Breastfeeding and PND

Mother breastfeeding baby

It’s in the news today that a major study has found that women who breastfeed are 50% less likely to have postnatal depression (PND) than those who choose not to, but those women who plan to breastfeed and are unable to achieve their breastfeeding goals, are twice as likely to get PND compared to the mothers who simply choose to not breastfeed.

I don’t think this will come as any surprise to anyone with experience of supporting breastfeeding and new mamas. Breastfeeding is incredibly emotional and I have seen, and felt myself, how a new mama’s emotional health can depend on how breastfeeding goes. Get it right and breastfeeding an be incredibly good for both mama and babe, even helping heal any hurts from a difficult pregnancy or birth. But if breastfeeding goes wrong, then a mama can be filled with grief, guilt, stress and exhaustion – a killer combo for anyone’s mental health.

I have several times come across mamas who blame breastfeeding, and not being able to successfully establish breastfeeding with a previous child, for past PND and who refuse to consider breastfeeding a subsequent child. I can see the logic. I can feel the fear of going there again. But I also think of the wasted chance to have a healing experience and reduce the risk of PND recurring.

In The Independent article, they say: The researchers said that more support needed to be given, both to encourage mothers to breastfeed, and also support those women who find they are unable to “. I have so far been unable to find a press release or abstract to check whether this wording was accurate, but either way, I have a major issue with how it is reported.

Yes, support is needed. And yes, in the rare cases when a mother cannot breastfeed no matter what, that mama needs, and should get, lots of support.

But what is needed is support so that women who want to breastfeed CAN breastfeed.

Most women have the physical capability to produce milk to feed their baby or babies. But they need good support, at the right time, to make that a reality.

They need good antenatal education and support for their breastfeeding journey through birth and from the moment baby is born. They need balanced evidence based information on how choices for birth may affect feeding. They need good, nearly continuous postnatal support in the first couple of days to ensure exhausted, inexperienced mamas don’t start their breastfeeding journey on the wrong foot with nipple trauma from poor latching. They need access to properly trained breastfeeding supporters who can signpost to more experienced/qualified supporters as needed (*newsflash* HCPs are often NOT qualified in breastfeeding support!). They need fast, accurate diagnosis AND treatment for any issues, like tongue-tie. They need protection from so-called support that scuppers their breastfeeding relationship. They need a shoulder to cry on, someone to say “you’re doing great”, someone to feed them and look after their children.

If they had all that, then we would be considering “women who can’t breastfeed” in the correct context. Rare. Needing exquisite support. But not a common, inescapable reason for PND.

If you’re concerned about PND and breastfeeding, call in the troops. Get your support networks set-up. And have that healing, protective breastfeeding journey I wish all women could experience.

Postnatal Mental Health Resources #DayofLight

This is part 4 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

Resources

NHS Choices: Postnatal depression

http://www.nhs.uk/conditions/postnataldepression

Basic information on symptoms, causes and medications for PND. Plus links to other organisations, the Map of Medicine, the NICE Guidance and the PNI.HealthUnlocked community.

Mind

http://mind.org.uk/

National mental
health charity. Includes information on PND and PTSD.

The Association for Post-Natal Illness

http://apni.org/

National charity established to:

  • Provide support to mothers suffering from post-natal illness
  • Increase public awareness of the illness
  • Encourage research into its cause and nature

PNI.org.uk

http://www.pni.org.uk

Support organisation run by people with personal experience of post-natal illness.

Parentline

0808 800 2222

Confidential helpline for information, advice, guidance and support on any aspect of parenting and family life.  Open 7am – midnight with overnight calls diverted to the Samaritans.

Bliss

http://www.bliss.org.uk

National charity relating to babies needing specialist neonatal care.

Sands

http://www.uk-sands.org

National stillbirth & neonatal death charity.

Postnatal Psychosis #DayofLight

This is part 3 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

Postnatal Psychosis

Postnatal Psychosis is a rarer and more serious mental health condition that can develop after birth. 4

Symptoms of postnatal psychosis include:

  • bipolar-like symptoms – feeling depressed one moment and very happy or excitable (manic) the next 4
  • believing things that are obviously untrue and illogical (delusions) – often relating to the baby, such as the mother thinking the baby is dying or that either herself or the baby have magical powers 4
  • seeing and hearing things that are not really there (hallucinations) – this is often the mother hearing voices telling her to harm the baby 4

Postnatal psychosis is regarded as an emergency and requires immediate medical care. If there is a danger of imminent harm to the mother, the baby or someone with them, then contacting the duty psychiatrist at the local A&E department is the appropriate course of action. 4

References

  1. 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.
  2. NHS Choices. 2012. NHS Choices: Postnatal Depression. http://www.nhs.uk/conditions/postnataldepression/pages/introduction.aspx . Accessed 15 February 2013.
  3. 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
  4. NHS Choices. 2012. NHS Choices: Postnatal Depression – Symptoms. http://www.nhs.uk/Conditions/Postnataldepression/Pages/Symptoms.aspx . Accessed 15 February 2013.
  5. NHS Choices. 2012. NHS Choices: Postnatal Depression – Causes. http://www.nhs.uk/Conditions/Postnataldepression/Pages/Causes.aspx . Accessed 16 March 2013.
  6. 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.
  7. NICE. 2010. CG45 Antenatal and postnatal mental health: understanding NICE guidance. http://guidance.nice.org.uk/CG45/PublicInfo/pdf/English . Accessed 25 March 2013.
  8. Mind. 2010. Understanding postnatal depression. http://mind.org.uk/assets/0001/7313/Understanding_postnatal_depression_2010.pdf . Accessed 25 March 2013.
  9. 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.
  10. The Birth Trauma Association. What is Birth Trauma? http://www.birthtraumaassociation.org.uk/what_is_trauma.htm . Accessed 25 March 2013.
  11. 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.
  12. Hodnett, ED., Gates, S., Hofmeyr, GJ. & Sakala, C. Continuous support for women during childbirth Cochrane Database of Systematic Reviews 2007, Issue 3.

Postnatal Post Traumatic Stress Disorder (PTSD) and Birth Trauma #DayofLight

This is a part 2 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 PTSD?

Post-traumatic stress disorder (PTSD) is an anxiety disorder caused by very stressful, frightening or distressing events. PTSD can develop immediately after someone experiences a disturbing event or it can occur weeks, months or even years later. PTSD can develop in any situation where a person feels extreme fear, horror or helplessness. 9

Postnatal PTSD (PN-PTSD) is PTSD that develops after birth.10

Birth Trauma is a term used both for PN-PTSD, but also for women who may have some symptoms of PTSD after birth, but may not fulfil the clinical criteria for a PTSD diagnosis. 10

PN-PTSD can affect fathers, and other birth companions, as well as the new mothers. 10

Postnatal PTSD can occur alone or in addition to the symptoms of PND.1 However, the 2 illness are distinct and need to be treated individually. Many women with PN-PTSD are wrongly diagnosed with PND, given treatment that is unlikely to help and may be given inappropriate advice by healthcare professionals, such as being told to “try and move on with their lives” or that they should be grateful for having a healthy baby. This kind of reaction can actually exacerbate feelings of guilt and isolation and worsen symptoms. 10

What are the signs and symptoms of PTSD?

The symptoms of postnatal PTSD can develop straight after the birth or months afterwards1.

The symptoms of PTSD include:

  • Persistent re-experiencing of the event through recurrent instrusive memories, flashbacks and nightmares1 10
  • Panic attacks1
  • Sleeping problems1
  • Lack of emotions 1
  • Severe irritability or anger1
  • Avoidance of anything that reminds them of the traumatic event(s). 10
  • Hyper-vigilance (feeling jumpy or needing to be on their guard all the time). 10 In new mothers, this may present as being unable to leave the baby at all.

What causes PTSD?

Postnatal PTSD may result from a traumatic birth, a fear of dying or the baby dying or life threatening situations1. What may be considered a traumatic birth can cover a wide range of situations and what one mother may find traumatic, another mother in a similar situation may not. Traumatic births may be related to a very long or painful labour1, a very fast labour, an emergency or problematic delivery1 and/or other factors10.

For some women, Birth Trauma may be triggered by factors other than sensational or dramatic events. For example, feelings of loss of control, loss of dignity, hostile attitudes of staff around them or the absence of informed consent to medical procedures can contribute to Birth Trauma developing. 10

Mind, the mental health charity, state that the impact of difficult labours and births leading to PTSD has been under-estimated, as people may feel that the baby is adequate compensation for the trauma and that new mothers will soon forget the ordeal in the joy of motherhood; but a traumatic

childbirth may impair a new mother’s relationships with both her baby and her partner.8

The Birth Trauma Association states that risk factors for the development of PN-PTSD include “a very complicated mix of objective (e.g. the type of delivery) and subjective (e.g. feelings of loss of control) factors”10. They include:

  • Lengthy labour or short and very painful labour
  • Induction
  • Poor pain relief
  • Feelings of loss of control
  • High levels of medical intervention
  • Traumatic or emergency deliveries, e.g. emergency caesarean section
  • Impersonal treatment or problems with the staff attitudes
  • Not being listened to
  • Lack of information or explanation
  • Lack of privacy and dignity
  • Fear for baby’s safety
  • Stillbirth
  • Birth of a damaged baby (a disability resulting from birth trauma)
  • Baby’s stay in SCBU/NICU
  • Poor postnatal care
  • Previous trauma (for example, in childhood, with a previous birth or domestic violence)

How is PTSD treated?

The NICE Guidance on Antenatal and Postnatal Mental Health6 recommends that single-session formal debriefing focused on the birth should not be routinely offered to women who have experienced a traumatic birth. However, this is usually an option available to those women who specifically request it. Independent options for debriefing are also available, for example, with an independent midwife.

The NICE Guidance on Antenatal and Postnatal Mental Health6 does recommend that maternity staff and other healthcare professionals should support women who wish to talk about their experience, encourage them to make use of natural support systems available from family and friends, and take

into account the effect of the birth on the partner.

For diagnosed cases of PTSD, NICE recommends psychotherapy as the first treatment to try for PTSD. In some cases, medication may also be used.11

Treatments include:

  • Watchful waiting, involving carefully monitoring symptoms. This may be recommended in cases of PTSD where symptoms are mild or have been present for less than 4 weeks after the traumatic event (or birth).11
  • Psychotherapy, involving seeing a trained mental health professional, a psychotherapist, who will listen and help the person affected come up with effective strategies to resolve their problems.11 The Birth Trauma Association Expert Board member, Psychologist Dr Susan Ayers, advises that PN-PTSD is best treated by psychotherapy.10
  • Cognitive Behavioural Therapy (CBT), a type of therapy that aims to help you manage your problems by changing how you think and act. Trauma-focused CBT uses a range of psychological treatment techniques to help you come to terms with the traumatic event. It is appropriate if the symptoms of PTSD are severe and develop within one month of a traumatic event and/or if the person affected still has PTSD symptoms within three months of a traumatic event.11
  • Eye movement desensitisation and reprocessing (EMDR), a relatively new treatment that has been found to reduce the symptoms of PTSD. EMDR involves making side-to-side eye movements while recalling the traumatic incident. It works by helping the malfunctioning part of the brain (the hippocampus) to process distressing memories and flashbacks so that their influence is reduced.11
  • Medications, such as the antidepressants paroxetine or mirtazapine may be considered for treating PTSD in adults. However, these antidepressants will only usually be used if the person affected:
    • chooses not to have trauma-focused psychological treatment.
    • cannot start psychological treatment due to a high risk of further trauma.
    • has gained little or no benefit from a course of trauma-focused psychological treatment.
    • has severe depression or hypersensitivity that significantly affects their ability to benefit from psychological treatment

Antidepressants can also be prescribed to reduce any associated symptoms of depression and anxiety and to help with sleeping problems.11

It is possible for PTSD to be successfully treated many years after the traumatic event occurred, which means it is never too late to seek help. 11

How could PTSD be avoided?

Birth is unpredictable and there is no way to guarantee that it will go the way a mother (or father) wants or expects and the traumatic element of some births might be unavoidable – e.g. in the case of a stillbirth. However, many of the factors that can contribute to the development of PN-PTSD could be dealt with, or had their risk reduced.

Antenatal education about birth and support with developing birth preferences that consider not just the ideal situation, may reduce a couple’s feeling that they have lost control, no matter how the birth develops. The antenatal education would ideally cover the decision making process in a medical environment – for example, the use of the BRAIN (What are the Benefits? What are the Risks? What are the Alternatives? What does your Instinct say? What if you do Nothing?) technique for considering options – so that the mother or couple feel able to make informed decisions that take their choices into account, even if things develop beyond what they had considered antenatally.

Continuous support, during pregnancy, labour/birth and then postnatally is likely to have a part to play and Doulas could potentially have a real impact here. There is considerable evidence that continuous support during labour may have the following benefits, many of which are reducing the risk of factors that could contribute to the development of PN-PTSD. With continuous support during labour/birth, women are:

  • more likely to have a spontaneous vaginal birth (fewer inductions). 12
  • less likely to have painkilling drugs or an epidural during birth. 12 In research studied, this was not due to a lack of these options, suggesting that the women had better pain control.
  • less likely to report dissatisfaction. 12
  • statistically going to have a shorter labour. 12 NB. This does not mean that all labours with continuous support will be short!
  • less likely to have a caesarean. 12
  • less likely to have an instrumental vaginal birth. 12
  • less likely to have a baby with a low 5-minute AGPAR score. 12 Although the research does not specifically state this, it is possible that the chance of baby needing a SCBU/NICU stay (which is one factor that can contribute to the development of PN-PTSD) is reduced.

Research has found that continuous support was most effective when provided by a woman who was neither part of the hospital staff nor the woman’s social network (i.e. A Doula). 12

Other, less medical, factors that may contribute to the development of PN-PTSD – such as impersonal treatment or problems with the staff attitudes; not being listened to; lack of information or explanation; and a lack of privacy and dignity10 – may also be reduced or have their impact reduced, by having a Doula providing continuous support during labour/birth. A Doula may be experienced at dealing with medical staff and may be able to help women or couples ensure that their wishes are heard and that they are given any information they need. They may also be able to help with practical matters – e.g. finding an available bathroom if there is no privacy because all labour rooms are in use – or taking on the role of ‘doorkeeper’.

In the case of previous trauma – such as childhood abuse, rape or sexual abuse or previous Birth Trauma – being a potential factor contributing to the development of PN-PTSD, if this is raised antenatally as a concern, then a plan could be put in place to try and avoid it becoming a problem. For example, these women might want to refuse consent to all vaginal examinations, they might want to only be cared for in labour/birth by female staff members or they might want to limit the number of people in the room with them at any one time. Simple measures, such as making it clear in their birth preferences and maternity notes that all staff must knock before entering the room and then introduce themselves and wait for the go-ahead before approaching, could help women in this situation. If a woman or a couple are able to raise concerns antenatally, then a plan could be put in place with the agreement of hospital staff and if it is clear why these measures are needed, then any reasonable medical staff would hopefully concur with them. If a woman is able to raise concerns antenatally (or even pre-pregnancy), then possibly treatment for the original PTSD, such as psychotherapy, could be used during pregnancy. However, some women may be unable to talk to their healthcare providers or even their Doula about past trauma and it may not come up until the labour/birth triggers an issue.

References

  1. 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.
  2. NHS Choices. 2012. NHS Choices: Postnatal Depression. http://www.nhs.uk/conditions/postnataldepression/pages/introduction.aspx . Accessed 15 February 2013.
  3. 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
  4. NHS Choices. 2012. NHS Choices: Postnatal Depression – Symptoms. http://www.nhs.uk/Conditions/Postnataldepression/Pages/Symptoms.aspx . Accessed 15 February 2013.
  5. NHS Choices. 2012. NHS Choices: Postnatal Depression – Causes. http://www.nhs.uk/Conditions/Postnataldepression/Pages/Causes.aspx . Accessed 16 March 2013.
  6. 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.
  7. NICE. 2010. CG45 Antenatal and postnatal mental health: understanding NICE guidance. http://guidance.nice.org.uk/CG45/PublicInfo/pdf/English . Accessed 25 March 2013.
  8. Mind. 2010. Understanding postnatal depression. http://mind.org.uk/assets/0001/7313/Understanding_postnatal_depression_2010.pdf . Accessed 25 March 2013.
  9. 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.
  10. The Birth Trauma Association. What is Birth Trauma? http://www.birthtraumaassociation.org.uk/what_is_trauma.htm . Accessed 25 March 2013.
  11. 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.
  12. Hodnett, ED., Gates, S., Hofmeyr, GJ. & Sakala, C. Continuous support for women during childbirth Cochrane Database of Systematic Reviews 2007, Issue 3.

Postnatal depression #DayofLight

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.

References

  1. 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.
  2. NHS Choices. 2012. NHS Choices: Postnatal Depression. http://www.nhs.uk/conditions/postnataldepression/pages/introduction.aspx . Accessed 15 February 2013.
  3. 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
  4. NHS Choices. 2012. NHS Choices: Postnatal Depression – Symptoms. http://www.nhs.uk/Conditions/Postnataldepression/Pages/Symptoms.aspx . Accessed 15 February 2013.
  5. NHS Choices. 2012. NHS Choices: Postnatal Depression – Causes. http://www.nhs.uk/Conditions/Postnataldepression/Pages/Causes.aspx . Accessed 16 March 2013.
  6. 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.
  7. NICE. 2010. CG45 Antenatal and postnatal mental health: understanding NICE guidance. http://guidance.nice.org.uk/CG45/PublicInfo/pdf/English . Accessed 25 March 2013.
  8. Mind. 2010. Understanding postnatal depression. http://mind.org.uk/assets/0001/7313/Understanding_postnatal_depression_2010.pdf . Accessed 25 March 2013.
  9. 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.
  10. The Birth Trauma Association. What is Birth Trauma? http://www.birthtraumaassociation.org.uk/what_is_trauma.htm . Accessed 25 March 2013.
  11. 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.
  12. Hodnett, ED., Gates, S., Hofmeyr, GJ. & Sakala, C. Continuous support for women during childbirth Cochrane Database of Systematic Reviews 2007, Issue 3.

#DayofLight: Bringing Depression out of Darkness

Today, February 5th, is the #DayofLight, a social media driven effort to throw the spotlight on depression and mental illness and get people talking about it. For more information on #DayofLight, see this blog post which inspired me to get involved or check out the hashtag #DayofLight on Twitter.

Depression has had a big impact on my family over the years and in recent times, I have myself been treated for postnatal depression (PND or PPD). There is still a stigma about depression. Mothers worry that they might be judged to be bad parents if they seek help for depression. Others get concerned because insurance companies will still penalise you for having been treated for mental health issues. And, of course, the nature of depression is that those in its throes are not meeting lots of people and talking about their depression – covering up and avoiding interaction with others can both be symptoms.

But it shouldn’t be this way. Depression is common. It is not something to be ashamed of. And seeking help for depression or mental health issue of any kind is a positive thing in so many ways. Insurance companies should give one a discount for being proactive and seeking treatment for depression as this is far healthier than not doing so and I don’t think there are many people who will not be affected by depression at some point in their lives.

One area I find really interesting is the neuro-psychology of infant development (for more on this subject, the book ‘Why Love Matters’ by Sue Gerhardt is both fascinating and slightly terrifying as a parent). So when I recognised that I was struggling to connect with my baby, and was fulfilling their physical needs without being emotionally present for them, I sought help in an attempt to prevent the depression from damaging my child. I feel all new mothers should be encouraged to not just speak up about any possible depression, but to seek help if they feel this might possibly be an issue for them, for the sake of their baby, asap. The exhaustion and emotional shock of new parenthood can be extremely hard to distinguish from depression and presumably can have the same impact. I would hope this might make mothers feel more positive about seeking help for PND. Perhaps not. But then I find all this science fascinating, which helps in dealing with the endless parental guilt of f***ing your kids up!

For my postnatal research topic as part of my Developing Doulas course, I choose postnatal mental health. I’ll put the info I put together then up as a series of blogs.