What Is Postpartum Depression? What Is Postnatal Depression?

Postnatal depression (PND), also known as Postpartum depression (PPD) is a type of depression that affects some women after having a baby. Typically, it develops within four to six weeks from giving birth, but can sometimes take several months to appear. Often, there is no clear reason for the depression. Some men also develop postnatal depression. The patient may experience fatigue, sadness, reduced libido, episodes of crying, irritability, anxiety, and irregular sleeping patterns.

Experts are aware of some risk factors linked to postnatal depression. However, nobody is completely sure what causes it. Doctors say that PND is effectively treatable, either with support groups and counseling, or such help combined with medication.
Parents need to be reassured that postnatal depression in absolutely no way means that the person does not love their baby - it is an clinical illness. Postpartum depression is not a character weakness. It is important that people with signs and symptoms see their doctor immediately.

Even though doctors and the general public are much more aware of postpartum depression today, a considerable number of women suffer in silence. A recent study carried out by 4Children, a UK charity, found that half of all women across the UK with postpartum depression do not see a healthcare professional about their problem. (Link to article)
Researchers from the Eastern Virginia Medical School, Norfolk, Va., found that approximately 10% of fathers experience postpartum or prenatal depression. They added that the highest rates are three to six months after childbirth. (Link to article)

Postpartum depression is a treatable condition

What are the signs and symptoms of postnatal depression?

Signs and symptoms have different meanings, although they are often incorrectly used interchangeably. A symptom is something the patient experiences and describes, such as a headache, while a sign is something everybody, including doctors and nurses can detect, such as a rash.
Postpartum depression can affect mothers in several different ways. Below are some common signs and symptoms:

• A feeling of being overwhelmed
• A feeling of being trapped
• A feeling that it is impossible to cope
• A low mood that lasts for longer than a week
• A sensation of being rejected
• Crying a lot
• Feeling guilty
• Frequent irritability
• Headaches, stomachaches, blurred vision - signs of tension
• Lack of appetite
• Loss of libido
• Panic attacks
• Persistent fatigue
• Problems concentrating or focusing on things
• Reduced motivation
• Sleeping problems
• The mother lacks interest in herself
• A feeling of inadequacy
• Unexplained lack of interest in the new baby
• Lack of desire to meet up or stay in touch with friends

Postpartum depression has nothing to do with baby blues, which affects many women for a few days after giving birth. If the woman's ability to go about her day-to-day life is significantly undermined, it is more likely she has postnatal depression.

For several possible reasons, a significant proportion of mothers with postnatal depression do not tell people how they feel. Partners, family and friends who are able to pick up on the signs of PND at an early stage should encourage her to get medical help as soon as possible.
Scary thoughts - some mothers may have thoughts about harming their child. Experts say this happens in about half of all patients with PND. The mother may also think about ending her life or harming herself. The mother and/or baby are very rarely harmed. However, having these thoughts are frightening and distressing.

What are the causes of postpartum depression?

Experts believe postpartum depression does not have just one cause, but is probably the result of multiple factors. However, the cause(s) of PND is still an enigma - nobody is sure.

Depression is usually caused by either emotional and stressful events, or some biological factor which leads to an imbalance of brain chemicals (neurotransmitters), or both.

The following potentially stressful events that may occur during pregnancy, childbirth or/and shortly afterwards, could be contributory factors:

• Depression develops during pregnancy
• Excessive worry about the baby and the responsibilities of being a parent
• Complicated or difficult labor and childbirth
• A Brazilian study published in The Lancet found that psychological violence by the pregnant woman's partner can raise the risk of her developing postpartum depression, regardless of whether or not there was any physical violence.(Link to article)
• Lack of family support
• Worries about relationships
• Financial difficulties
• Loneliness, not having close friends and family around
• A history of mental health problems, such as depression, or a previous postpartum depression
• Health consequences following childbirth, such as urinary incontinence, anemia, changes in blood pressure, and alterations in metabolism. A Dutch study found that complications around the time of childbirth can raise the risk of postnatal depression. (Link to article)
• Hormonal changes - after giving birth, estrogen and progesterone (hormones) levels may drop considerably, as may other hormones produced by the thyroid gland
• Lack of sleep - newborn babies can cry a lot at night and deprive parents of a lot of sleep
• An unplanned or unwanted pregnancy
• A UK study found that certain genes may have a positive or negative effect on postpartum depression risk, depending on a person's environment (Link to article)

A person with a family history of depression has a higher risk of developing it themselves. However, nobody knows why this occurs in detail.

Women who have bipolar disorder have a higher risk of developing postpartum depression compared to other mothers.

Researchers at South London and Maudsley NHS Foundation Trust, England, found that postpartum depression is not just confined to after the birth of the baby, but can start during the pregnancy itself. (Link to article)

How is postpartum depression diagnosed?

Postpartum depression is considered a subtype of major depression by DSM (Diagnostic and Statistical Manual of Mental Disorders). DSM is the standard classification of mental disorders used by doctors and psychologists in the USA - it is published by the American Psychiatric Association.

The DSM says that the signs and symptoms of major depression must have developed within four weeks of the baby being born (many experts say this period is too short).

A GP (general practitioner, primary care physician) and other health care professionals may ask the patient to complete a depression-screening questionnaire, The aim here is to rule out baby blues.

The doctor may also order some diagnostic tests, such as blood tests, to determine whether there are any hormonal problems, such as those caused by an underactive thyroid gland, or anemia.

According to the NHS (National Health Service), UK, a GP will probably ask the patient two questions:

• Have you been bothered by feeling down, depressed or hopeless during the past month
• Have you been bothered by taking little or no pleasure in taking part in activities that would usually make you happy?

A patient who answers "Yes" to both questions is much more likely to have postpartum depression.

The doctor may then ask the patient whether she feels she needs or wants help. Whether the doctor asks this will usually depend on how the first two questions were answered.
The NHS says that many mothers with no partner or close relative to help out with baby care might not want to answer openly, because they fear they will be diagnosed with postpartum depression and will have the baby taken away from them. UK authorities stress that this is most unlikely to happen. A baby is only taken away in very exceptional situations. Even in very severe cases where the mother has to be hospitalized in a mental health clinic, in the UK and most developed nations, she will usually have her baby next to her.
In most countries, a GP is trained to diagnose and treat postpartum depression. The doctor will probably try to determine what the signs and symptoms are so that the severity of the depression can be assessed (so that the best course of treatment can be decided upon).

The doctor will ask if the patient has:

• Sleeping problems
• Problems making decisions and concentrating
• Self-confidence problems
• Changes in appetite - this could be lack of appetite or eating more than usual (comfort eating)
• Anxiety
• Fatigue, listlessness, reluctance to be involved in any physical activity
• Been feeling guilty
• Been self-critical
• Been having suicidal thoughts

A patient who answer "yes" to three of the questions above probably has mild depression. In cases of mild depression, the mother is still able to go about her normal activities. The more "yes" answers there are, the higher the severity of depression, to "moderate" and finally "severe" depression.

A mother with moderate depression will find normal activities hard to do - but with the right help will probably cope. If she has severe depression she will not be able to function at all and will need extensive help from a dedicated mental health team.

What are the treatment options for postpartum depression?

Mothers who wonder whether they might have postpartum depression symptoms should get in touch with their doctor. In the UK and many other countries which offer universal healthcare, talking to a health visitor or midwife is also recommended.

Although postpartum depression is treatable and curable, recovery may sometimes take several months, and in some cases even longer.

The mother's most important step on the road to treatment and recovery is to acknowledge the problem. Family, partner and close friends' support can have a major impact on a faster recovery.

Experts say it is better for the mother to express how she feels to people she can trust, rather than bottling everything up inside. There is a risk partners and sometimes other loved ones may feel shut out, which can complicate things.

Self-help groups are useful because not only will the mother have access to useful data, she will also meet other mothers who share similar problems and symptoms. This may help her feel less isolated.

Drugs

In moderate or severe postpartum depression the doctor may prescribe an antidepressant. These are supposed to help balance the chemicals in the brain that affect mood. Antidepressants may help with irritability, hopelessness, a feeling of not being able to cope, concentration, and sleeplessness. These medications tend to have good results and help the mother cope better and bond with her baby.

Antidepressant may take a few weeks to kick in. Patients who despair at experiencing no immediate results need to be reminded about this. Depending on how patients respond, the doctor may alter the medication's dosage.

According to the NHS, between 50% and 70% of patients respond well to antidepressants within a few weeks. However, they do not work for everybody.

Antidepressant can be passed onto babies through breast milk. Nobody knows what the long-term risks are for the baby. According to some small studies, TCAs (tricyclic antidepressants), such as imipramine and nortriptyline are most likely the safest to take while breastfeeding a baby. If the mother has a history of heart disease, epilepsy, or severe depression with frequent suicidal thoughts she should not be prescribed TCAs.

Those who cannot take TCAs may be prescribed an SSRI (selective serotonin reuptake inhibitor), such as paroxetine or sertraline. The amount of paroxetine or sertraline that eventually gets into breast milk is minimal.

The mother should discuss feeding options with her doctor so that selecting the right treatment, which may include an antidepressant, is an informed choice decision.

Breastfeeding, apart from its nutritional benefits for the baby, also helps mother and child bond, and boosts the patient's confidence in being a good mother.

Tranquilizers may be prescribed in cases of postnatal psychosis, where the mother may have hallucinations, suicidal thoughts and irrational behavior. However, in such cases the medications should be used for a short time. Tranquilizers may cause loss of balance, memory loss, lightheadedness, drowsiness and confusion. Patients on tranquilizers may have impaired driving skills.

Talking therapies

Studies have found that CBT (cognitive behavioral therapy) has a success rate of between 50% to 70% for patients with moderate postpartum depression - a similar rate to medication. For those with severe depression, where motivation is low, talking therapies alone are much less effective.

Most studies agree that the best results come from a combination of talking therapies with medication, also known as counseling and drugs.

Examples of talking therapies may include:

• Cognitive therapy - this type of therapy is based on the principle that a person's thoughts can trigger depression. The patient is shown (taught) how her thoughts can have a harmful impact on her state of mind. The aim is to alter the patients thought patterns so that they become more positive.
• Cognitive behavioural therapy (CBT) - this is a combination of behavioral therapy and cognitive therapy. The patient is shown how to change the way she thinks, behaves and feels.
• Other therapies - these may include problem-solving therapy, interpersonal therapy, etc.

Severe postpartum depression - the patient may be referred to a team of specialists, including psychiatrists, psychologists, occupational therapists, and specialized nurses. If the doctor(s) feels that the patient is at risk of harming herself or her child, she may be hospitalized in a mental health clinic. In some cases, the baby may be cared for by the partner or family member while the mother is being treated.

In the UK, if the mother has nobody to help out, the team will usually find her a mother-and-baby mental health clinic so that the two can remain together. Initially, the baby may sleep in a separate room. As the mother improves, mother and baby spend more time together.

Electroconvulsive therapy (ECT) - if the mother's symptoms are very severe, she might benefit from electroconvulsive therapy. However, this is always a treatment of last resort - when all other options, such as medication, talking therapies, have failed.

ECT is applied under general anesthetic, plus drugs to relax the muscles. ECT is usually very effective in cases of very severe depression.

However, sometimes the improvements may be short-lived. There may be some side effects, such as headaches, and memory loss (usually short term, but not always). Memory is monitored closely after each ECT session. If doctors detect any sizeable memory loss, the treatment is stopped.

Preventing postpartum depression

The more a doctor knows during or even before a pregnancy about the patient's medical and family history, the higher the chances are of preventing postpartum depression. The GP should be told about any previous episodes of depression or mental illness.

A study carried out at the School of Physiotherapy at the University of Melbourne, Victoria, Australia, found that a physical therapy exercise and health education program effectively reduced the risk of developing postpartum depression. (Link to article)

An article published in Methods of Information in Medicine reported on a Spanish study that found that 80% percent of cases of postnatal depression can be predicted by a new method involving artificial neuronal networks and a series of risk factors. (Link to article)

According to the National Health Service, the following may help:

• Stay physical fit. Do regular exercise
• Eat a well balanced, healthy diet
• Rest - get at least 7 to 8 hours good quality sleep each night
• Blood sugar - eat frequently, don't let your blood glucose levels drop too much by not eating for long periods
• Make lists - organize yourself so you are not rushing around and becoming frustrated at not achieving much. Try not to do too much; prioritize
• Be open - talk to close friends, partners, and family members about how you feel, and things you are worried about
• Get in touch with local help groups
• Remember that postpartum depression affects millions of women every year. It is not your fault

A UK study found that properly trained health visitors can have a considerable impact in preventing the development of postpartum depression. (Link to article)

Related articles

• What Is Postpartum Depression? What Is Postnatal Depression? (beinhealthwomen.blogspot.com)
• What Is Postpartum Depression? What Is Postnatal Depression? (medicalnewstoday.com)
• 35,000 Mothers With Postnatal Depression Suffer In Silence Each Year In The UK (beinhealthwomen.blogspot.com)

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35,000 Mothers With Postnatal Depression Suffer In Silence Each Year In The UK

Widespread lack of awareness of postnatal depression signs and symptoms results in 35,000 untreated mothers suffering in silence each year in the United Kingdom, national charity 4Children revealed in a new report. The authors wrote that the consequences for the mothers and their families can be devastating.
Half of all women across the country with postnatal depression do not see a healthcare professional about their problem, the charity revealed. Serious faults in the National Health Services mean thousands more are not being treated properly or promptly - shortcomings in the system listed by the authors include an over-reliance on antidepressant usage, and inadequate screening and referral. In a significant number of cases, the stigma surrounding mental illness discourages women from being forthcoming about their symptoms.
This report is the first of three that explores how family crises can be prevented, and forms part of 4Children's "Give Me Strength" campaign. It explains how postnatal depression can burden families with enormous relationship problems and breakdowns, placing pressure on older brothers and sisters to take over the care of babies and children. Postnatal depression can undermine early bonding between mother and child, which can have long-term consequences.
The authors add that GPs (general practitioners, primary care physicians) and other health care professionals need to do more to diagnose the condition early on so that mothers may be treated properly and promptly.
The report found that among the mothers with postnatal depression who were not treated (49% of all cases):

• 29% did not know they had postnatal depression
• 60% did not believe their symptoms were severe enough to merit treatment
• 33% kept quiet about their condition for fear of what might happen to them or their child

There is a serious lack of data and hunger for knowledge among postnatal depression sufferers, the report explained. Dissatisfaction with treatment is common.
The authors wrote that:

• 65% of the women interviewed said they wanted more information about available support groups
• 52% want information on counseling and other talking therapies
• 46% found the information they were given on postnatal depression symptoms unsatisfactory

Even though the guidelines issued by the National Institute for Clinical Excellence (NICE) include "the effective and timely treatment of postnatal depression . . . . which stipulates that talking therapies should be offered to patients with a mild or moderate diagnosis", what really happens to a considerable number of women is very different, the report shows.

Postnatal depression can interfere with the bonding between mother and baby

Only 41% of diagnosed women were referred to talking therapies and 70% were prescribed antidepressants by their GPs. Talking therapies form an important part of effective and long-lasting treatment.
The report highlighted some disturbing facts regarding postnatal depression surveillance in the UK:

• Most Primary Care Trusts do not gather data on postnatal depression rates, or on severity or treatments at local levels.
• Two trusts reported just one diagnosis of postnatal depression during the whole year
• The Department of Health, by its own admission, has no national data on postnatal depression rates or treatment
• Inpatient care for mothers with severe symptoms is described as a "postcode lottery" - with a lack of provision of Mother and Baby Units in Cornwall, Devon, East Anglia, and Cumbria, as well as vast pasts of Scotland and Wales. There are no Mother and Baby Units in Northern Ireland.

Chief Executive of 4Children, Anne Longfield OBE, said:

"Postnatal depression is a problem that with the right help, early on, can be treated successfully avoiding long-term impact on the rest of the family. However, many families are suffering the consequences of postnatal depression in silence, and even when they do seek help they all too often encounter a wall of indifference and a lack of empathy from medical professionals with an over reliance on antidepressants for treatment.

The best ways to treat maternal depression are set out clearly in the NICE guidelines, but all too often there is a shocking lack of awareness. So many women have to rely on luck to come across a sympathetic GP or health visitor who will lead them to the right course of treatment. This report calls for an end to the neglect of this destructive and prevalent illness to ensure that every mother is guaranteed the practical and emotional support she needs to avoid her unnecessary suffering and that of her family."

Postnatal depression

Postnatal depression (PND), also called postpartum depression (PPD) is a type of depression that a mother can develop after childbirth, and requires treatment. Onset of symptoms may develop from a few days to several months after giving birth. PND should not be confused with baby blues which lasts for a short time after childbirth. Postnatal depression has more severe symptoms and can seriously undermine the woman's ability to go about her daily duties. If the mother is not treated, there is a serious risk that her condition becomes long-lasting with worsening symptoms. Experts say that treatment today is effective, especially if the patient is diagnosed early on.

The signs and symptoms of PND may be different from patient to patient, and usually include some of those listed below:

• A low mood that prevails for long periods
• A constant feeling of irritation
• Tearfulness
• A feeling of being trapped
• Panic attacks
• Concentration problems
• Lack of motivation
• Lack of interest in the baby
• Lack of interest in herself
• A feeling of loneliness
• Feeling inadequate
• Feeling guilty
• Feeling rejected
• Feeling overwhelmed
• A feeling that it is impossible to cope
• Insomnia
• Constant fatigue
• Headaches
• Stomachaches
• Loss of libido
• Loss of appetite

Some mothers with postnatal depression may have frightening thoughts, some of them about harming their baby - experts say that approximately half of all women with PND have such thoughts. Some may have thoughts about harming themselves. It is rare for a mother with these symptoms to harm either her baby or herself.

Some mothers may not be aware that they have postnatal depression, while others might not talk to friends and family about how they feel. It is helpful if partners, family members and friends recognize PND signs, especially at an early stage, and to seek professional advice.

Written by Christian Nordqvist

Related articles

• 35,000 Mothers With Postnatal Depression Suffer In Silence Each Year In The UK (medicalnewstoday.com)
• The vital 6 week postpartum period (whatmotherssay.com)

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