POST-NATAL DEPRESSION

by Royal College of Psychiatrists

Post-natal depression (PND) means becoming depressed after having a baby. Sometimes this is easy to explain if the baby is unwanted or abnormal. Mostly, though, the depression makes no obvious sense. The mother expresses feelings such as: "I was so looking forward to having this baby, and now I feel utterly miserable. What's the matter with me?", or: "The labour went beautifully - much better than I expected, and everyone's been marvellous, especially Jim. So why aren't I over the moon?", or: "I was so afraid there'd be something wrong with her, but she's perfect. So why aren't I enjoying her? Perhaps I'm not cut out to be a mother?".

These women are not ungrateful or unmotherly. They are experiencing one of the most common complications of childbirth, from which too many women still suffer unnecessarily in silence, i.e. post-natal depression.

Incidence

PND is very common. Again and again it has been found that no less than one in ten women suffer depression after childbirth. This blight on the experience of motherhood is therefore one of the most common illnesses following childbearing. It can go on for months, or even years, yet if treated soon enough it can be nipped in the bud.

Symptoms

Depression is the most common symptom of PND. It means feeling low, unhappy, and wretched, for much or all of the time. Sometimes the depression is worse at particular times of the day (e.g. mornings or evenings). Sometimes there are good days and bad, which are the more disappointing because the previous good day raised hopes of getting better. Sometimes it can seem that life is not worth living, at a time when it should be at its most joyous.

Irritability often accompanies the depression. It can be shown towards any other children, and occasionally the baby, but most of all the partner, who may well wonder what on earth is wrong.

All new mothers get pretty weary, but the depressed mother is so utterly exhausted that she may think that there is something physically wrong with her. However, when at last she gets to bed she may find that she cannot fall asleep, or if she does, that she wakes early, even if her partner is feeding the baby that night.

Depressed mothers usually do not have the time or the interest to eat, and this contributes to feeling tetchy and run down. Some women, though, eat too much, for comfort, but then feel guilty and uncomfortable about getting fat.

Loss of enjoyment is common. What used to be a pleasure is unappealing, what used to be of interest is a bore. This may be especially true of sex. Some women regain interest in sex (if they ever lost it) before the six weeks' post-natal examination, but PND usually takes any enthusiasm away. The partner who seeks to share the comfort and excitement of intercourse meets reluctance or a rebuff. This puts further strain on the relationship.

PND causes a feeling of having too little time, doing nothing well, and not being able to do anything about it. A new routine, to cope with the baby as well as everything else, is hard to establish.

Anxiety is acute. Often it takes the form of being afraid to be alone with the baby, who might scream the place down, not feed, choke, or be dropped or harmed in some other way. Some depressed mothers perceive the baby as "it". Instead of feeling that they have given birth to the loveliest, most adorable creature in the world, they feel detached from their infant. They cannot see that it is all that beautiful. Indeed, they may find it a rather strange, mysterious little being, whose thoughts (if any) cannot be fathomed, and whose unpredictable needs and emotions have somehow to be satisfied. The task of a new mother who has not yet "fallen in love" with her baby is extra difficult. The love comes in the end, but usually when the baby is older and more interesting.

However, PND may develop even when love is strong. The mother then worries desperately in case she should lose her precious baby through infection, mishandling, faulty development, or a "cot death". Snuffles cause her terrible worry, she frets over how much weight has been (or not been) gained, she is alarmed if the baby is crying, or if it is too silent (has its breathing stopped?). So she wants constant reassurance from her partner, the health visitor, the doctor, her family, the woman next door - anyone, really.

Anxiety may also make the mother concerned about her own health. She may panic, when her pulse races and her heart thumps. She may feel that she has heart disease or be on the brink of a stroke. She feels so drained and worries whether there some dreadful illness, and whether she will ever have any energy again. Her feelings are so odd and unusual that she may worry that she is going mad. The terror of being left alone with all this can cause even the most capable woman to cling desperately to her partner, not wanting him to go to work.

Fortunately, not all women are like this after having a baby. Many women (at least one in two) feel a bit weepy, flat, and unsure of themselves on the third or fourth day after having a baby. This is the "baby blues", which soon passes. Many women are weary and a bit disorganised when they get home from hospital, but they usually feel on top of the situation in a week or so. But for mothers with PND things get worse and worse.

Most cases of PND arise within a month of the birth, but sometimes depression appears up to six months later.

Causes

There is insufficient knowledge of PND to know who will suffer from it. Rather than a single cause, a number of different stresses may have the same consequence, or may act together. Amongst known risk factors are:

• a previous history of depression (especially PND)
• lack of support from the partner
• a premature or otherwise ailing baby
• the mother's loss of her own mother when a child
• an accumulation of misfortunes, like a bereavement, the partner's losing his job, housing and money problems, etc.

However, a woman can suffer from PND when none of these apply and there is no obvious reason at all.

Hormones

It seems likely that PND is related to the huge hormone changes which take place at the time of giving birth, but the evidence is lacking. Levels of oestrogen, progesterone, and other hormones related to reproduction (which may also affect emotions) drop suddenly after the baby is born, but no real differences have been found in the hormone changes of women who do and do not get PND. Some women, though, may be more vulnerable to such changes than others.

Physical Abuse

Women with PND do not harm their babies. They may feel like it, and they worry very much in case they should actually harm their babies, but they never do so. Women who do "batter" their babies (the proper term is non-accidental injury, or NAI) have often been emotionally damaged by ill-treatment when they themselves were children.

Rarely, however, a baby is injured or even killed by a mother who is severely mentally disturbed at the time. This is a tragic consequence of puerperal psychosis, a very serious (but very treatable) mental illness which usually comes on within days of giving birth. The mother may be deluded that her baby is evil or, feeling suicidal, she may decide to take the baby's life with her own. This is called infanticide, rather than murder. Puerperal psychosis arises only after one birth in 500, and infanticide is fortunately very rare.

Treatment

Many depressed mothers do not realise what is wrong with them, and are ashamed to admit that they are less than thrilled by new motherhood. They may feel that if they say how they feel the baby may be taken away. Then, some doctors and health visitors are good at spotting PND, because they know about it and look out for it, but others overlook or ignore it, or say (wrongly) that it is just the "baby blues".

Now that there is a greater awareness of depression in general, PND should be missed less often. A questionnaire with only ten questions (the Edinburgh Scale) is now widely used and is helping health visitors and GPs to spot the disorder.

Once the condition is suspected, the mother is encouraged to say how she has really felt since she had the baby. If she says that she has felt miserable, irritable, incompetent, frightened, and not all that keen on her baby, then this is accepted with compassion and understanding, not alarm and reproaches.

It helps many a mother to be told "You've got PND". At last she knows her enemy. She can be reassured that she is not a freak or a bad mother, and that many others are in the same boat. PND is very common and anyone can get it. She can then be told that she will get better, but it may take time, and that arrangements will be made to see that she is supported until she has recovered.

It is now important to bring the partner into the picture, so that he can understand what has been going on (he, too, has been suffering the effects of PND) and be helped to be helpful. He is usually best placed to give support, provided that he has goodwill and gets a bit of support himself. Particularly if this is the first baby, he may feel that he has been pushed aside by the new arrival. If he then feels resentful without grasping how much his partner needs his support and encouragement, he may withdraw and add to her problems. He too may be hugely relieved by the diagnosis and guidance about what to do. Practical help with the baby, sympathetic listening, patience, affection, and being positive go a long way. They will be much appreciated even when at last the depression is over.

Talking treatments can be a great relief and release. They give an opportunity to "off-load" to a sympathetic, understanding, uncritical listener (a friend, relative, volunteer, or professional). Many general practices now have a counsellor, and trained health visitors have been shown to be helpful to groups of depressed mothers. More specialised psychological treatments, such as psychotherapy (which attempts to understand the depression in terms of what has happened in the past) and cognitive therapy (which attempts to make the woman feel more positive about herself) are sometimes appropriate, and may be arranged through the GP with, for example, community psychiatric nurses, psychologists, or psychiatrists.

Tablets

Doctors do not always dismiss their patients who have emotional problems with a prescription. However, sometimes the nature of the depression is such that one of the antidepressant drugs will help a lot. These drugs:

• are not tranquillisers or pep pills
• are not addictive
• take two weeks or more to work
• need not stop breast-feeding; an antidepressant can usually be found which does not get into the mother's milk, so that the baby is not affected in any way
• need to be continued for six months after the depression has lifted, to reduce the risk of relapse

Hormones appeal to many women more than antidepressants, because they seem more natural. However, the evidence that they work is less impressive, and they are not necessarily harmless (e.g. if there is a previous history of blood clots). Progesterone is best as a suppository, while oestrogen is now sometimes applied in skin patches. There is no doubt that many women feel that they have benefited greatly from hormone treatments, but it has yet to be shown that this is more than a placebo effect.

Although most women will get better anyway, after weeks, months, or even a year or two, this entails a lot of suffering. PND gets the experience of new motherhood off to a bad start, and strains the relationship with the baby's father. So the shorter it lasts, the better. It is very worth while to find and treat PND.

Prevention

There are three kinds of prevention: stopping it happening in the first place; nipping it in the bud; and stopping things from getting worse. This article has been mainly concerned with the second form - spotting PND and treating it quickly.

Not enough is yet known about PND to prevent it happening in the first place, but certain principles make sense. There is no need to be a superwoman. Having a baby may be a full-time occupation, so try to reduce commitments during your pregnancy (if you are at work, make sure that you get regular and sufficient nourishment and put your feet up in the lunch hour).

Try to avoid moving home while pregnant, or until the baby is six months old. Make friends with other couples who are expecting or have just had a baby. Among other things, this could lead to a baby-sitting circle. Identify someone in whom you can confide. It helps so much to have a close friend you can turn to. (if you cannot easily find someone, try the National Childbirth Trust or MAMA; their local groups are very supportive before and after childbirth). Go to ante-natal classes, and take your partner with you if possible.

If you have suffered PND before, that does not mean that you will do so again. However, it is only sensible to keep in touch with your GP (and, after the birth, your health visitor) so that should there be any signs of recurrence, treatment can start at once.

After the baby has arrived, take every opportunity to rest. Try to learn the knack of cat-napping. Your partner can give the baby a bottle-feed at night, using your own expressed breast milk if you like.

Ensure that you get enough nourishment. Healthy foods like salads, fresh vegetables, fruit, fruit juices, milk, and cereals are all packed with vitamins and do not need much cooking.

Find time to have fun with your partner. Try to find a baby-sitter and get out together for a meal, a show, to see friends, or just visit the pub. Let yourself and your partner be intimate. Even if you do not yet feel like sex, at least kiss and cuddle, stroke and fondle. This will comfort both of you and lead all the sooner to the return of full sexual feeling.

Do not blame yourself or your partner. Life is tough at this time, and tiredness and irritability on both sides can lead to quarrels, which may weaken your relationship when it needs to be at its strongest. Do not be afraid to ask for help when you need it. It may be up to doctors, health visitors, and midwives to diagnose PND, rather than the mothers themselves. But those who have learnt about it from ante-natal classes could help by asking themselves, their partners, and the professionals, whether they could be depressed.

Finally even if the PND is well established by the time it is recognised, support, counselling, and medication, will often make a big difference and will speed eventual recovery.