This is a part 1 of a reproduction of a research paper I wrote on postnatal mental health as part of my Developing Doulas course. I’m posting this on my blog now as part of the #DayofLight
What is PND?
During the first week after giving birth, women commonly get what is called “the baby blues”. This is largely due to the huge physical and hormonal changes that take place after birth. Symptoms can include: feeling emotional and irrational; bursting into tears for no apparent reason; feeling irritable or touchy; and feeling depressed and anxious. All this is perfectly normal and symptoms should only last a few days at most. 1
Postnatal Depression (PND) is different to “the baby blues”. Postnatal depression is depression that usually develops in the first 12 weeks after childbirth, though it may not develop for some months 2 3. Unlike “the baby blues”, PND caused by many different factors, is a problem to be taken seriously and will not resolve itself quickly. 2
PND affects around 13% of all new mothers3 and up to around 40% of teenage mothers1. PND is thought to affect all ethnic groups equally2, although women from migrant groups may be at higher risk (perhaps because of an increase in other risk factors, such as a lack of family support, for these women) 3.
As long as PND is recognised and treated, it is a temporary condition that a mother can recover from2. However, for about 8% of mothers the symptoms will continue past the first year post-birth 3.
In recent years, it has also been recognised that PND can affect fathers as well (although it is mostly a problem for mothers). It has been suggested that as many as 4% or 1-in-25 new fathers are affected.8
What are the signs and symptoms of PND?
Key symptoms are:
- a persistent feeling of sadness and low mood 4
- loss of interest in the baby and the world around you 1 4
- lack of energy and feeling tired all the time 1 4
- Other symptoms can include:
- excessive anxiety and panic attacks1
- disturbed sleep, such as not being able to fall asleep during the night and then being sleepy during the day 1 4
- memory loss or difficulties with concentration and making decisions 1 4
- low self-confidence & feelings of not being able to cope 1 4
- poor appetite 1 4 or “comfort eating” 4
- feeling very agitated or alternatively very apathetic (can’t be bothered) 4
- feelings of guilt and self-blame 4
- thinking about suicide and self-harming 4
Postnatal depression can interfere with your day-to-day life. Some women feel unable to look after their baby, or feel too anxious to leave the house or keep in touch with friends.
Healthcare professionals may use a depression scale, such as the Edinburgh Postnatal Depression Scale, as a tool in diagnosing PND, though these cannot be used alone to diagnose PND 3.
What causes PND?
The cause of PND is not clear, but it is thought to be the result of several factors, rather than one single cause for all women2.
Factors that may contribute to the development of PND include:
- The physical and emotional stress of looking after a newborn baby2. This may be increased in some cases, perhaps because of a difficult birth or a difficult recovery from birth for the mother3 5, health concerns with the mother or baby following the birth3 5 or difficulties with feeding the baby.
- The hormonal changes that occur after birth. It is thought that some women may be more sensitive to these changes than others2 5.
- The mother’s individual psycho-social circumstances, such as financial worries, stressful life circumstances (such as bereavement), lack of support at home or relationship problems and no friends or family around them2 3 5.
- A past history of mental health problems3, antenatal depression or anxiety3 or a family history of depression or postnatal depression5.
There are also specific subgroups of women who may be at higher risk, such as those with a history of abuse (emotional, physical or sexual), young mothers and migrant groups3.
Women who already have a mental health problem are more likely to become ill again during pregnancy or in the first year after giving birth than at other times in their life. 7 One factor is that sometimes women who have a mental health problem will stop taking their medication, without talking to their doctor or midwife, when they find out that they are pregnant. This can make their illness return or become worse.7
How is PND treated?
PND is unlikely to get better by itself quickly and the mother’s health, the care of the baby and family life may suffer.2 It is important for partners, family and friends to recognise signs of PND as early as possible and seek professional advice or encourage the mother to do so2.
Treatment for PND includes:
- Self-help advice2.
- Talking therapies, such as cognitive behavioural therapy (CBT) 2 and counselling1.
- Other psycho-social interventions, around increasing levels of support available to the mother3.
- Antidepressant medications1 2.
Because providing support can help with PND, increasing levels of support available to a mother with PND may help. This can involve including family & friends, and/or putting the new mother in touch with local postnatal groups1. Intensive, professionally-based postnatal home visits and the provision of telephone-based peer support have been shown to be effective3.
Milder cases of PND can be treated with counselling, including non-directive counselling delivered at home (“listening visits”) and/or brief courses of CBT or individual psychotherapy (IPT), as well as self-help strategies 1 6.
More severe cases often require antidepressant medications as well 1. If a woman is showing signs of mild PND, and she has a history of severe depression, or she declines, or does not respond to, psychological treatments, then antidepressant medications should be considered. 6
How could the risk of PND be reduced?
Trying to identify women at risk of PND and providing them with interventions antenatally can reduce the risk of them developing PND.3
The National Institute for Health and Clinical Excellence (NICE) Guidance on Antenatal and Postnatal Mental Health6 recommends that, at a woman’s first contact with healthcare services, both antenatally and postnatally, healthcare professionals (midwives, obstetricians, health visitors and GPs) should ask questions about:
- Past or present mental illness, including schizophrenia, bipolar disorder, postnatal psychosis and severe depression.
- Previous treatment by a psychiatrist or the specialist mental health team.
- A family history of perinatal mental illness.
Doulas may not want to as their clients detailed questions about their personal or family medical history, but mentions of these risk factors in particular, could lead to discussion about PND and hot to reduce the risk of it.
For women who are taking medication for depression before pregnancy, the NICE Guidance on Antenatal and Postnatal Mental Health6 recommends that they do not stop treatment suddenly on becoming pregnant. If they are being treated for mild depression, the medication should be withdrawn gradually and monitoring considered. If intervention is then needed, self-help approaches (such as guided self-help, computerised cognitive behavioural therapy (CBT) or exercise) or brief psychological treatments (including counselling, CBT and individual psychotherapy (IPT)) should be considered.6 If they are being treated for moderate or severe depression, then switching to an antidepressant with lower risk, switching to psychological therapy (CBT or IPT) or combining both strategies should be considered. 6
Research has shown that intensive, individualised postpartum home visits provided by nurses or midwives, lay (peer)-based telephone support and interpersonal psychotherapy are all effective in reducing the risk of PND. 3 A lack of support at home, whether from a partner, or because the mother does not have friends and family able to help, is known to be a risk factor for developing PND, so putting more support in place could help reduce the risk of PND developing. 1
However, interventions that start postnatally are also effective3, and for some women, the risk factors – such as ongoing health concerns for the mother or baby or a difficult delivery – cannot be known about beforehand. For those mothers who become more at risk because of the circumstances of the birth or postnatally, early identification that those mothers are at higher risk of developing PND can enable interventions to be put in place. 5
It is important that partners, family members and friends are able to recognize signs of PND in an early stage and seek professional advice or encourage the mother to do so 2. Warning signs include:
- They frequently cry for no obvious reason. 4
- They have difficulties bonding with their baby. 4
- They seem to be neglecting themselves – for example, not washing or changing clothes. 4
- They seem to have lost all sense of time – often unaware if 10 minutes or two hours have passed. 4
- They lose all sense of humour and cannot see the funny side of anything. 4
- They worry something is wrong with their baby, regardless of reassurance. 4
In order to try and encourage the early identification of antenatal and postnatal depression, the NICE Guidance on Antenatal and Postnatal Mental Health6 recommends that, at a woman’s first contact with primary care, both antenatally at her booking visit and postanatally at the 4-6 week and 3-4 month checks, healthcare professionals should ask 2 questions:
- During the last month, have you often been bothered by feeling down, depressed or hopeless?
- During the past month, have you often been bothered by having little interest or pleasure in doing things?
And if the mother answers “yes” to either of these questions, she should then be asked if this is something she feels that she needs or wants help with.
- NHS Choices. 2011. NHS Choices: Feeling depressed after childbirth. http://www.nhs.uk/conditions/pregnancy-and-baby/pages/feeling-depressed-after-birth.aspx . Accessed 15 Feb 2013.
- NHS Choices. 2012. NHS Choices: Postnatal Depression. http://www.nhs.uk/conditions/postnataldepression/pages/introduction.aspx . Accessed 15 February 2013.
- Dennis C-L, Creedy DK. Psychosocial and psychological interventions for preventing postpartum depression. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD001134. DOI: 10.1002/14651858.CD001134.pub2
- NHS Choices. 2012. NHS Choices: Postnatal Depression – Symptoms. http://www.nhs.uk/Conditions/Postnataldepression/Pages/Symptoms.aspx . Accessed 15 February 2013.
- NHS Choices. 2012. NHS Choices: Postnatal Depression – Causes. http://www.nhs.uk/Conditions/Postnataldepression/Pages/Causes.aspx . Accessed 16 March 2013.
- NICE. 2007. Antenatal and Postnatal Mental Health: The NICE Guideline on Clinical Management and Service Guidance. http://www.nice.org.uk/nicemedia/live/11004/30431/30431.pdf . Accessed 16 March 2013.
- NICE. 2010. CG45 Antenatal and postnatal mental health: understanding NICE guidance. http://guidance.nice.org.uk/CG45/PublicInfo/pdf/English . Accessed 25 March 2013.
- Mind. 2010. Understanding postnatal depression. http://mind.org.uk/assets/0001/7313/Understanding_postnatal_depression_2010.pdf . Accessed 25 March 2013.
- NHS Choices. 2011. NHS Choices: Post-traumatic stress disorder. http://www.nhs.uk/conditions/post-traumatic-stress-disorder/pages/introduction.aspx . Accessed 25 March 2013.
- The Birth Trauma Association. What is Birth Trauma? http://www.birthtraumaassociation.org.uk/what_is_trauma.htm . Accessed 25 March 2013.
- NHS Choices. 2011. NHS Choices: Post-traumatic stress disorder – Treatment. http://www.nhs.uk/Conditions/Post-traumatic-stress-disorder/Pages/Treatment.aspx . Accessed 25 March 2013.
- Hodnett, ED., Gates, S., Hofmeyr, GJ. & Sakala, C. Continuous support for women during childbirth Cochrane Database of Systematic Reviews 2007, Issue 3.