Postnatal depression is a psychiatric condition that affects 10 – 15% of women after they give birth.
It may occur at any time within 6 months of childbirth but is usually apparent within the first 2 postnatal months.
How does it present?
A depressed mother may be noticeably weepy and not her normal self. There may be excessive anxiety about the baby’s health that cannot be allayed by reassurance. This may lead to sleepless nights in order to watch over the baby and repeated checking behaviour. It may also lead to a preoccupation with the idea that the baby is deformed or physically ill despite evidence to the contrary.
Self-blame can sometimes be evident. A mother may believe that she cannot live up to her own expectations of a ‘good mother’, nor is she as competent as her own mother. She may also compare herself unfavourably with others in her peer group and even remain at home to avoid their criticism. Suicidal thoughts or fear of harming the baby, irritability and loss of libido affect some women with more severe depression. The latter can lead to significant relationship conflict in a previously harmonious couple.
Symptoms and signs of Postnatal depression
- Persistent low mood and tearfulness
- Loss of interest and enjoyment
- Sleep disturbance
- Low confidence / self esteem (‘bad mother’)
- Difficulty coping with childcare
- Difficulty bonding
- Extreme anxiety about health of baby
- Over concern about baby’s feeding / sleeping regime
- Physical anxiety symptoms / panic attacks
- Suicidal thoughts
- Infanticidal thoughts
- Relationship difficulties / conflict
How is it treated?
Postnatal depression is a highly treatable condition and a depressed mother should not suffer in silence or feel ashamed to admit that they may be struggling with motherhood. Help is available, with one’s GP being the first port of call.
The treatment of postnatal depression depends on a variety of factors. These include the severity of depression, presence of psychiatric co-morbidity (e.g, alcohol misuse, personality disorder), level of risk of suicide or harm to the baby, and presence of social support.
The NICE guidelines on Antenatal and Postnatal mental health indicate that optimal treatment is based on a stepped care model in which mild to moderate illness is treated in primary care, moderate to severe illness may need input from secondary care, and severe, complex illness is the remit of a specialist Perinatal Mental Health service. Specialist Perinatal Mental Health services were once sparsely distributed throughout the UK but government investment over the last decade or so has meant that this is no longer the case.
The first line of treatment of mild postnatal depression is non-directive counselling, support and understanding. Moderate postnatal depression is unlikely to respond to counselling alone. Moreover, formal psychological intervention such as Cognitive behaviour therapy (CBT) and / or Antidepressant therapy may be required.
Breastfeeding is not a contraindication to antidepressant therapy. However, in breastfeeding women, the risk-benefit balance of antidepressant drugs is altered, with a consequent shift in emphasis towards psychological therapies. If an antidepressant is considered, the choice will depend on the woman’s preference, previous response to treatment, local availability of psychological therapies, the severity of the illness, and the risks involved.
Certain antidepressants are considered safer than others in breastfeeding women, but in general, the long-term outcomes for exposed babies are unknown. Sertraline and imipramine are preferred antidepressants as they pass into breastmilk at relatively low levels. If the depression is severe, complicated by suicidal, infanticidal ideas or child protection issues, a referral to a specialist Perinatal mental health service is indicated. In some cases, severe postnatal depression will require inpatient treatment in a specialist Mother & Baby Unit, with or without use of the Mental Health Act.
Treatment of Postnatal depression
- Counselling / Cognitive behaviour therapy for mild symptoms
- Antidepressant medication may be needed for moderate symptoms
- Sleep disturbance
- Breastfeeding is not a contraindication to antidepressants
- Some antidepressants pass on at very low levels in breastmilk
- Severe cases warrant referral to Perinatal Mental Health
- Admission to a Mother & Baby Unit is sometimes necessary
