The National Institute for Clinical Excellence (NICE) has released guidance on the management of mental health conditions in the antenatal and postnatal period.¹ NICE prefers not to use the term postnatal depression (PND) per se as it is concerned that it should not be used as an umbrella term for all mental illness following delivery.

Depression can occur de novo, can be a recurrence of a depressive condition occurring prior to pregnancy, or be a symptom of a major psychosis such as bipolar disorder.¹ Nevertheless, PND is a widely recognised concept in the literature, and is considered to be a useful term in many circumstances.

The Scottish Intercollegiate Guidelines Network (SIGN) defines PND as any non-psychotic depressive illness of mild to moderate severity occurring during the first postnatal year.²

Epidemiology

PND is common. The incidence in the first month after childbirth is three times the average monthly incidence in non-childbearing women. A meta-analysis of studies mainly based in the developed world found the incidence of PND to be 12-13% with higher incidence in developing countries.³

Risk factors

These include:³

• Past history of any psychopathology (including history of previous PND)
• Low social support
• Poor marital relationship
• Recent life events, e.g. bereavement
• Spousal disappointment with the gender of the newborn child in some cultures

A number of studies also suggest the following factors may be important:⁴

• Parents' perceptions of their own upbringing
• Unplanned pregnancy
• Unemployment
• Not breastfeeding
• Antenatal parental stress
• Antenatal thyroid dysfunction
• Coping style
• Longer time to conception
• Depression in fathers
• Emotional lability ('baby blues')
• Low-quality social support
• Having two or more children

Presentation

PND presents with similar symptoms to general depression but with some variation:

• 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:

• 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?

Health professions may consider using the Edinburgh Postnatal Depression Scale (EPDS)⁵, the Hospital Anxiety and Depression (HAD) Scale^6,7 or the Patient Health Questionnaire-9 (PHQ-9)⁸ as part of subsequent assessment or to monitor treatment.

Management

General measures

• Empowerment:
  Involve patients in decisions about their care. For patients who lack capacity, follow the Department of Health guidelines - Reference Guide to Consent for Examination or Treatment (2001)⁹ - and the code of practice accompanying the Mental Capacity Act (which came into force in April 2007).¹⁰ 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 (e.g. 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 Health 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 breastfeeding.¹

Psychological strategies¹

• 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 CBT, computerised CBT, or exercise .¹¹
• Non-directive counselling delivered at home (listening visits).
• Brief CBT or interpersonal psychotherapy.

Pharmacological therapy¹

• 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 breastfeeding mothers. The tricyclics imipramine and nortriptyline and the serotonin reuptake inhibitor (SSRI) sertraline are present in breast milk at relatively low levels, whilst the SSRIs fluoxetine and citalopram are present in breast milk at relatively high levels. SSRIs are however better tolerated and less toxic in overdose than tricyclics. NICE does not go as far as recommending any particular drug or group of drugs, and there are indeed no conclusive trials supporting the risk-benefits of any particular drug. Several guidelines support the use of fluoxetine or paroxetine, and consider that reservations concerning their effects on the baby during breastfeeding have been exaggerated.^2,3,12
• Hormones:
  There is no place for synthetic progestogens in the treatment of PND. Long-acting norethisterone is in fact associated with an increased risk of PND. This means that progesterone-only contraceptives should be used with caution in the postnatal period, especially in women with a history of depression before or during pregnancy.^12,13 Oestrogen therapy may be of modest value at a late stage of severe PND.¹³

Management of severe depression

Patients with 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 too severe a depression 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

Although some cases of PND last less than three months, 30-50% may last for more than six months. One in four affected mothers is still depressed on the child's first birthday. Suicide is the main cause of maternal deaths in the first year postpartum, in the developed world. PND is associated with reduced likelihood of mother-baby bonding and impaired cognitive and emotional development of the child, particularly in areas of socio-economic deprivation.³

Prevention

Psychological support¹

• NICE recommends 4-6 sessions of CBT or interpersonal psychotherapy for pregnant women who have symptoms of depression and/or anxiety that do not meet diagnostic criteria but have had a previous episode of depression and anxiety, and have symptoms that significantly interfere with personal and social functioning.¹ For women who have symptoms but no previous such history, social support in the form of regular informal individual or group-based support should be offered. There is no evidence to support the use of such intervention otherwise.
• Single-session formal debriefing focused on the birth should not be routinely offered to women who have experienced a traumatic birth, but 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.
• Mothers whose infants are stillborn or die soon after birth should not be routinely encouraged to see and hold the dead infant, but should be offered an appropriate follow-up appointment in primary or secondary care.

Pharmacological methods

A role for oestrogen and for SSRIs has been mooted, but to date there is no definitive evidence to support the use of either.^14,15

Document references

1. Antenatal and postnatal mental health: clinical management and service guidance, NICE Clinical Guideline (February 2007); (amended April 2007)
2. Postnatal depression and puerperal psychosis, SIGN (2002)
3. Howard L; Postnatal Depression Clinical Evidence 2006
4. SIGN; Publication No. 60 (2002) - Postnatal Depression and Puerperal Psychosis
5. Edinburgh Postnatal Depression Scale, University of California, San Francisco
6. Hospital Anxiety and Depression (HAD) Scale, NHS Specialist Libraries; MS Word document
7. Hospital Anxiety and Depression (HAD) Scale, GL Assessments; for purchase of questionnaire from copyright owners
8. PHQ9 - Patient Health Questionaire
9. Department of Health; Good practice in consent implementation guide: consent to examination or treatment; Department of Health; Nov 2001.
10. Mental Capacity Act 2005; Department of Health 2007
11. MIND; Making sense of cognitive behaviour therapy 2007
12. Hoffbrand S, Howard L, Crawley H; Antidepressant drug treatment for postnatal depression. Cochrane Database Syst Rev. 2001;(2):CD002018. [abstract]
13. Lawrie TA, Herxheimer A, Dalton K; Oestrogens and progestogens for preventing and treating postnatal depression. Cochrane Database Syst Rev. 2000;(2):CD001690. [abstract]
14. Howard LM, Hoffbrand S, Henshaw C, et al; Antidepressant prevention of postnatal depression. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD004363. [abstract]
15. McGillivray S, Arroll B, Hatcher S et al; Efficacy and tolerability of selective serotonin reuptake inhibitors compared with tricyclic antidepressants in depression treated in primary care: systematic review and meta-analysis BMJ 2003;326:1014 (10 May).

Internet and further reading

• Depression - antenatal and postnatal, Clinical Knowledge Summaries (March 2008)
• Postnatal depression. Mums who have had postnatal depression talk about the feelings they faced, and perinatal psychiatrist Dr Margaret Oates explains how it can be treated quickly with the right help. A short video from NHS Choices. (October 2007)

Acknowledgements