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Postnatal depression

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Postnatal depression



Introduction 

Postnatal depression is a type of depression some women experience after having a baby.

It can develop within the first six weeks of giving birth, but is often not apparent until around six months.

Postnatal depression is more common than many people realise, affecting around one in 10 women after having a baby.

Women from all ethnic groups can be affected. Teenage mothers are particularly at risk.

Postnatal depression can sometimes go unnoticed and many women are unaware they have it, even though they don't feel quite right.

The symptoms of postnatal depression are wide-ranging and can include low mood, feeling unable to cope and difficulty sleeping.

Signs and symptoms 

Mood changes, irritability and episodes of tearfulness are common after giving birth. These symptoms are often known as the "baby blues" and they usually clear up within a few weeks. However, if your symptoms are more persistent, it could be postnatal depression.

Some women don’t recognise they have postnatal depression, or they choose to ignore their symptoms because they’re afraid of being seen as a bad mother.

If you think that a partner, relative or friend is showing the signs and symptoms of postnatal depression, be supportive and encourage her to see a GP.

It's very important to understand that postnatal depression is an illness. If you have it, it doesn't mean you don't love or care for your baby.

Postnatal depression screening

Your GP will ask you the following two questions if they suspect you have postnatal depression:



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



During the past month, have you often taken little or no pleasure in doing things that would normally make you happy?



It's possible you have postnatal depression if you answer yes to either question. If you answer yes to both questions, it's likely you have postnatal depression.

If you answer yes to either of the above two questions, your GP may also ask you:



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



Treating postnatal depression

Postnatal depression can be lonely, distressing and frightening, but there are many treatments available.

As long as it's recognised and treated, postnatal depression is a temporary condition you can recover from.

It's very important to seek treatment if you think you or your partner has postnatal depression. The condition is unlikely to get better by itself quickly and it could impact on the care of the baby.

Treatment for postnatal depression includes:



self-help advice



talking therapies, such as cognitive behavioural therapy (CBT)



antidepressant medication



Why do I have postnatal depression?

The cause of postnatal depression isn't clear, but it's thought to be the result of several things rather than a single cause. These may include:



the physical and emotional stress of looking after a newborn baby, particularly a lack of sleep



hormonal changes that occur shortly after pregnancy; some women may be particularly sensitive to these changes



individual social circumstances, such as money worries, poor social support or relationship problems



The following will put you at greater risk of developing postnatal depression:



a previous history of depression or other mood disorders



a previous history of postnatal depression



if you experience depression or anxiety during pregnancy



Preventing postnatal depression

You should tell your GP if you've had postnatal depression in the past and you're pregnant, or if you're considering having another baby. A previous history of postnatal depression increases your risk of developing it again.

If you keep your GP informed, they'll be aware that postnatal depression could develop after your baby is born. This will prevent a delay in diagnosis and treatment can begin earlier. In the early stages, postnatal depression can be easy to miss.

The following self-help measures can also be useful in preventing postnatal depression:



get as much rest and relaxation as possible



take regular gentle exercise



don't go for long periods without food, as low blood sugar levels can make you feel much worse



don't drink alcohol because it can make you feel worse



eat a healthy, balanced diet



Symptoms of postnatal depression 

Postnatal depression can affect women in different ways.

Symptoms can start soon after giving birth and last for months or, in severe cases, they can persist for more than a year.

The main symptoms of postnatal depression are:



a persistent feeling of sadness and low mood



loss of interest in the world around you and no longer enjoying things that used to give pleasure



lack of energy and feeling tired all the time (fatigue)



Other symptoms can include:



disturbed sleep, such as having trouble sleeping during the night and then being sleepy during the day



difficulties with concentration and making decisions



low self-confidence



poor appetite or an increase in appetite ("comfort eating")



feeling very agitated or, alternatively, very apathetic (you can’t be bothered)



feelings of guilt and self-blame



thinking about suicide and self-harming



Postnatal depression can interfere with your day-to-day life and can be associated with increased anxiety. Some women feel they're unable to look after their baby, or they feel too anxious to leave the house or keep in touch with friends.

Frightening thoughts

Some women who have postnatal depression get thoughts about harming their baby. These thoughts, known as obsessional ruminations, are very rarely acted upon.

Harmful thoughts are believed to be extremely common. However, it's difficult to know exactly how common they are because many mothers feel too ashamed to admit to having such thoughts and think it might encourage the involvement of social services.

If you're troubled by thoughts of harming your baby or yourself, it's best you discuss it with your GP who may refer you for specialist help.

Treatment will benefit both your health and the healthy development of your baby, as well as your relationship with your partner, family and friends. Seeking help for postnatal depression doesn't mean you're a bad mother or unable to cope.

Spotting the signs in others

Many mothers don't recognise they have postnatal depression and don't talk to family and friends about their true feelings.

It's therefore important for partners, family members and friends to recognise the signs of postnatal depression at an early stage.

Warning signs in new mothers include:



frequently crying for no obvious reason



having difficulty bonding with their baby



neglecting themselves – for example, not washing or changing their clothes



losing all sense of time – for example, being unaware whether 10 minutes or two hours have passed.



losing all sense of humour and not being able to see the funny side of anything



worrying that something is wrong with their baby, regardless of reassurance



If you think someone you know has postnatal depression, encourage them to open up and talk about their feelings to you, a friend, GP or health visitor.

Postnatal depression needs to be properly treated and isn't something you can just snap out of.

Postnatal psychosis

Postnatal psychosis is a rarer and more serious mental health condition that can develop after giving birth. It's thought to affect around one in 1,000 women.

Symptoms of postnatal psychosis include:



bipolar-like symptoms – feeling depressed one moment and very happy the next



believing things that are obviously untrue and illogical (delusions) – often relating to the baby, such as thinking the baby is dying or that either you or the baby have magical powers



seeing and hearing things that aren't really there (hallucination) – this is often hearing voices telling you to harm the baby



 

Postnatal psychosis is regarded as a medical emergency.

If you think there's a danger of imminent harm to you, your partner or your baby, call your local A&E services and ask to speak to the duty psychiatrist.  

Postnatal OCD

Some women develop a mental health condition called obsessive compulsive disorder (OCD) after giving birth.

An obsession is an unwanted, unpleasant thought, image or urge that repeatedly enters a person's mind, causing them anxiety. A compulsion is a repetitive behaviour or mental act that someone feels they need to carry out to try to prevent an obsession coming true.

For example, someone who is obsessively scared they will catch a disease may feel the need to have a shower every time they use a toilet.

Causes of postnatal depression 

The cause of postnatal depression isn't completely clear. Most experts think it's the result of a combination of factors.

These may include:



depression during pregnancy



a difficult delivery



lack of support at home



relationship worries



money problems



having no close family or friends around you



physical health problems following the birth, such as urinary incontinence (loss of bladder control), or persistent pain from an episiotomy scar or a forceps delivery



Even if you don't have any of these problems and your pregnancy and labour is straightforward, having a baby can be a stressful and life-changing event that can sometimes trigger depression.

People often assume they'll naturally adapt to parenthood overnight. However, it can take months before you begin to cope with the pressures of being a new parent. This is true even for those who already have children.

In addition, some babies are more difficult and demanding than others and don't settle so easily. This can lead to exhaustion and stress.

Who's at risk

Factors that can increase your risk of experiencing postnatal depression include having:



a family history of depression or postnatal depression (genetics appears to play a role in both of these conditions but exactly how is still unclear)



previously experiencing depression, postnatal depression or other mood disorders



The role of hormones

It was once thought that huge changes in hormone levels during and after pregnancy were the sole cause of postnatal depression. This is no longer thought to be the case, although changes in hormone levels may still play a part.

One theory is that some women are more sensitive to the effects of falling hormone levels after they've given birth. All mothers will experience hormonal changes but only some mothers will be affected emotionally.

It's possible that this, as well as the stress of looking after a baby or money problems, may trigger the depression.

 


Postnatal depression in men

Postnatal depression can also affect men. A 2011 study found that like mothers, around one in 10 fathers experienced depression after the birth of their child.

Having a baby can be stressful for both parents, and some fathers feel unable to cope or that they’re not giving their partner enough support.

Visit your GP if you’ve recently become a father and you have depression. The treatment for men is much the same as for women.

Diagnosing postnatal depression 

If your GP suspects you have postnatal depression they'll ask you two screening questions.

These are:



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



During the past month, have you often taken little or no pleasure in doing things that normally make you happy?



It's possible you have postnatal depression if you answer yes to either of these questions. If you answer yes to both questions, it's likely you have postnatal depression.

If you answer yes to either of the above questions, your GP may also ask you whether you feel you need or want help.

Some mothers, particularly those without a partner or relative to help care for their baby, can be reluctant to answer these questions honestly. This is because they worry that being diagnosed with postnatal depression will mean they're seen as a bad mother and their baby may be taken into care.

However, it's important to realise there are often many different complicating factors associated with postnatal depression, and a baby will only be taken into care in the most exceptional of circumstances. One of the main goals of treating postnatal depression is to help you care for and bond with your baby.

Even if your symptoms of postnatal depression are so severe you require treatment at a mental health clinic, specialist mother and baby clinics are available.

Other tests

Sometimes, your GP may carry out blood tests to make sure there isn't a physical reason for symptoms like tiredness and low mood, such as an underactive thyroid gland or anaemia (lack of red blood cells which can lead to tiredness). These conditions often occur after having a baby.

Sometimes, your GP or health visitor may ask you to complete a questionnaire, such as the Edinburgh Postnatal Depression Scale (EPDS) (PDF, 136kb). This can help assess your situation by focusing on certain symptoms and difficulties commonly encountered in postnatal depression. It can also help to track your response to treatment as you get better.

Assessing the severity of postnatal depression

If your GP suspects postnatal depression, they'll want to know your symptoms so they can assess how severe it is.

They'll want to know if you have:



disturbed sleep



problems concentrating or making decisions



low self-confidence



a loss of appetite or increased appetite (comfort eating is often a symptom of depression)



been feeling anxious



been feeling tired, listless and reluctant to undertake physical activity



been feeling guilty or self-critical



been experiencing suicidal thoughts



Honesty is important when answering these questions because providing your GP with accurate information will ensure you receive appropriate treatment.

If you have three of the above symptoms, it's likely you have mild depression.

If you have five or six symptoms, it's likely you have moderate depression. People with moderate depression will have great difficulty carrying out normal activities.

The number of symptoms you have in total, and above all their severity and persistence, will help your doctor decide whether your depression is mild, moderate or severe.

If you have all of the above symptoms, it's likely you have severe depression. People with severe depression are unable to function at all, and almost always need help from a dedicated mental health team.

Treating postnatal depression 

Speak to your GP, midwife or health visitor as soon as possible if you think you have postnatal depression.

It's important for you and your family to remember it can take time to recover fully from the condition.

Common treatments and help for postnatal depression are detailed below.

Support and advice

The most important first step in managing postnatal depression is recognising the problem and taking action to deal with it. The support and understanding of your partner, family and friends plays a big part in your recovery.

However, to benefit from this, it's important for you to talk to those close to you and explain how you feel. Bottling everything up can cause tension, particularly with your partner, who may feel shut out.

Support and advice from social workers or counsellors can also be helpful. Self-help groups can provide good advice about how to cope with the effects of postnatal depression, and you may find it reassuring to meet other women who feel the same as you.

Ask your health visitor about the services in your area.

Exercise

Exercise has been proven to help depression, and it's one of the main treatments for mild depression.

Your GP may refer you to a qualified fitness trainer who will be able to provide you with a suitable exercise programme.

Psychological treatments

Psychological therapies are usually recommended as the first line of treatment for mild-to-moderate postnatal depression for women with no previous history of mental health conditions.

Some common ones are discussed below.

Guided self-help

Guided self-help is based on the principle that your GP can "help you to help yourself".

For example, your GP can provide self-help manuals detailing types of issues you might be facing and practical advice on how to deal with them. They also contain information on using cognitive behavioural techniques to help combat feelings of helplessness (see below for more information).

Your GP may also give you details about an interactive computer programme that's available on the internet, called Beating the Blues. This also takes a cognitive behavioural approach to battling depression.

Talking therapies

Talking therapies are where you're encouraged to talk through problems either one-to-one with a counsellor or with a group. You can then discuss ways to approach problems in a more positive manner.

Cognitive behavioural therapy (CBT) and interpersonal therapy are two talking therapies widely used in the treatment of postnatal depression.

Cognitive behavioural therapy

CBT is a type of therapy based on the idea that unhelpful and unrealistic thinking leads to negative behaviour.

CBT aims to break this cycle and find new ways of thinking that can help you behave in a more positive way.

For example, thinking there's a perfect ideal of "motherly behaviour" that is both unrealistic and unhelpful. All mothers are human and humans make mistakes. It's neither necessary nor helpful to try and be “Supermum”.

CBT is usually provided in four to six weekly sessions.

Interpersonal therapy

Interpersonal therapy (IPT) aims to identify whether your relationships with others may be contributing towards feelings of depression.

Again, IPT is usually provided in four to six weekly sessions.

Antidepressants

Antidepressants may be recommended if:



you have moderate postnatal depression and a previous history of depression



you have severe postnatal depression



you've not responded to counselling or CBT or would prefer to try tablets first



A combination of talking therapies and an antidepressant may be recommended.

Antidepressants work by balancing mood-altering chemicals in your brain. They can help ease symptoms such as low mood, irritability, lack of concentration and sleeplessness, allowing you to function normally and helping you cope better with your new baby.

Contrary to popular myth, antidepressants aren't addictive. A course usually lasts six to nine months.

Antidepressants take two to four weeks to start working, so it's important to keep taking them even if you don't notice an improvement straight away. You should also continue taking your medicine for the full length of time recommended by your doctor. If you stop too early, depression may return.

Between 50-70% of women who have moderate to severe postnatal depression improve within a few weeks of starting antidepressants. However, they're not effective for everyone. 

Antidepressants and breastfeeding

Selective serotonin reuptake inhibitors (SSRIs) are a type of antidepressants that are often recommended for breastfeeding women.

However, some SSRIs, such as fluoxetine, should be avoided while breastfeeding. The doctor who is treating you will prescribe an SSRI that is suitable for you to use.

Side effects of SSRIs include:



feeling sick



blurred vision



diarrhoea or constipation



dizziness



feeling agitated or shaky



insomnia (not sleeping well) or feeling very sleepy



These side effects should pass once your body gets used to the medication.

You should discuss feeding options with your GP when you're making decisions about taking antidepressants.

Many mothers are keen to continue breastfeeding because they feel it helps them to bond with their child and boosts their self-esteem and confidence in maternal abilities. These are important factors in combating symptoms of postnatal depression.

Severe postnatal depression

Referral

You may be referred to a mental health team if you have severe postnatal depression, or if it doesn't respond to treatment. These teams are usually made up of a range of specialists, including psychologists, psychiatrists, specialist nurses and occupational therapists.

The specialist team will be able to provide you with a more intensive course of CBT to help you overcome your depression. If necessary, other types of talking therapies, such as psychotherapy, can be given at a later stage.

If it's felt your postnatal depression is so severe you're at risk of harming yourself or your baby, you may be admitted to hospital or referred to a mental health clinic. If you have the support of your partner or family, it may be recommended they care for your baby until you're well enough to return home.

If you don't have support available to help you care for your baby, or your mental health team feels separation from your baby would adversely affect your recovery, a transfer to a specialised "mother and baby" mental health clinic may be recommended.

Your baby may have to sleep in a separate nursery until you're well enough to look after them. Once your symptoms begin to respond to treatment, your baby will sleep in your room.

Medication

A small number of women develop symptoms of psychosis after giving birth (being unable to tell the difference between reality and their imagination).

This is termed puerperal psychosis and if this happens to you, you may be treated with a combination of:



mood-stabling medications, such as lithium or an anti-epileptic medication 



an antipsychotic (this helps combat the symptoms of psychosis)



a tranquiliser, such as a benzodiazepine, to help relax you



You can't breastfeed while taking these types of medications, so your baby will have to be bottle-fed.

Electroconvulsive therapy (ECT)

Electroconvulsive therapy (ECT) may be recommended if you have severe postnatal depression. However, it's only used when antidepressants and other treatments haven't worked.

If ECT is recommended, you'll be given a general anaesthetic and medication to relax your muscles. Electrodes will be placed on your head and a pulse of electricity passed through your brain. Most people have either six or 12 sessions of ECT, usually with two sessions a week.

For most people, ECT is effective in relieving severe depression, but it's necessary to take antidepressants afterwards to keep symptoms under control. It's unclear how ECT works, but the generally agreed view is that electricity changes the chemical composition of the brain in such a way as to elevate mood.

Some people experience unpleasant side effects after having ECT, including headaches and both short-term and long-term memory loss. Due to the risk of memory loss, your memory will be assessed at the end of each ECT session.

If it looks like your memory is being affected, or you experience other adverse side effects, the ECT sessions will be stopped. However, most people tolerate ECT very well.

Preventing postnatal depression 

To try to prevent postnatal depression, tell your GP about any previous depression you've had or if you have felt very low or anxious during your pregnancy.

Also, speak to your GP if you've had postnatal depression in the past and you're pregnant or if you're considering having another baby, as there can be a risk you'll develop postnatal depression again.

Keeping your GP informed will ensure they're aware of the possibility of postnatal depression developing after your baby is born. This will help prevent a delay in diagnosis and allow treatment to begin earlier. In the early stages, postnatal depression can be easy to miss.

It's difficult to estimate the exact risk of a woman developing postnatal depression because many factors are involved, including:



previous medical history



individual social and psychological circumstances



current relationships



complications during labour



Even if you have a high risk of developing postnatal depression, it can be avoided. Getting support from your GP, midwife and other healthcare professionals will help reduce your risk of developing postnatal depression.

The self-help measures listed below can also be useful.



Get as much rest and relaxation as possible.



Take regular gentle exercise.



Don't go for long periods without food because low blood sugar levels can make you feel much worse.



Don't drink alcohol because it can make you feel worse.



Eat a healthy, balanced diet.



Don't try to do everything at once. Make a list of things to do and set realistic goals.



Talk about your worries with your partner, close family and friends.



Contact local support groups or national helplines for advice and support.



Don't try to be "Supermum". Avoid extra challenges either during pregnancy or in the first year after your baby is born. A new baby is enough of a challenge for most people.



Don't despair. Postnatal depression can affect anyone. You're not to blame.



Preventative treatment

If your risk of developing postnatal depression is thought to be particularly high, your GP or the doctor in charge of your care may recommend you start taking antidepressants as a precaution shortly or soon after giving birth.

Similarly, if you have a history of bipolar disorder or psychosis and you're at risk of developing puerapal psychosis (severe postnatal depression), you may be advised to start taking lithium shortly before or after the birth. Lithium has a mood-stabilising effect and can often help prevent psychosis reoccurring.

 


Help and support

If you have postnatal depression, charities such as the National Childbirth Trust (NCT) and online communities such as Netmums, can be useful sources of help and support.


Postnatal depression