Both the National Institute for Health and Clinical Excellence (NICE) and the Scottish Intercollegiate Guidelines Network (SIGN) have released guidance on the management of mental health conditions in the perinatal period. Some prefer not to use the term postnatal depression (PND) as it then tends to be used as an umbrella term for all mental health problems following delivery.
Depression can occur de novo, can be a recurrence of a depressive condition occurring prior to pregnancy, or be part of a wider problem eg bipolar disorder. Nevertheless, PND is a widely recognised concept in the literature, and is considered to be a useful term in many circumstances.
SIGN defines PND as 'any non-psychotic depressive illness occurring during the first postnatal year'.
PND is common. A meta-analysis of studies mainly based in the developed world found the prevalence of PND to be 10-15%. Higher rates are found in developing countries.
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The greatest risk factor is previous history of mental health problems. Around the world poverty, lack of education and sex inequality also predispose women to depression. Other factors include:
- Poor social support and marital relationship (or single).
- Domestic violence.
- Unplanned pregnancy.
- Adolescent mothers.
- Baby blues.
Other factors that have been found to be more common in the at risk group are poor coping skills, 2 or more children, stressful recent life events eg bereavement, bottle-feeding and depression in the father (of the infant).
PND presents with similar symptoms to general depression but with some variation:
- Low mood and loss of enjoyment.
- Disturbed sleep and eating patterns.
- Poor concentration.
- Low self-esteem.
- Low energy levels.
- Loss of libido.
NICE recommends that women be proactively screened for PND and high-risk patients identified. It is advised that when women present for booking and at the postnatal check, health professionals (including midwives, obstetricians, health visitors and GPs) should ask questions about:
- Past or present severe mental illness including schizophrenia, bipolar disorder, psychosis in the postnatal period and severe depression.
- Previous treatment by a psychiatrist/specialist mental health team including inpatient care.
- A family history of perinatal mental illness.
Diagnosis should be made as soon as possible. Subtle changes in behaviour (often noted by the partner) may be the first symptom of PND.
All women at booking and at postnatal checks should be asked the following screening questions:
- During the past 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?
If the woman answers 'Yes' to both questions a further question should be asked:
- Is this something you feel you need or want help with?
Use of self-report measurement tools (see further reading below) may be helpful in further assessment or for monitoring of response to treatment, but should not be used for diagnosis.
Involve patients in decisions about their care. For patients who lack capacity, follow the Department of Health guidelines and the code of practice accompanying the Mental Capacity Act (which came into force in April 2007). Family and carers should also be involved, unless the patient expressly forbids it.
- Communication Good communication is important - patients, relatives and carers should be given information in a form that is culturally appropriate and takes account of any physical disabilities that present an obstacle to comprehension (eg deafness).
- The wider family environment Consider the needs of other children, dependent adults, and the effect the illness may have on relationships with partners.
- Adolescents Bear in mind local and national guidelines concerning confidentiality and the rights of the child. When obtaining consent, issues that may need to to be considered include Gillick competence, child protection concerns, current mental health legislation, and the Children Act 1989.
- 'Stepped Care Approach' PND should be treated according to the same NICE guidelines (the 'Stepped Care Approach') as non-puerperal depression, with the exception that there is a lower threshold for non-drug management when the patient is breast-feeding.
The Stepped Care Approach
Step 1: GP, practice nurse Assessment Recognition Step 2: Primary care team,
primary care mental health worker
- Watchful waiting
- Guided self-help
- Computerised CBT
- Brief psychological interventions
Step 3: Primary care team,
primary care mental health
Moderate or severe
- Psychological interventions
- Social support
Step 4: Mental health
atypical and psychotic
depression, and those at
- Complex psychological
- Combined treatments
Step 5: Inpatient
care, crisis teams
Risk to life, severe self-
- Combined treatments
- The evidence supporting one psychological therapy over another is small, so choice should be based on patient preference and availability.
- Watchful waiting may be appropriate for patients with mild depression who do not want any intervention. If this approach is adopted, re-assessment should take place within 2 weeks.
- Self-help strategies - this includes self-help programmes based on cognitive behavioural therapy (CBT) or computerised CBT.
- Non-directive counselling delivered at home (listening visits).
- Brief CBT or interpersonal psychotherapy.
Drug therapy should be considered for any patient with mild, moderate or severe PND who does not respond to, or who does not wish to undertake, non-drug management. All patients should have a discussion about the risks and benefits of medication, but this is particularly important for breast-feeding mothers.
The tricyclics imipramine and nortriptyline and the serotonin reuptake inhibitors (SSRIs) sertraline and paroxetine are present in breast milk at relatively low levels. Fluoxetine, citalopram and escitalopram are present in breast milk at relatively high levels. Doxepin should also be avoided when breast-feeding.
SSRIs are however better tolerated and less toxic in overdose than tricyclics. NICE does not recommend any particular drug or group of drugs, and there are indeed no conclusive trials supporting the risk-benefits of any particular drug.
There is no place for synthetic progestogens in the treatment of PND. There may be a modest role for oestrogens in the treatment of severe postpartum depression, but further research is required.
Management of severe depression
Women who have ideas of either suicide, or harming the baby, should be referred immediately for urgent psychiatric assessment. Child protection procedures may need to be invoked.
A few mothers have depression that is too severe to be managed solely in primary care and will require the involvement of a psychiatrist; sometimes needing compulsory admission using the Mental Health Act. Dedicated 'mother and baby units' offer the ideal environment but are not available in all areas. Care needs to be delivered and monitored by a multidisciplinary team linking closely with social services and family mental health services.
The course of the illness is widely variable and will depend on predisposing factors and response to treatment. PND is associated with reduced likelihood of mother-baby bonding and impaired cognitive function in the child.
Whilst women are at generally low risk of suicide during pregnancy, it is a significant cause of maternal death in the year following birth in the UK. Improving awareness of perinatal mental health problems, in all their diversity, is important.
When postnatal depression is untreated it is associated with adverse effects on the infant. These effects are both short and long term poorer cognitive, emotional, social and behavioural development. Negative influences of mothers' depression are seen in their language skills and intelligence quotients (particularly in boys).
However these effects are not universal. It is only seen when the mother is unable to actively engage with the infant.
It is recommended that enquiry about depressive symptoms should be made (as the minimum), on booking and postnatally at 4-6 weeks and 3-4 months.
NICE recommends 4-6 sessions of CBT or interpersonal psychotherapy for pregnant women who have several risk factors for postnatal depression. However SIGN concludes that 'there is insufficient consistent evidence on which to base a recommendation for psychological or psychosocial interventions for the prevention of postnatal depression.'
There is no evidence to support this currently.
Further reading & references
- Edinburgh Postnatal Depression Scale, University of California, San Francisco
- Frayne J, Nguyen T, Allen S, et al; Motherhood and mental illness--part 2--management and medications. Aust Fam Physician. 2009 Sep;38(9):688-92.
- Patient Health Questionnaire (PHQ9) Screeners
- Antenatal and postnatal mental health: clinical management and service guidance, NICE Clinical Guideline (2007)
- Management of perinatal mood disorders, Scottish Intercollegiate Guidelines Network (March 2012)
- O'Keane V, Marsh MS; O'Keane V, Marsh MS; Depression during pregnancy. BMJ. 2007 May 12;334(7601):1003-5.
- Depression - antenatal and postnatal, Prodigy (March 2008)
- The Mental Capacity Act 2005, Dept of Health
- The Children Act 1989, DirectGov
- Lanza di Scalea T, Wisner KL; Antidepressant medication use during breastfeeding. Clin Obstet Gynecol. 2009 Sep;52(3):483-97.
- Dennis CL, Ross LE, Herxheimer A; Oestrogens and progestins for preventing and treating postpartum depression. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD001690.
- Saving Mothers' Lives. Reviewing maternal deaths to make motherhood safer: 2006-2008; Centre for Maternal and Child Enquiries (CMACE), BJOG. Mar 2011
- Hay DF, Pawlby S, Waters CS, et al; Antepartum and postpartum exposure to maternal depression: different effects on J Child Psychol Psychiatry. 2008 Oct;49(10):1079-88.
|Original Author: Dr Laurence Knott||Current Version: Dr Hayley Willacy||Peer Reviewer: Prof Cathy Jackson|
|Last Checked: 19/07/2012||Document ID: 6926 Version: 7||© EMIS|
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