you cannot be certain what effect it will have.

Taking St John's wort with some other medications - such as anticonvulsants, anticoagulants, antidepressants and the contraceptive pill - can cause serious problems.

You should not use St John's wort if you are breastfeeding as there is not enough evidence that it is safe in this case.

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Complications

In rare cases, a severe form of depression called postnatal psychosis can develop after childbirth. As well as the symptoms of severe depression, mothers with postnatal psychosis may also have delusions (believing things that are untrue) and hallucinations (seeing things that are not there, or hearing voices), as well as irrational or suicidal thoughts. 

As with postnatal depression, women who have postnatal psychosis often do not realise that they are ill. However, it is a serious mental illness thought to be triggered by chemical and hormonal changes in the body that occur after birth, and it is vital that someone with the condition sees their GP as soon as possible because their health, and the health of their baby, may be at risk.

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Prevention

In order to try to prevent developing postnatal depression (PND), you should inform your GP about any previous periods of depression that you have had, or if you have felt very low or anxious during your pregnancy. This will ensure that your GP is aware of the potential risk of postnatal depression after your baby is born.

You should also speak to your GP if you have had PND in the past and are pregnant, or you are considering having another baby, as there is a risk of you having another episode of PND.

It is difficult to estimate the exact risk as so many factors are involved, such as previous medical history, individual social and psychological circumstances, current interpersonal relationships and any possible complications arising during labour.

It should be stressed that whatever the risk of you having another episode of PND, it is not inevitable. Getting support from your GP, midlife and other healthcare professionals will help reduce that risk.

The following self-help measures can also be useful:

  • get as much rest and relaxation as possible,
  • take some gentle exercise and follow a healthy diet,
  • do not go for long periods without food because low blood sugar levels can make you feel much worse,
  • do not drink too much alcohol because heavy drinking can make you feel worse,
  • eat a healthy balanced diet,
  • do not try to do everything at once, instead make a list of things to do and set realistic goals,
  • talk about your worries with your partner, and close family and friends,
  • contact local support groups, or national helplines for advice and support, and
  • do not despair. PND can affect anyone, and you are not to blame. Remember that most people who have depression make a full recovery.
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