Postnatal Depression: A need for vigilance

Postnatal depression is under-reported, often under- or misdiagnosed and usually undertreated. But practice nurses, with their frequent contact with new mothers, are ideally placed to reverse this unhappy situation

In our culture motherhood is idealised - media images of happy, successful mothers with beautiful, smiling babies are everywhere.¹ Having a baby usually is a joyful experience but it can also be a time of emotional upheaval and psychological difficulty.² Even when all goes smoothly, suddenly finding you are responsible 24 hours a day for a little helpless human being whose main method of communication is crying is daunting, and feeling emotional and tearful for a short period affects up to 85% of new mothers.^1,2

These 'baby blues,' which usually peak around the 3rd to 5th day after birth and are over by the 10th day,³ are generally manageable and regarded as 'normal'.² But sometimes difficult feelings become unmanageable, and a deeper and longer term postnatal depression (PND) that impacts on daily life occurs.³

PND often starts in the first two months of giving birth, but can start several months after having a baby. For a third of women, symptoms begin in pregnancy and continue.³ According to the Royal College of Psychiatrists, 10 to 15% of mothers are thought to experience PND,3 but this may be a serious underestimate.¹ Of 5,300 mothers who responded to a survey conducted by the parenting charity 'netmums', a staggering 52% said they had experienced PND, whether diagnosed or not.⁴ The charity, '4Children' suggests there is a 'silence' around PND with health professionals failing to identify it, and half of new mothers seeking no help for it.⁵ Many Primary Care Trusts collected no information on the prevalence, severity or treatment of PND.⁵ If up to half of new mothers are not to suffer in silence,5 we need better vigilance, understanding and treatment of PND with further research and good statistics.¹

ORIGINS OF POSTNATAL DEPRESSION

PND can arise whatever the circumstances, and whether or not the baby is the first. Often there is no obvious reason for PND and there is no single cause, but some possibilities may account for it.³ However much a woman longs for a baby, and however uncomplicated the birth, major changes take place which affect self esteem and how a woman feels about herself.¹ Body shape alters, relationships with friends, family, and partner can be affected, sex life and career status may be disrupted and sleep will be disturbed. If there are extra stresses such as illness, bereavement, moving house, loss of employment or poverty, PND is more likely.² Women who have a history of depression or other mental health problems are at particular risk, as are those without support from family or friends — a sense of isolation can be the most stressful aspect of mothering.^1,3 An unsupportive or abusive partner, being very young, having a sick or premature baby can also contribute to PND.¹ Childhood experiences such as early separation or abuse, or loss of a parent, may surface and can be very troubling.² Physical problems such as an under-active thyroid can also be a factor.³ Women such as recent immigrants, refugees or asylum seekers giving birth in an unfamiliar environment are more vulnerable to PND.² A difficult labour can play a part in PND, and when labour is traumatic, there is the added risk of post traumatic stress disorder characterised by flashbacks, nightmares and a feeling the experience is being constantly repeated, playing like a film in the mind.⁶

COMMON SYMPTOMS²

Some of the symptoms of PND are similar to those experienced in any other form of depression, but others are more specific to the new parent. They include:

• Feeling low and hopeless
• Feeling tired, lethargic or numb, with little interest in the outside world
• A sense of inadequacy and inability to cope
• Feelings of guilt (about not coping or not loving the baby enough)
• Feeling irritable and/or tearful
• Loss of appetite
• Difficulty sleeping
• Feelings of hostility towards partner, baby or others
• Thoughts about death
• Obsessive fears about the baby's health or wellbeing
• Loss of libido
• Difficulty concentrating and/or making decisions
• Panic attacks, involving overpowering anxiety (e.g. about being left alone in the house)
• Physical symptoms such as stomach pains, headaches, blurred vision

FAILING TO IDENTIFY PND

If PND goes unrecognised, it is more likely to be long lasting and severe, spoiling the experience of early motherhood and straining relationships with partner, baby and other family members.² There is evidence too that PND can affect the child's development and behaviour, even after the depression ends.³ Although most cases of PND resolve spontaneously, this may not be for several months after onset, so early intervention and appropriate treatment are crucial.²

TREATMENT

The best treatment for PND is a combination of practical support, advice, counselling or psychotherapy and if necessary, antidepressants.² Sources of help include the GP, midwife, health visitor, counsellor or psychotherapist. But practice nurses who see new mothers for a variety of reasons, including baby immunisations, may be the first to suspect PND. At a time when women are expected to feel emotionally turbulent and exhausted, considerable skill is needed in diagnosing PND.³ Anxious mothers may not realise they are ill, may feel symptoms are not bad enough to get help, or fear their baby may be taken away from them.⁵ Good communication, with a gentle tone and warm approach, is essential if a trusting relationship is to develop. There are two simple but specific questions NICE7 recommends that you ask:

1. During the past month have you been bothered by feeling down, depressed or hopeless?

2. During the past month have you been bothered by having little interest or pleasure in doing things?

If the answer to both questions is yes, then a third question is asked

3. Is this something you need or want help with?

If the mother answers yes to the third question, we can reassure her that what she is experiencing is not peculiar to her and there are effective treatments. We may not be equipped to diagnose PND and it is essential we liaise with our colleagues, the GP, midwife and or health visitor, letting them know our concerns. But practice nurses are well placed to signpost routes to emotional and practical support.

PND can be lonely, distressing and frightening and a survey by '4Children' found:

• 65% of women wanted more information regarding support groups
• 52% would have liked more information about talking therapies
• 40% were not satisfied with the information they received5

For affected women, it can be a relief to talk about their true feelings and know others feel the same way. A postnatal support group can reduce isolation and speed recovery.² Some trained health visitors offer counselling at home, or the new mother may be referred for counselling, or psychotherapy which can help to uncover causal factors that may have contributed to PND, and alter the way she feels.² Brief cognitive behavioural therapy (CBT) offers practical strategies for dealing with the problem.³ In PND drugs should be used with caution and antidepressants should only be considered if the woman has a history of severe depression and her mild symptoms worsen or don't improve.^1,2 Yet '4Children' found in their survey that 70% of new mothers were automatically prescribed antidepressants when they asked for help, and many experienced a lack of empathy from health professionals.⁵ Talking therapies may produce a better long term outcome than antidepressants alone, and NICE says they should be more widely available.⁷

PUERPERAL PSYCHOSIS

There is a severe form of PND, puerperal psychosis, which is much less common, occurring in about one per 1,000 women.³ Puerperal psychosis requires specialist treatment in an inpatient mother and baby unit, and treatment with antipsychotic drugs.¹ Symptoms include:

• Mania (for example, cleaning floors in the middle of the night)
• Severe depression with delusions (seeing objects or people that are not there)
• Confusion or stupor
• Extreme mood swings
• Loss of touch with reality²

Puerperal psychosis usually begins suddenly, often without warning, a few weeks after birth. The mother will be restless, excitable or elated, and unable to sleep. She may find it hard to relate to her environment, failing to recognise friends and family.³ It is hard for her to bond with her baby and the behaviour is disturbing for those around her.² Psychiatric treatment is essential.

FATHERS EXPERIENCE POSTNATAL DEPRESSION TOO

It is now recognised that fathers may also become depressed, with as many as 1 in 25 affected.² Causes include pressures of fatherhood, increased responsibility and expense, and changes in life style. When the baby arrives, the father may feel left out and hurt, or may feel unable to support his partner, or find it hard to adjust to the demands of a new baby.⁵ Lack of sleep can cause irritability, and anxiety and may contribute to male PND.

If fathers are depressed after the birth, children, especially boys, are at increased risk of emotional and behavioural problems.² More than 50% of women in the '4Children' survey wished their partner had been given more information on PND, 30% said their partner needed to discuss his anxieties with someone, and 11% wanted treatment for their partner who also experienced PND.⁵ Yet studies have found that both midwives and health visitors may see fathers as difficult and potentially aggressive and may marginalise them when working with the family.² Few services exist for men, though awareness of this problem is improving slowly.²

CONCLUSION

No one can say exactly why one woman may suffer PND and another may not, or why the disorder is on the increase.¹ However, today's mothers have a different experience of childbirth and parenting to that of their own mothers and grandmothers. Formerly mothers could rely on the extended family for emotional and practical support. Now there is every chance the new mother's own mother is in the workplace or living far away.¹ Health visitors have huge caseloads and visits may be brief. There are manuals offering competing views on how to feed, wean, and interact with babies. PND is a horrible experience and mothers may feel unsupported, confused and anxious as they struggle to do the right thing.² But if it is recognised in the early stages and treated, PND is a temporary condition from which parents can recover4 and practice nurses can play a key role in bringing PND to light.

REFERENCES

1. Bueno J. Life after birth. Therapy Today 2010;21(4):19-21 www.therapytoday.net

2. MIND. Postnatal depression. Available at: http://www.mind.org.uk/mental_health_a-z/8007_postnatal_depression (Accessed May 2013)

3. Royal College of Psychiatrists. Postnatal depression. Available at: http://www.rcpsych.ac.uk/expertadvice/problemsdisorders/postnataldepression.aspx (Accessed May 2013)

4. Netmums. Screening for Postnatal depression. Available at: http://www.netmums.com/home/netmums-campaigns/screening-for-post-natal-depression (Accessed May 2013)

5. 4Children. Suffering in silence (2011). www.4children.org.uk/Page/Give-me-strength (Accessed May 2013)

6. Briggs G. The birth of my nightmares The Times, 23 November 2011: 10-11

7. NICE. Antenatal and postnatal health. Clinical guideline 45. Available at: http://www.nice.org.uk/CG45