Postnatal depression research brief Introduction
Postnatal depression (PND) has been defined as non-psychotic depression occurring during the first few months postpartum. Guidelines have varied with regards to the amount of time following childbirth that depression is still regarded as postnatal. In 2009, depression occurring up to three months postpartum was suggested in the UK as a useful clinical definition for PND. However, there is increasing recognition that the depression often starts during pregnancy (BMJ 2010).
Facts and figures
• Postpartum depression is the most common complication of childbirth (Wilsner et al
• The most frequently quoted statistic is that one in 10 mothers suffer from postnatal
depression (RCP 2007), although a number of studies show the incidence to be higher. Some studies have found that as many as one in five women experience depression in the postpartum period (Almond 2009, Marcus et al 2003).
• The incidence of depression in the first month after childbirth is three times the average
monthly incidence in non-childbearing women (BMJ 2010, Cox et al 1993).
• The most common time for postnatal depression to develop is when the baby is
between four and six weeks old (CKS 2010).
• Most episodes of PND resolve spontaneously within three to six months (BMJ 2010).
• One in four affected mothers are still depressed at their child's first birthday (BMJ 2010).
• Women whose depression persists beyond six months postpartum have been found to
have fewer positive interactions with their infants than women who were depressed but whose depressive symptoms ended before six months (BMJ 2010).
• Puerperal psychosis affects around one in 1,000 women (CKS 2010, MIND 2008).
• The exact number of women who experience the baby blues is likely to be between five
and eight out of every 10 women (CKS 2010, DA 2003). These feelings will usually be at their worst on the fourth or fifth day after the birth (BMJ 2009).
• It has been suggested that up to one in 25 men suffers from PND (MIND 2008). A
review of studies in the United States in 2010 concluded that as many as one in 10 men experience PND, with the highest incidence in the three to six month postpartum period. Men are also more likely to experience PND if their partner is depressed (Paulson and Bazemore 2010).
There is debate over why women get postnatal depression. Some experts believe that it is caused by hormonal changes after childbirth. Others think it is a combination of social and psychological factors (CKS 2010). The following are some of the most likely reasons:
• previous depression or mental health problems
• physical health problems after the birth, such as anaemia or incontinence
• money worries, housing difficulties or problems at work
• no supportive partner, family or friends living close by
• absence or death of one parent as a child
• difficult birth (CKS 2010, Mind 2008, NICE 2007, RCP 2007)
A meta-analysis in the United States of a large number of studies indicated that low social status showed a small but significant predictive relation to postpartum depression (O'Hara and Swain 1996). There is also an increased risk of PND among immigrant populations. Studies from India suggest that spousal disappointment with the sex of the newborn child, particularly if the child is a girl, is associated with the development of PND (BMJ 2010).
Some women have prenatal depression and their depression continues into the postnatal period (BMJ 2010). For others, PND starts in the weeks and months after giving birth (DA 2003). The most common time for postnatal depression to develop is between four and six weeks after the birth (CKS 2010). The symptoms of PND are different for every woman, but are similar to clinical depression. Most women with PND will experience some of the symptoms listed below. Women with PND can feel:
• indifferent or hostile towards their baby
• difficulty concentrating or remembering things
• no appetite or the urge to comfort eat
• sleep disturbed by early morning waking or vivid nightmares
• physical symptoms such as stomach pains, headaches or blurred vision
• sudden panic attacks that cause a rapid heartbeat, sweating, sickness or
• suicidal feelings (CKS 2010, MIND 2008, RCP 2007)
If a woman is experiencing three of the above symptoms, she is considered to have mild PND. Five or six symptoms is considered moderate PND and more is considered severe PND. If a woman is experiencing all of the above symptoms, it should be recommended that she has a dedicated a mental health team (CKS 2010).
Detection and diagnosis
Since 2007, NICE guidelines for GPs, midwives, obstetricians and health visitors have been that all women at their first contact with primary care, then at their booking visit and subsequently postnatally (usually at four to six weeks and between three and four months), are routinely asked the following questions:
• During the past month, have you often been bothered by feeling down, depressed or
• During the past month, have you often been bothered by having little interest or
If the answer to either one of these questions is "yes", a third question should be considered:
• Is this something you feel you need or want help with?
They may also enquire if the patient has a past or present severe mental illness including schizophrenia, bipolar disorder or psychosis, a previous treatment by a psychiatrist/specialist mental health team, or a family history of perinatal mental illness. Sometime GPs will perform a blood test to make sure that there is not a physical reason for symptoms, such as an under-active thyroid gland or anaemia (NICE 2007). Another tool that is used to diagnose PND is the Edinburgh scale (Cox et al 1987). This is a questionnaire designed to detect depression during pregnancy and in the postnatal period. The scale is used by midwives, health visitors and GPs.
Treatment Antidepressants Antidepressants are often the first line of treatment for PND. They work by balancing brain chemistry to lift mood, aid sleep and reduce irritability. Between five and seven out of every 10 women who take antidepressants to treat postnatal depression feel their symptoms ease within a few weeks of starting treatment (CKS 2010). Antidepressants are not always effective. They can cause unpleasant side effects and lead to dependency (MIND 2008b). They can also pass into breastmilk and very little is known about the long-term effect this could have on the baby's health. However, many women who take antidepressants do breastfeed because it improves their confidence and strengthens their bond with their child, which can also help their postnatal depression (CKS 2010).
Women considering taking antidepressants should talk to their GP to get a clear understanding of the risks that are involved. They can then weigh up the risk versus the benefit and make an informed decision about which is the safest option (MIND 2008b). If a breastfeeding woman chooses to take antidepressants, breastfeeding is best immediately before taking a dose and should be avoided for one to two hours afterwards (NHS Surrey 2005). There has been some controversy regarding the use of antidepressants (particularly Seroxat and Prozac) during pregnancy, reported in the press. See: www.guardian.co.uk. Counselling and psychotherapy GPs sometimes refer patients with PND to a support group, counsellor or psychotherapist. Evidence consistently demonstrates that individual non-directive (listening/supportive) counselling and psychotherapy (interpersonal therapy) significantly reduces symptoms of PND (Sign 2002). There is some evidence that individual counselling is more effective than group-based counselling (NICE 2007). If postnatal depression is severe, the patient may be referred to a psychologist or psychiatrist (NICE 2007). Cognitive Behavioural Therapy (CBT) Individual CBT is considered to be effective for the treatment of PND in the short-term, because it is good for providing coping strategies. However, it may not have long-term beneficial effects compared with usual care (BMJ 2010, CKS 2010). Charity-run telephone-based support The Association for Postnatal Illness and the Depression Alliance put people in touch with trained volunteers who have experience talking to people with postnatal depression (NICE 2007). Family focused interventions Several early intervention studies suggest that working with depressed mothers to teach different response patterns to their children, can significantly improve the mother-baby bond (SIGN 2000). There is also evidence that psychoeducation with a woman and her partner is more effective than psychoeducation with the mother alone (NICE 2007). Hormonal therapies
There has been considerable debate surrounding treating PND with hormonal therapies, such as natural or synthetic progesterone and oestrogen/progesterone skin patches. There is little reliable evidence to support their effectiveness (SIGN 2000). Complementary Therapies A number of studies have investigated the role of complementary therapies, such as massage and relaxation therapies. The majority of published studies use small sample sizes and are of a descriptive/observational nature, so it is difficult to draw conclusions about the effectiveness of complementary therapies for treating PND (Sign 2002). A small randomised control study found that attending infant massage classes had a positive effect on mother-infant interaction and depressive symptoms (Onzawa et al 2001). Exercise Regular exercise has been found to be effective for the treatment of depressive disorders, such as PND (DA 2003). NICE guidelines for treating PND include health professionals suggesting exercise to relieve symptoms (NICE 2007). A small study on the effects of regular pram walks on mothers with postnatal depression, showed a significant reduction in their symptoms and a significant improvement in their fitness levels, compared to mothers who just attended a social support group (NHS Surrey 2005).
This is a serious condition that affects around one in 1,000 women and starts within days or weeks of childbirth (CKS 2010, MIND 2008). It can develop in a few hours and can be life-threatening, so needs urgent treatment. Causes Puerperal psychosis is thought to be triggered by chemical and hormonal changes that occur after the birth. Women who have had previous mental health problems, such as bipolar disorder are at an increased risk of developing puerperal psychosis. A family history of mental illness also increases risk. Symptoms The symptoms of puerperal psychosis are the same as mania, depressive psychosis or atypical psychosis. They can include rapid mood swings, confusion, catatonic episodes, over-
excitement, hysteria, paranoia, delusions, hallucinations and irrational or suicidal thoughts (CKS 2010). Treatment
Puerperal psychosis is treated in the same way as affective psychosis and psychotic disorders. This usually involves hospitalisation with specialist psychiatric treatment, such as one or more drugs from the antidepressant, mood stabilising or neuroleptic groups and/or occasionally electroconvulsive therapy (ECT). However, care should be taken choosing the right medication if the patient is breastfeeding (CKS 2010, SIGN 2002). There is limited evidence for the effectiveness of treatments for puerperal psychosis. Support groups Support for women with PND Action on Puerperal Psychosis www.app-network.org A network of women who have suffered puerperal (postpartum) psychosis and want to find out more about the illness. They are also willing to hear about research projects that they may be able to help with. Association for Postnatal Illness www.apni.org Trained volunteers talk to women with postnatal depression. Depression Alliance www.depressionalliance.org Produces a leaflet entitled Depression during & after Pregnancy and runs a helpline specifically for anyone affected by perinatal depression or PND. Home Start www.home-start.org.uk Visits women at home and offers friendship, support and practical help, putting them in touch with other parents in their community. Meet-A-Mum Association (MAMA) www.mama.co.uk Offers support and self-help groups for women who are isolated or affected by postnatal illness.
National Childbirth Trust www.nctpregnancyandbabycare.com Puts women in touch with other women who have or have had postnatal depression. The Surrey Postnatal Depression Support and Information www.surreypnd.nhs.uk A website developed by the NHS, with the help of mothers, that offers useful information and discussion boards for mums, dads and other family members to share their feelings with other people going through similar experiences.
Support for healthcare professionals Royal College of Psychiatrists www.rcpsych.ac.uk The RCP produces a leaflet entitled Postnatal Depression for carers and professionals working with women who have PND. It includes useful tips and points to remember.
Information for parents
Parents can find information about PND in the BabyCentre articles:
• Postnatal depression after a second baby
• Supporting someone with postnatal depression
Mums can get in touch with thousands of other mothers and share their experiences of PND in the BabyCentre community.
• Postnatal depression campaign urges wider treatment access (Guardian 2010)
• Family under the microscope: Turn to Freud's psychoanalysis for postnatal depression
• Antidepressants once seen as miracle drugs: now risks are becoming evident
• Difficult pregnancies lead to post-natal depression (The Independent 2010)
• Postnatal depression clues found (Telegraph 2010)
• Exercise can combat postnatal depression (Telegraph 2010)
• Fighting the stress of pregnancy (Times 2009).
• Postnatal depression 'can be worse with a male baby' (Times 2008).
• Postnatal depression affects one in five mothers (Times 2007)
• Postnatal depression drives mother to murder her two sons (Times 2007)
• Postnatal blues are prehistoric hangover (Times 2005).
• Postnatal Depression (BBC Radio Four 2007)
• Postnatal Depression in Fathers (BBC Radio Four 2003)
• Postnatal Depression (BBC Radio Four 2003)
• New dads not immune to postnatal depression (Guardian and BMJ 2010)
• Postnatal depression in fathers 'often undiagnosed' (BBC 2010)
• Postnatal Depression (podcast with Ruby Wax) (BBC 2010)
• Young mothers' depression risk (BBC 2008)
• BJOG release: Pregnancy complications can increase development of postnatal
• ‘Too few’ health visitors to meet call for more postnatal depression treatment (Midirs
• Antenatal depression – time for wider recognition? (Midirs 2008)
• Postnatal depression in Ancient Greece (Midwives magazine 2009)
• Health visitors could help combat postnatal depression (Midwives magazine 2009)
• Link between antenatal depression and early child development (Midwives magazine
• Postnatal depression following operative delivery (Midwives magazine 2007)
• Depression: assessing the causes (Midwives magazine 2007)
• Preventing postnatal depression (Midwives magazine 2006)
• Depression in fathers linked to child development (Midwives magazine 2005)
• Postnatal depression and poor growth infants (Midwives magazine 2003)
Almond P. 2009. Postnatal depression: A global public health perspective. Perspectives in Public Health 129(5):221-227. APNI. 2007. Post Natal Depression. London: The Association of Post-Natal Illness. www.apni.org [pdf file, accessed May 2010] BMJ. 2010. Postnatal depression. BMJ Evidence Centre. www.bestpractice.bmj.com [accessed May 2010] CKS. 2010. Postnatal depression. Clinical Knowledge Summaries. www.cks.nhs.uk [accessed May 2010] Cox JL, Holden JM, Sagovsky R. 1987. Detection of postnatal depression: Development of the
10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 150:782-786. www.bjp.rcpsych.org [accessed August 2010] Cox JL, Murray D, Chapman G. 1993. A controlled study of the onset, duration and prevalence of postnatal depression. Br J Psychiatry 163:27-31. www.bjp.rcpsych.org [accessed May 2010] DA. 2003. Depression during & after Pregnancy. London: Depression Alliance. www.depressionalliance.org [pdf file, accessed May 2010] Marcus SM, Flynn HA, Blow FC, et al. 2003. Depressive symptoms among women screened in obstetrics settings. J Womens Health 12(141):373-80 MIND. 2006. How to look after yourself. London: National Association for Mental Health. www.mind.org.uk [pdf file, accessed May 2010] MIND. 2008a. Understanding postnatal depression. London: National Association for Mental Health. www.mind.org.uk [pdf file, accessed May 2010] MIND. 2008b. Making sense of antidepressants. London: National Association for Mental Health. www.mind.org.uk [pdf file, accessed May 2010] NHS Surrey. 2005. Surrey Post Natal Depression: Support & Information. www.surreypnd.nhs.uk [accessed May 2010] NICE. 2007. Antenatal and postnatal mental health: the NICE guideline on clinical management and service guidance. London: National Institute of Clinical Excellence. www.nice.org.uk [pdf file, accessed May 2010] O’Hara MW, Swain AM. 1996. Rates and risk of postpartum depression - a meta-analysis. Int Rev of Psychiatr 8(1):37-54 Onozawa K, Glover V, Adams D, et al. 2001. Infant massage improves mother-infant interaction for post-natal depression. J Affect Disord 63:201-7 Paulson JF, Bazemore MS. Prenatal and Postpartum Depression in Fathers and Its Association with Maternal Depression. JAMA 303(19):1961-1969 RCP. 2007. Postnatal depression. The Royal College of Psychiatrists. www.rcpsych.ac.uk [accessed May 2010] RCP. 2010. Mental health in pregnancy. The Royal College of Psychiatrists. www.rcpsych.ac.uk [Accessed May 2010]
SIGN. 2002. Postnatal depression and puerperal psychosis: a national clinical guideline. Edinburgh: Scottish Intercollegiate Guidelines Network. www.sign.ac.uk [pdf file, accessed May 2010] Wisner KL, Parry BL, Piontek CM. 2002. Postpartum Depression. N Engl J Med 347(3):194-199 If you have put together a research brief and would like to have it published on BabyCentre Midwives, email email@example.com.
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