Postnatal depression

Postnatal depression (PND) is a type of depression some women experience after they have had a baby. It usually develops in the first four to six weeks after childbirth, although in some cases it may not develop for several months. There is often no reason for the depression.

There are many symptoms of PND, such as low mood, feeling unable to cope and difficulty sleeping, but many women are not aware that they have the condition. It is important for partners, family, friends and healthcare professionals to recognise the signs of PND as early as possible so that appropriate treatment can be given.

It is very important to understand that having PND does not mean you do not love or care for your baby.

Who is affected

PND affects about one in 10 mothers. If you feel depressed most of the time and the feelings do not go away, you may have PND. Your GP will be able to determine whether you have the condition and suggest an appropriate course of treatment.

Also, although postnatal depression is more common in women, men can be affected too. The birth of a new baby can be stressful for both parents and some fathers feel unable to cope, or feel they are not giving their partner the support she needs. They can also find it difficult to adjust to the big changes and demands made by a new baby.

Outlook

PND can be lonely, distressing and frightening, but you should be reassured that there are many treatments available. As long as PND is recognised and treated, it is a temporary condition that you can recover from.

Glossary
Depression
Depression is when you have feelings of extreme sadness, despair or inadequacy that last for a long time.

Myths surrounding PND

PND is often misunderstood and many myths surround the condition. These include:

  • PND is less severe than other types of depression. In fact, PND is as serious as other types of depression.
  • PND is entirely caused by hormonal changes. PND is actually caused by many different factors.
  • PND will go away by itself. Unlike the ‘baby blues’ (see Postnatal depression - symptoms), PND can only be resolved with treatment.

Postnatal depression (PND) can affect women in different ways. The symptoms can begin soon after the birth and last for months, or in severe cases can last for over a year.

The symptoms of PND usually include one or more of the following:

  • low mood for long periods of time (a week or more)
  • feeling irritable for a lot of the time
  • tearfulness
  • panic attacks or feeling trapped in your life
  • difficulty concentrating
  • lack of motivation
  • lack of interest in yourself and your new baby
  • feeling lonely
  • feeling guilty, rejected or inadequate
  • feeling overwhelmed
  • feeling unable to cope
  • difficulty sleeping and feeling constantly tired
  • physical signs of tension, such as headaches, stomach pains or blurred vision
  • lack of appetite
  • reduced sex drive

Some of these symptoms affect women after childbirth anyway, and may not mean you are depressed.

PND can interfere with your day-to-day life. Some women feel unable to look after their baby, or feel too anxious to leave the house or keep in touch with friends.

Many mothers do not recognise that they have PND, and do not talk to family and friends about how they are really feeling. It is important for partners, family members and friends to recognise the signs of PND at an early stage and to seek professional advice as soon as possible.

Frightening thoughts

Some women who have PND get thoughts about harming their baby. This is quite common, affecting about half of all women with the condition. You may also have thoughts about harming or killing yourself. These thoughts do not mean you are a bad mother, and it is very rare for either mother or baby to be harmed.

However, it is vital that you see your GP if you have these or any other symptoms of PND. Treatment will benefit both your health and the healthy development of your baby, as well as your relationship with your partner, family and friends.

Glossary

Stomach
The sac-like organ of the digestive system. It helps digest food by churning it and mixing it with acids to break it down into smaller pieces.
Panic
To panic is to be quickly overcome with a feeling of fear or worry.
Depression
Depression is when you have feelings of extreme sadness, despair or inadequacy that last for a long time.

Postnatal psychosis

In rare cases, a severe form of depression called postnatal psychosis can develop after childbirth. As well as the symptoms of severe depression, mothers with postnatal psychosis may also have delusions (believing things that are untrue), hallucinations (seeing things that are not there, or hearing voices) and irrational or suicidal thoughts.

As with postnatal depression, women who have postnatal psychosis often do not realise they are ill. However, it is a serious mental illness thought to be triggered by chemical and hormonal changes in the body that occur after birth.

If someone has postnatal psychosis it is vital that they see their GP as soon as possible, because their health and the health of their baby may be at risk.

Baby blues

‘Baby blues’ is a mild type of depression that occurs after childbirth, usually around the third to the tenth day after giving birth. It can last from a few hours to a few days. During this time you may feel tearful and irritable, but no medical treatment is needed.

Baby blues is said to be experienced by more than half of all mothers in the western world.

The cause of postnatal depression (PND) is not completely clear. PND does not usually have a single cause, but is the result of a combination of factors.

Generally, depression is caused by emotional and stressful events, such as moving house, the break-up of a relationship, the death of a relative or having a baby.

Stressful events around the birth of your child can increase your risk of getting PND. This may include factors such as:

  • depression during the pregnancy
  • worry and anxiety about the responsibility of having a new baby
  • a difficult delivery
  • lack of support at home
  • relationship worries
  • money problems
  • having no close family or friends around you
  • mental health problems in the past, such as depression or previous postnatal depression
  • physical health problems following the birth, such as anaemia or urinary incontinence

Also, having a baby is a life-changing event in itself and can be an extremely exhausting and stressful experience.

Genetics

As depression tends to run in families, genetics are thought to play a part in PND, but the exact nature of the link between the condition and genetics is not fully understood.

Hormones

The huge changes in hormone levels that occur during and after pregnancy were once thought to cause PND. However, there is no evidence to suggest this is the case. It is much more likely that the condition is related to the combination of life changes that occur after childbirth.

Glossary

Incontinence
Incontinence is when you pass urine (urinal incontinence), or stools or gas (faecal incontinence), because you cannot control your bladder or bowels.
Depression
Depression is when you have feelings of extreme sadness, despair or inadequacy that last for a long time.

Two important questions

Your GP should be able to diagnose postnatal depression (PND) by asking you two 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 taking little or no pleasure in doing things that normally make you happy?

If the answer to both of these questions is yes, then it is likely you have PND.

Depending on your answers to the above questions, you may also be asked whether this is something you feel you need or want help with.

Some mothers, especially those who do not have a partner or relative to help with the care of their baby, can be reluctant to provide honest answers to these questions. This is because some worry that a diagnosis of PND will mean that they are seen as a bad mother and that there is a chance their baby will be taken into care.

It should be stressed that a baby will only be taken into care in the most exceptional of circumstances. One of the prime goals of treatment of PND is to help you care for and bond with your baby. Even if the symptoms of your PND are so severe that you require treatment at a mental health clinic, specialist mother and baby clinics are available.

Other tests

Sometimes, your GP may do a blood test to make sure there is not a physical reason for symptoms like tiredness and low mood, such as an underactive thyroid gland or anaemia. These conditions often occur after having a baby.

Diagnosing the severity of PND

If your GP suspects that you have PND, they will want to know about your associated symptoms so they can assess the severity of your PND and decide on the best course of treatment.

They will want to know if you have:

  • disturbed sleep
  • had problems concentrating or making decisions
  • low self-confidence
  • a loss of appetite or an increased appetite (comfort eating is often a symptom of depression)
  • been feeling anxious
  • been feeling tired, listless and reluctant to undertake any physical activity
  • been feeling guilty or self-critical
  • been experiencing suicidal thoughts

If you have three of the above symptoms, it is likely you have mild depression. People with mild depression are generally able to carry out normal activities.

If you have five or six of the above symptoms, it is likely you have moderate depression. People with moderate depression will have great difficulty carrying out normal activities.

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

Glossary

Blood test
During a blood test, a sample of blood is taken from a vein using a needle, so it can be examined in a laboratory.
Thyroid
The thyroid is a jointed piece or cartilage that encloses the vocal cords and forms the Adam's apple in men.
Depressed
Depression is when you have feelings of extreme sadness, despair or inadequacy that last for a long time.

If you think you have postnatal depression (PND), see your GP, midwife or health visitor as soon as possible so a diagnosis can be made and an appropriate course of treatment started.

If you do have PND, it is important for you and your family to remember that it can sometimes take a long time to recover fully from the condition.

Common treatments for PND are detailed below.

Support and advice

The most important step in treating PND is recognising the problem and then taking action to deal with it. The support and understanding of your partner, family and friends can play a big part in your recovery.

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

The support and advice from social workers or counsellors can be very helpful if you have PND. Self-help groups can also provide you with good advice about how to cope with the effects of PND, 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.

Medication

If you have been advised to start a course of medication for your PND,  talk to your GP about the type of medicine that is most suitable for you, and any possible side effects.

If you experience any side effects, tell your GP so they can alter your dose or change your medicine.

Antidepressants

Antidepressants are often prescribed to treat moderate or severe cases of PND. They work by balancing the mood-altering chemicals in your brain.

Antidepressants can help ease symptoms such as low mood, irritability, lack of concentration and sleeplessness, allowing you to function normally and giving you the ability to cope better with your new baby.

A course of antidepressants usually lasts for four to six months. However, if your symptoms improve, the dose may be steadily reduced by your doctor.

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

Between 50 and 70% of women who have moderate to severe PND improve within a few weeks of starting treatment with antidepressants. However, antidepressants are not an effective method for everyone.

Not enough is known about the possible long-term risks to babies of antidepressants taken by breastfeeding mothers. It is known that antidepressants can pass into breast milk. The small amount of evidence available suggests that tricyclic antidepressants (TCA) are probably the safest to take while breastfeeding. The preferred TCAs for breastfeeding women are imipramine and nortriptyline.

TCAs are not suitable for some people, including:

  • those with a history of heart disease
  • those with epilepsy
  • those with severe depression who have frequent suicidal thoughts (because an overdose of TCAs can be fatal)

In these circumstances, another type of antidepressant known as a selective serotonin reuptake inhibitor (SSRI) may be prescribed. The preferred SSRIs are paroxetine or sertraline, because tests have shown that the amount of these medicines found in breast milk is so small that it is unlikely to be harmful.

Women who are taking antidepressants may wish to discuss feeding options with their GP so they can make an informed choice about whether to take 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 their maternal abilities. These are important factors in combating the symptoms of PND.

Tranquillisers

In severe cases of PND, such as postnatal psychosis, where symptoms can include irrational behaviour, hallucinations and suicidal thoughts, tranquillisers may be prescribed as a treatment option. However, they are usually only recommended for short-term use.

Tranquillisers can cause side effects including confusion, loss of balance, memory loss, drowsiness and light-headedness. Because of these side effects, they can affect your ability to drive or operate machinery, so these activities should be avoided when taking tranquillisers. Your GP may be able to adjust your dose of medication or prescribe an alternative if necessary.

Talking treatments

For people with moderate PND, talking treatments such as cognitive behavioural therapy have about the same success rate as antidepressants (50-70%).

Talking treatments may not be as effective for people with severe depression, because they require a certain level of motivation, and those with severe depression often find this difficult.

Research has suggested that a combination of antidepressants and counselling is better than either treatment alone.

If your GP feels that a talking treatment may help you, you will be referred to a psychologist or other mental health specialist. There are various different types of talking treatment outlined below.

Cognitive therapy

Cognitive therapy is based on the idea that certain thoughts can 'trigger' mental health problems, such as depression. Your therapist will help you to understand how your thoughts can be unhelpful or harmful to your state of mind. Sessions are usually conducted on a weekly basis over several months, and the aim is to help you change your thought patterns in a way that is more helpful and positive.

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) combines cognitive therapy and behavioural therapy. Behavioural therapy is about changing any behaviour that is harmful or unhelpful. The aim of CBT is to help you change the way you think, feel and behave for the better. See the Health A-Z topic about CBT for more information.

Other talking therapies

Other talking therapies include interpersonal therapy and problem-solving therapy. In some areas, trained health visitors can also give short counselling sessions over several weeks, which have been shown to help PND.

Treating severe PND

Referral

You may be referred to a mental health team if your PND is severe, or does not respond to treatment. These teams are usually made up of a range of specialists, including psychologists, psychiatrists, specialist nurses and occupational therapists, and can provide intensive talking treatments such as cognitive therapy or psychotherapy.

If it is felt that your PND is so severe that you are at risk of harming yourself or your baby, you may be admitted to hospital or referred to a mental health clinic. If you have support available from your partner or family, it may be recommended that they care for your baby until you are well enough to return home.

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

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

Electroconvulsive therapy (ECT)

Electroconvulsive therapy (ECT) may be recommended if you have severe PND. ECT works for severe PND, but is only used when antidepressants and other treatments have not worked.

If ECT is recommended, you will be given a general anaesthetic and medication to relax your muscles. Electrodes are then placed on your head and a pulse of electricity passed through your brain, which will trigger a fit or seizure (which is why you are given muscle relaxants). Most people have either six or twelve sessions of ECT, normally with two sessions a week.

For most people the treatment is effective in relieving severe depression, but the effect may not be permanent. Nobody is entirely sure how ECT works, but the generally agreed view is that the 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 memory loss is occurring, or you experience any other adverse side effects, then the ECT sessions will be stopped.

Glossary

Counselling
Counselling is guided discussion with an independent trained person, to help you find your own answers to a problem or issue.
Antidepressants
Antidepressant medicine is used to treat depression. For example fluoxetine, paroxetine.
Brain
The brain controls thought, memory and emotion. It sends messages to the body controlling movement, speech and senses.
Anxiety
Anxiety is an unpleasant feeling when you feel worried, uneasy or distressed about something that may or may not be about to happen.
Dose
Dose is a measured quantity of a medicine to be taken at any one time, such as a specified amount of medication.
Depression
Depression is when you have feelings of extreme sadness, despair or inadequacy that last for a long time.

St John's Wort

St John's Wort is a herbal supplement that some people take for depression. Although there is some evidence that it is beneficial in treating mild or moderate depression, its use is not recommended. This is because it is not tested as rigorously as a medicine. Also, the quantity of its active ingredients varies between different brands and batches, so you cannot be certain of the effect it will have.

Taking St John's Wort with some other medications (such as anticonvulsants, anticoagulants, antidepressants and the contraceptive pill) can cause serious problems.

You should not use St John's Wort if you are breastfeeding, as there is not enough evidence that it is safe.

To try to prevent postnatal depression (PND), you should inform your GP about any previous periods of depression that you have had or if you have felt very low or anxious during your pregnancy. You should also speak to your GP if you have had PND in the past and are pregnant or are considering having another baby, as there is a risk you will develop PND again.

Keeping your GP informed will ensure they are aware of any potential risk of PND after your baby is born.

It is difficult to estimate the exact risk of a women developing PND as so 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 PND, it can be avoided. Getting support from your GP, midwife and other healthcare professionals will help reduce your risk of developing PND.

The following self-help measures can also be useful:

  • Get as much rest and relaxation as possible.
  • Take regular gentle exercise.
  • Do not go for long periods without food because low blood sugar levels can make you feel much worse.
  • Do not drink too much alcohol because heavy drinking can make you feel worse.
  • Eat a healthy, balanced diet.
  • Do not 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.
  • Do not despair. PND can affect anyone and you are not to blame.

Finally, remember that most people who have depression make a full recovery.

Glossary

Blood
Blood supplies oxygen to the body and removes carbon dioxide. It is pumped around the body by the heart.
Depression
Depression is when you have feelings of extreme sadness, despair or inadequacy that last for a long time.

NICE guidelines on postnatal depression

The National Institute for Health and Clinical Excellence has published guidelines on mental health problems during pregnancy and after giving birth, covering:

  • how to recognise mental health problems in the first year after birth
  • advice on the care and treatment (including drugs and psychological treatment) of women who develop a mental health problem in the first year after giving birth
  • advice on the care and treatment of women who had a mental health problem before becoming pregnant
  • how families and carers may be able to support women with mental health problems and get support for themselves

Content provided by NHS Choices www.nhs.uk and adapted for Ireland by the Health A-Z.

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