Postnatal Depression (PND).
The World Health Organization’s definition of health was formulated in 1948 as “...a state of complete physical, social and mental well-being, and not merely the absence of disease or infirmity”. I would like to take it a step further, and get all expectant and new parents to ask themselves a question: “Are we thriving, and what do we need to put into place to thrive?”
This article is split into 2 parts, each will take approximately 15 minutes to read. This first part defines PND, describes its symptoms and how you can spot them in your partner or a friend. We will discuss the possible risks if undetected or left untreated, and what the standard treatment routes are. I will also touch on Postnatal Psychosis and PND in men. Lastly, I provide links to major charities involved in mental health.
In my view prevention is key, so the second part of this article provides a list of tips, suggestions, strategies and quotes by other women, covering what they wish they were told. The aim is to provide some support and prevent mental health deterioration. While this part can be read independently of the second part I suggest reading both.
What is PND and its causes?
PND is also referred to as postpartum depression (PPD) or postnatal anxiety and/or depression (PAD), for consistency we will use PND throughout.
It is a common problem, and no woman should ever feel or be made feel bad about it. The prevalence is estimated to be about 1 in 7 women and up to 4 in 10 teenage mothers. It usually occurs between the 2nd-8th week after birth, some literature reports the peak between 3-6 months, but it can occur anytime up to 1 year after birth. It can last for months or years if not addressed.
The annual cost of all perinatal mental health is estimated at £8.1 billion per annum, of which 28% relates to the mother and 72% to the child (Bauer et al., 2014). This includes costs associated with time off work, marriage breakdown, social support and impact on the child.
Unfortunately, it is estimated that half of women have no access to specialist perinatal mental health services in the UK (Bauer et al., 20114). Only 50% of affected women seek help and only 10-15% receive effective treatment. PND can be very serious and should not be underestimated. The rate of maternal death by suicide remains unchanged since 2003, maternal suicides are the leading cause of direct maternal deaths occurring within a year after giving birth (Knight et al., 2016).
PND was historically seen as a hormonally driven condition, and although the cause is unknown, it is now understood to be linked to biological, genetic, hormonal, psychological and environmental components. Mostly it is a multifactorial issue with more than one of these components involved.
The main risk factors can be loosely divided into 5 broad groups.
*HPA axis = hypothalamic-pituitary-adrenal axis is an interactive neuroendocrine pathway comprising of the hypothalamus, pituitary gland (both form part of our brain) and the adrenal glands (above our kidneys). Amongst other roles, HPA axis plays a key role in the body's response to stress.
Oxytocin and prolactin regulate milk let-down reflex and synthesis of milk; it is often observed that inability to lactate and onset of PND occur at the same time.
It is worth saying here the even if you fall within one or more of the above categories, that doesn’t automatically mean that you will develop PND.
Many women feel a bit down, tearful or anxious in the first week after giving birth. This is called “baby blues” and is so common it is considered normal. Baby blues don’t last more than 2 weeks after giving birth, commonly occur 2-5 days post birth and resolve by days 10-14. They are attributed to the sudden hormonal and chemical changes that take place in your body after childbirth.
Symptoms include feeling emotional and irrational, bursting into tears for no apparent reason, feeling irritable or touchy, depressed or anxious, having disturbed sleep and appetite changes. These symptoms do not affect daily functioning or the ability to take care of the baby.
PND is classified as “sudden onset”, however the symptoms might develop gradually, so many women do not realise they have PND and take the symptoms as their “new normal”.
You might be experiencing:
These are examples of how a woman may feel about motherhood; no specific symptoms but a mix of emotions, cognitions, a feeling of discontent.
Spotting the signs and risks if left untreated.
Things to ask about the new mother are:
PND affects the entire family. Some of the risks if undetected or untreated have been identified as:
The most severe risks are suicide and harm to the baby.
I do not intend to concern you by listing the above. It is purely to highlight the importance of seeking help and insisting on treatment. Treatment leading to remission of symptoms reduces the above risks, so early diagnosis and action are crucial.
And not all children of mums with low mood experience difficulties. If the baby has a good relationship with mum (or someone else with whom they have regular contact), even if mum has low mood, then the baby has a very good chance of growing up to be healthy and happy.
PND in men.
This article is mainly written for mothers, but we need to acknowledge that PND also affects fathers. Currently, there is only limited research on new fathers although this is slowly improving, let alone same sex partners.
Some sources report that 1 in 10 men suffers from PND, and others that it has approximately half of the prevalence than in women. Fathers with PND present with different symptoms to women: they tend to use different language, have different needs and are less likely to access health services.
Studies show that fathers may feel reluctant and unable to express their support needs or seek help and question the legitimacy of their experiences. The issue can be compounded by prioritising their partner’s needs and feeling excluded by services that they perceive to be under-resourced.
Paternal symptoms increase the risk of worsening maternal symptoms. And paternal positive involvement decreases the risk of adverse behavioural outcome in children. I include links below to organisations that support new parents and fathers.
Postnatal Psychosis (PP).
Postnatal psychosis is a completely unrelated condition to PND. I mention it here because it is the most severe form of postnatal mental illness; it is a psychiatric disorder and is a medical emergency.
It can start suddenly within the first 2 weeks of birth. It is less common and affects around 1-2 in 1000 women. History of psychotic episodes is a risk factor, but half of affected women have no history of mental health issues at all. It can be a frightening experience for the woman and her family but it is treatable and immediate care is crucial.
Women with PP described their feelings as being excited, elated, high, over the moon and giggly. Active, energetic, overactive, chatty, sociable, talking more and always on the phone. Busy mind, racing thoughts and lots of ideas. Muddled thinking, messed up, confused, not with it and disorientated. No need for sleep, not able to sleep, irritable, people getting on their nerves, arguing, angry, impatient and anxious. In a dream world, unreal and detached from the world (Action on Postpartum Psychosis, APP).
In addition to the above, some feedback from partners was: “she was behaving like a supermum” or “she had everything under control” or “she was so on top of it all, I didn’t know how she was doing it.”
Just to remind you, PP is a psychiatric emergency but is treatable.
What to do and what is likely to happen?
If you think you are experiencing symptoms of PND, speak to your GP directly, or to your midwife or health visitor who will refer you to your GP.
Contact your GP immediately if you suspect that you or someone you know may have postpartum psychosis, as this is an emergency. If this isn’t possible, call NHS 111 or your local out-of-hours service.
And if you think there’s a danger of immediate harm, call 999 and ask for an ambulance.
When you are referred to your GP, they will likely order blood tests and give you the Edinburgh Postnatal Depression Scale (EPDS), which is a 10-item questionnaire.
The blood tests are taken to exclude metabolic and hormonal imbalances, such as iron, vitamin B12 and B6 deficiency, malnutrition and hypo- or hyperthyroidism. They also need to exclude other conditions such as obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD), anxiety and panic disorder, baby blues and other psychiatric disorders, such as post-partum psychosis, schizophrenia and bipolar disorder.
Your midwife might already be monitoring your mental health. Midwifes are likely to use modified Whooley questions which are simple yet effective. They might ask you about how you’ve been feeling, sleeping or if you’ve been interested in doing things since they last saw you.
Once PND is confirmed, psychosocial and psychological therapy are the first line treatment options for women with mild to moderate symptoms, especially if they are hesitant about medication and want to continue to nurse the baby.
A combination of therapy and antidepressants is recommended for women with moderate to severe symptoms.
There are 3 main types of treatment:
If symptoms are severe and the above treatment methods are not effective, a referral is made to a specialist mental health team for more intensive cognitive behavioural therapy (CBT) & psychotherapy.
If at risk of harm to the mother or the baby, the woman may be admitted to hospital or a mental health clinic. Many women fear that their baby will be taken away, but rest assured that the healthcare providers’ priority is NOT to allow this to happen. The baby can either stay with your partner or your family whilst you are in hospital. And when you are more stable and the capacity allows, you are likely to be transferred to a Specialised Perinatal In-Patient Mother and Baby Units.
In London and England, we are fortunate to have a better provision of mother and baby units than the rest of the UK. The units provide a multidisciplinary approach and women who spend time there speak highly of their experience. Once you are able to return home, you will receive care and support from the outreach team until you no longer require intensive home support, your condition stabilised and the risk of recurrence and readmission passed. You will then return to the care of the Specialised Perinatal Community Team/Community Team.
There are other treatment options if medication doesn’t work, such as Electroconvulsive Therapy (ECT) or Transcranial Magnetic Stimulation (TMS). These are both different kinds of stimulation of different parts of your nervous system. ECT is available on the NHS but is not commonly used. This procedure is performed under general anaesthetic and has recently received some negative press. TMS awareness is increasing but not all NHS Trusts currently provide this treatment. As with all treatment options, they have their benefits, limitations, side effects and risks.
We will now discuss what the treatment methods consist of:
What else is there?
There are many organisations, mostly charities, that provide mental health support. To name just a few:
What can you do?
Whether or not you fall into any of the risk categories listed at the beginning of this article, I put together a list of practical tips and strategies that any expectant or new parent can put into place, to potentially prevent mental health deterioration.
To read on, click here: Expectant and new parents’ coping strategies - PND Part II.
Please note that the above is only general information and is not intended to diagnose. If you have any concerns, speak with your GP, midwife or health visitor. The information is accurate at the time of writing in June 2020, some variations may appear between different trusts. I have no financial or other interests in any of the parties above.
Bauer, A., Parsonage, M., Knapp, M., Iemmi, V. and Adelaja, B. (2014). Costs of perinatal mental health problems. Centre for Mental Health and London School of Economics: London.
Knight M, Nair M, Tuffnell D, Kenyon S, Shakespeare J, Brocklehurst P, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK (2016). Saving Lives, Improving Mothers’ Care - Surveillance of maternal deaths in the UK 2012-14 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-14. Oxford: National Perinatal Epidemiology Unit, University of Oxford.
NICE. (2014). Antenatal and Postnatal Mental Health: Clinical Management and Service Guidance. National Institute for Health and Care Excellence.
NHS England. (2016). Publications Gateway Reference 06050. SCHEDULE 2 – THE SERVICES. November 2016.