Epidemiology

PND is common. A meta-analysis of studies mainly based in the developed world found the prevalence of PND to be 10-15%.^[2] Higher rates are found in developing countries.

Risk factors

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:^[3]

• 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).

Presentation

PND presents with similar symptoms to general depression but with some variation:^[4]

• Low mood and loss of enjoyment.
• Anxiety.
• 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:^[4]

• 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

Diagnosis should be made as soon as possible.^[1] 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.

Management

General measures

• Empowerment
  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).^[5] 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.^[6]
• '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.^[1]

  The Stepped Care Approach
  Step 1: GP, practice nurse	Assessment	Recognition
  Step 2: Primary care team, primary care mental health worker	Mild depression	Watchful waiting Guided self-help Computerised CBT Exercise Brief psychological interventions
  Step 3: Primary care team, primary care mental health worker	Moderate or severe depression	Medication Psychological interventions Social support
  Step 4: Mental health specialists including crisis teams	Treatment-resistant, recurrent, atypical and psychotic depression, and those at significant risk	Medication Complex psychological interventions Combined treatments
  Step 5: Inpatient care, crisis teams	Risk to life, severe self- neglect	Medication Combined treatments ECT

Psychological strategies^[1]

• 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.

Pharmacological therapy

• Antidepressants:
  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.^[7] 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.
• Hormones:
  There is no place for synthetic progestogens in the treatment of PND.^[8] 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.

Prognosis

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.^[9] Improving awareness of perinatal mental health problems, in all their diversity, is important.

Complications

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.^[10] 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.

Prevention

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.^[2]

Psychological support

NICE recommends 4-6 sessions of CBT or interpersonal psychotherapy for pregnant women who have several risk factors for postnatal depression.^[1] 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.'^[2]

Pharmacological methods

There is no evidence to support this currently.