Postnatal Depression

What is meant by postnatal depression?

Having a baby is a very emotional experience. You may feel tearful and your mood may feel low. There are three causes of low mood after childbirth:

• 'Baby blues'. This is so common that it can be considered normal. Symptoms include being weepy, irritability, anxiety and feeling low. It usually starts around the 3rd day, but usually goes by the 10th day after childbirth. It does not usually need any medical treatment. 'Baby blues' is not discussed further in this leaflet.
• Postnatal depression. This occurs in about 1 in 10 mothers. It usually develops within the first four weeks after childbirth. However, it can start several months or even up to one year following childbirth. Symptoms, including low mood, last for much longer than with baby blues. Treatment is advised. Most of this leaflet is about this common form of depression.
• Postnatal (puerperal) psychosis. This is an uncommon, but severe, form of depression. It develops in about 1 in 1000 mothers. It is discussed briefly at the end of this leaflet.

Sometimes postnatal depression can also affect a father after the birth of their child.

What are the symptoms of postnatal depression?

The symptoms are similar to those that occur with depression at any other time. They usually include one or more of the following. In postnatal depression, symptoms are usually there on most days, for most of the time, for two weeks or more.

• Low mood. Tends to be worse first thing in the morning, but not always.
• Not really enjoying anything. Lack of interest in yourself and your baby.
• Lack of motivation to do anything.
• Often feeling tearful.
• Feeling irritable a lot of the time.
• Feelings of guilt, rejection, or inadequacy.
• Poor concentration (like forgetting or losing things) or being unable to make a decision about things.
• Feeling unable to cope with anything.

You may also get thoughts about harming your baby. Around half the women with postnatal depression get these thoughts. If things are very bad you may get ideas of harming or killing yourself. The reality is that only in very rare cases is anyone harmed. If you have such thoughts, you must seek some help.

In addition, you may also have: less energy, disturbed sleep, poor appetite, and a reduced sex drive. However, these are common and normal for a while after childbirth, and on their own do not necessarily mean that you are depressed.

Why should you do anything about postnatal depression?

If you do nothing about the depression, or do not even know that you are depressed, you are likely to get better anyway in 3-6 months (like other types of depression). However, about 1 in 4 affected mothers are still depressed on their child's first birthday. There are a number of reasons to get help:

• To help yourself get better quickly. You need not feel like this. It is not a sign of weakness to admit that you are depressed.
• To help your partner or family. If you are depressed, it can cause problems in your relationships, your job, and life in general.
• To help your child (or children). If you are depressed, your relationship with your baby may not be as good as it could be. You may not give as much attention to your baby as you would like to. As a result, your baby's development may not be as quick as it might be. There is evidence to suggest that developmental problems that occur in the baby because of a mother's depression may persist in some cases even when the mother has recovered. Sometimes a young child's behaviour can also be affected if their mother had postnatal depression.

Many women are able to 'hide' their postnatal depression. They care for their baby perfectly well, and appear 'fine' to those around them. However, they suffer the condition as an internal misery. Do seek help if you are like this.

What causes postnatal depression?

The exact cause is not clear. Common misconceptions are that it is just due to hormone changes after you give birth and that it will go away by itself. Any mother can develop postnatal depression. Some studies suggest that depression after childbirth is no more common than at other times (depression is common). However, it is thought that women are more prone to develop depression just after childbirth.

The main cause seems to be stressful events after childbirth such as feelings of isolation, worry, and responsibility about the new baby, etc. In addition, you may be at greater risk of developing postnatal depression if you have/have had:

• Mental health problems in the past (including depression, previous postnatal depression, bipolar disorder or schizophrenia).
• Previous treatment by a psychiatrist or mental health team.
• Depression during your pregnancy.
• Postnatal depression that runs in your family.
• Marital or relationship problems.
• No close friends or family around you.
• Money troubles.
• Physical health problems following the birth (such as anaemia, incontinence, etc).

However, in many cases, there is no apparent cause.

How is postnatal depression diagnosed?

A doctor, midwife or health visitor will usually check for depression in all women who have recently given birth. They may ask the following two questions when they see you (this may be during one of your postnatal checks or visits):

• 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 you answer yes to either of these questions, they may ask a third question:

• Is this something you feel you need or want help with?

It is very important that you are truthful about how you are feeling. You should not think that having postnatal depression makes you a bad parent or will mean that your baby is taken away from you. This is extremely rare. Every aim when treating postnatal depression is to keep you with your baby wherever possible so that the bond between you can develop.

If the healthcare professional that you see suspects that you may have postnatal depression, they will usually refer you to your GP so that the diagnosis can be confirmed. The diagnosis of postnatal depression is usually made by your doctor based on what you, and those who know you, tell him or her. Tests are not usually needed but sometimes your doctor may do a blood test to make sure that there is not a physical reason for the symptoms such as an underactive thyroid or anaemia.

You may not recognise that you are depressed. However, your partner or a family member or friend will probably have noticed that you are different, and may not understand why. Sometimes a friend or family member may suggest that you see a doctor because they are worried that you may have postnatal depression.

What are the treatments for postnatal depression?

The type of treatment that is best for you can depend on various things including:

• How severe your depression is and what symptoms you have.
• The impact of your symptoms on your ability to function (to look after yourself and your baby).
• Whether you have had depression or other mental health problems in the past.
• The likely waiting time for any of the treatments.
• Your current situation.

Together you and your doctor should be able to decide which is the right treatment for you. The following are some of the treatments available. More than one treatment may be suggested in some cases.

Support and advice

Understanding and support from family and friends can help you to recover. It is often best to talk to close friends and family to explain how you feel rather than bottling up your feelings. Support and help from a health visitor can also help. Do tell your health visitor if you feel depressed as they may be able to talk things through with you.

Independent advice about any social problems may be available and of help (money issues, child care, loneliness, relationships, etc.). Ask your health visitor about what is available in your area. Also, ask about which support or self-help groups are available. You may be surprised at how many women feel the same way as you. Self-help groups are good at providing encouragement and support, as well as giving advice on how best to cope.

You may also benefit from some help from family and friends in caring for your baby. This may give you some time off to rest and/or to do some things for yourself.

Antidepressants

An antidepressant drug is often prescribed for women with postnatal depression, especially if the depression is moderate or severe. Symptoms such as low mood, poor sleep, poor concentration, irritability, etc, are often eased with an antidepressant. This may then allow you to function more normally, and increase your ability to cope better with your new baby.

Antidepressants do not usually work straight away. It takes 2-4 weeks before their effect builds up fully. A common problem is that some people stop the drug after a week or so as they feel that it is doing no good. You need to give it time. Also, if it is helping, follow the course that a doctor recommends. A normal course of antidepressants lasts up to six months or more after symptoms have eased. Some people stop treatment too early and the depression can quickly return.

There are several types of antidepressants, each with various 'pros and cons'. For example, they differ in their possible side-effects. (The leaflet that comes in the drug packet provides a full list of possible side-effects.) If the first one that you try does not suit, then another may be found that is fine. Therefore, tell your doctor if you have any problems with an antidepressant. Antidepressants are not tranquillisers and are not thought to be addictive.

About 5-7 in 10 people with moderate or severe depression improve within a few weeks of starting treatment with a prescribed antidepressant. However, up to 3 in 10 people improve with dummy tablets (placebo) as some people would have improved in this time naturally. So, you are roughly twice as likely to improve with antidepressants compared to taking no treatment. But, antidepressants do not work in everybody.

Some antidepressants come out in breastmilk. The amounts are very small and are unlikely to cause any harm to the baby. However, if you are breastfeeding your doctor is likely to choose a drug that is well established and has a good safety record with breastfeeding mothers rather than a newer drug with less data about confirming safety in babies.

Counselling

Some studies suggest that counselling types of treatment given by trained health visitors in short sessions over several weeks can be of help to ease postnatal depression. The counsellor can listen to your problems and help you reflect on things and make decisions. Some women find this very helpful.

Psychological treatments

Another treatment option is to be referred to a psychologist or other professional for a psychological treatment. There are various types, but their availability on the NHS can vary in different parts of the country. Psychological treatments include the following:

• Cognitive-behavioural therapy (CBT). This is a combination of cognitive therapy and behaviour therapy. Briefly, cognitive therapy is based on the idea that certain ways of thinking can trigger, or 'fuel', certain mental health problems such as depression. The therapist helps you to understand your thought patterns. In particular, to identify any harmful, unhelpful, and 'false' ideas or thoughts which you have that can make you depressed. The aim is then to change your ways of thinking to avoid these ideas. Also, to help your thought patterns to be more realistic and helpful. Therapy is usually done in weekly sessions over several months. You are likely to be given 'homework' between sessions. Behaviour therapy aims to change any behaviours which are harmful or not helpful. In short, CBT helps people to achieve changes in the way that they think, feel and behave. (See separate leaflet called 'Cognitive Behaviour Therapy (CBT)' for more details.)
• Interpersonal therapy. This type of psychological therapy can help you to identify any problems in your relationships with family, friends, partners, and other people, and see how these may relate to your depression and other problems.
• Other types of therapy including problem-solving therapy and psychodynamic psychotherapy may also be used to treat postnatal depression.

For moderate depression, the number of people who improve with cognitive behavioural therapy is about the same as with antidepressants. Psychological treatments may not be so good for some people with severe depression. This is because you need some motivation to do these treatments and people with severe depression often find motivation difficult.

Another thing to bear in mind is that psychological treatments are sometimes not practical for women with postnatal depression due to the time commitments required. Unfortunately, there is also often a waiting list. Sometimes computer-based cognitive behavioural therapy may be available, or it may be available over the internet, or via telephone using interactive voice response systems.

Some research suggests that a combination of an antidepressant plus a psychological treatment such as CBT may be better than either treatment alone.

Exercise

Regular exercise such as jogging, swimming, gym sessions, etc, is thought to help ease symptoms (if you are able to do some exercise).

Other treatments

St John's Wort (hypericum)

This is a herbal antidepressant that you can buy from pharmacies without a prescription. It recently became a popular 'over the counter' treatment for depression. There is some evidence that it may be helpful for mild or moderate depression. However, there is still some uncertainty about its use. This is because:

• It is not clear exactly how well it works. Although some studies suggest that it may help depression, other studies have failed to confirm this.
• Side-effects sometimes occur. (Some people think that because St John's wort is 'natural' then it is totally safe. This is not true. It contains many chemicals which sometimes cause problems.)
• It may react with other drugs that you may take. Sometimes the reactions can cause serious problems. For example, you should not take St John's wort if you are taking warfarin, the oral contraceptive pill, ciclosporin, anticonvulsants, digoxin, theophylline, or some anti-HIV drugs. Also, you should not take it at the same time as some prescribed antidepressants.

Note: St John's wort is not recommended if you are breastfeeding. This is because there is only limited information about its safety during breastfeeding.

Specialist and hospital based treatments

If your depression is severe, or does not get better with treatment, your doctor may suggest that they refer you to a specialist mental health team. They may be able to suggest other treatments such as specialist drugs. Occasionally, admission to hospital may be needed. Ideally this would be to a mother and baby unit so that your baby can stay with you.

Some dos and don'ts about depression

• Don't bottle things up and 'go it alone'. Try and tell people who are close to you how you feel. It is not weak to cry or admit that you are struggling.
• Don't despair. Most people with depression recover. It is important to remember this.
• Do try and distract yourself by doing other things. Try doing things that do not need much concentration but can be distracting such as watching TV. Radio or TV is useful late at night if sleeping is a problem.
• Do eat regularly, even if you do not feel like eating.
• Don't drink too much alcohol. Drinking alcohol is tempting to some people with depression as the immediate effect may seem to relieve the symptoms. However, drinking heavily is likely to make your situation worse in the long run.
• Don't make any major decisions whilst you are depressed. If possible, delay any major decisions about relationships, jobs, or money until you are well again.
• Do tell your doctor if you feel that you are getting worse, particularly if suicidal thoughts are troubling you.

Will it happen again?

If you have an episode of postnatal depression you have a greater than average chance of it happening again if you have another baby. About 3 in 10 mothers who have postnatal depression have another episode of depression if they have another baby. However, you and your doctor are more likely to be aware of the possibility in future pregnancies. This means that you are more likely to be diagnosed and treated promptly should it recur.

What is postnatal (puerperal) psychosis?

Postnatal psychosis is an uncommon, but severe, form of depression that can occur after childbirth. As well as symptoms of severe depression, there are also other serious symptoms such as delusions (false beliefs), hallucinations (such as hearing voices), odd behaviours, and irrational thoughts. Affected mothers may not recognise that they are ill. Postnatal psychosis usually occurs within the first month of giving birth. Women generally need to be admitted to hospital with their baby for treatment.

If you are a relative or friend of a mother who appears to be acting strangely, then do alert a doctor or health visitor. There is a risk of harm to both mother and baby in this uncommon, but serious, mental illness. But note: the vast majority of women with postnatal depression do not develop this severe form of depression.

Further help and information

See you health visitor for further advice. The following may also be of help:

Association for Post-Natal Illness

145 Dawes Road, Fulham, London, UK, SW6 7EB
Tel: 020 7386 0868 Web: www.apni.org
Aims to help women who suffer from postnatal depression.

PNi-SHA - PostNatal illness-Support & Help Association

PO Box 7066, Ashbourne, Derbyshire, DE6 1JQ
Web: www.pnisha.org.uk
A charitable organisation which offers information, emotional support and practical help to women and their families affected by any type of antenatal and postnatal illness.

MAMA (Meet-A-Mum-Association)

Helpline: 0845 120 3746 (7pm - 10pm, weekdays only) Web: www.mama.co.uk
Services includes advice and support for mothers with postnatal depression.