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What is postnatal depression?

By PANDA (Post and Antenatal Depression Association)
 
 

The arrival of a new baby is usually a happy event. It can also be a stressful time during which many adjustments have to be made.  Unfortunately, many women aren't aware that mood changes are common after childbirth and vary from mild to severe.  In fact, in the year after childbirth a woman is more likely to need psychiatric help than at any other time in her life.

Types of postnatal mood disorder

There are three recognised mood disorders in the period after birth.

At one end of the spectrum is ‘baby blues’, affecting about 80% of new mothers and occurring between the third and tenth day after birth.  Symptoms include tearfulness, anxiety, mood fluctuations and irritability.  The ‘blues’ are transient and will pass with understanding and support.

At the other end of the spectrum is puerperal or postnatal psychosis.  This affects 1 in 500 mothers, usually in the first 3-4 weeks after delivery.  Postnatal psychosis is a serious condition.  The mother herself may be unaware she is ill as her grasp on reality is affected.  Symptoms include severe mood disturbance (either marked elation or depression or fluctuations from one to the other), disturbance in thought processes, bizarre thoughts, insomnia and inappropriate responses to the baby.  There is risk to the life of both mother and baby if the problem is not recognised and treated.  Postnatal psychosis requires a hospital stay.  With appropriate treatment women suffering from postnatal psychosis fully recover.

Between the ‘blues’ and psychosis lies postnatal depression (PND).  Most women find adjusting to life with a new baby very difficult, but 10-15% of women develop PND.  Many women do not know that PND can occur unexpectedly after delivery and typically blame themselves, their partners or their baby for the way they feel.  Some try hard to ‘snap out of it’ without understanding that women with PND have little control over the way they are feeling.  It is very important for women to learn to recognise the signs and symptoms of PND so that they can ask for help as early as possible.

Why does it happen?

Professor Elizabeth Herz, Professor of Gynaecology, Obstetrics and Psychiatry, George Washington University Medical Centre, USA says:

In our brains we have the hypothalamus, one of the deep brain centres where physical and psychological equilibrium are constantly monitored.  It regulates many involuntary functions including sleep, body rhythms and appetite.

In the hypothalamus, neuro-transmitters which control mood, interact with important neuro-hormones that stimulate all the other hormones maintaining our systems and usually our equilibrium.  The hypothalamus receives constant internal input from various parts of the body via the hormones and metabolism.  It also gets messages from the higher brain centres that have been exposed to external stimuli.  The hypothalamus’s job is to balance it all out.

However if the system is overloaded the hypothalamus gets into a state of disequilibrium.  That is why in addition to mood changes we also find sleep disturbances, changes in appetite and decreased sexual interest.  The regulatory system can’t cope.  This explains why stresses that a woman can cope with at other times when exacerbated by these internal changes become too much.

(Carol Dix:  ‘The New Mother Syndrome’, Allen and Unwin)

Symptoms of PND

  • Sleep disturbance unrelated to baby’s sleep needs: most women with a young baby fall asleep as soon as they are able to.  Women with PND often lie awake for hours feeling anxious while the baby sleeps.  Some women have trouble falling asleep or wake early in the morning, and may have bad dreams.
  • Appetite disturbance: women may feel totally uninterested in food and say. ‘I force myself to eat because I am breastfeeding, but I don't taste anything’.  Sometimes women overeat in an attempt to control their anxiety or forget to eat.
  • Crying: women may feel sad and cry without apparent reason.  Tears come easily.  They may cry watching news coverage of a plane crash.  Some women say, ‘I want to cry but can't.  I am crying on the inside’.
  • Inability to cope: daily chores seem insurmountable.  Women may feel like running away from it all.
  • Chronic exhaustion or hyperactivity
  • Irritability: women with PND may snap at their partners without cause.  Partners often say, ‘I can't do anything right.  If I fold nappies she complains I do it the wrong way.  If I don't help, I'm being unsupportive’.
  • Anxiety: women may feel a ‘knot in the tummy’ most of the time and panic without cause.  Some women experience heart palpitations so severe that a heart attack is feared.  They may be anxious about their own health or their baby's, even after reassurance that nothing is wrong.  Many women describe anxiety as their most obvious symptom and reject the term postnatal depression.  They deny being ‘depressed’.  The term ‘postnatal disorder’ might more accurately describe the way some women feel.
  • Negative obsessive or morbid thoughts: women may be afraid to let their partners go to work in case he has a car accident. They may be afraid to leave the baby with a friend in case something happens.  They may feel like life has no meaning.
  • Fear of being alone: many women go out a lot because they are afraid of being alone at home.
  • Fear of social contact: some women don't want to go out and may find being with groups of people overwhelming.
  • Memory difficulties and loss of concentration: women may forget what they want to say mid-sentence or be unable to concentrate on simple tasks.
  • Feeling guilty and inadequate: women may feel they are ‘bad mothers’ even when those around them comment on what a good job they are doing.
  • Loss of interest in sex
  • Loss of confidence and self-esteem: women who enjoyed their jobs may panic at the thought of going back to it.  They are no longer sure they are able to do it.  Women who enjoyed entertaining may panic at the thought of visitors.  They may feel unable to prepare a meal when they enjoyed doing so before the baby was born. 
  • Feelings of self harm, harm to the baby or suicide: this may be fleeting or very detailed.  It is important to assess the risk to the mother and her baby’s wellbeing, and to intervene.

Some women sum it all up by saying, ‘There is no joy in anything any more’.

The severity of the illness depends on the number of symptoms, their intensity and the extent to which they impair normal functioning.

Risk factors for PND

PND can happen to any woman, but some women are more vulnerable than others.  Some risk factors are:

  • previous experience of PND
  • family history of psychiatric illness (bipolar disorder, schizophrenia, PND).  Just as women are asked whether they have a family history of multiple births or diabetes they should be asked in the antenatal period if anyone in the family has suffered from a psychiatric illness
  • stressful life events, for example, a recent death in the family, financial problems, moving house, and so on.
  • history of pre-menstrual tension
  • difficult marital or family relationships.

Women with these risk factors should be encouraged to talk with their doctor before the birth of their baby.

Causes of PND

Experts call postnatal depression a multi factorial problem with biological, psychological and social factors all playing some part.  A different combination of factors is probably responsible for each sufferer's PND.  The factors thought to be responsible are as follows:

Biological

  • Genetic predisposition to developing depression
  • Hormonal – that is, a sudden drop in pregnancy hormones after delivery can affect brain chemistry

Psychological

  • Difficult pregnancy
  • Difficult or traumatic birth, eg emergency caesarean
  • Relationship difficulties with partner or parents
  • Traumatic or abusive childhood

Social

  • Lack of family, marital and community support
  • Social isolation

Probably for every woman with PND there will be a different combination of contributing factors.

Treatments

All women with PND need emotional support from family and friends.  Some women find psychological treatments helpful especially if they have experienced traumatic events in their childhood or more recently.

Antidepressant medication is a most successful treatment for many women.  Unfortunately there are many misconceptions about antidepressants and many women who could benefit from them are refusing to take them because they are afraid the medication is harmful.  Antidepressants are not addictive and some can be safely taken while breastfeeding.

This type of medication does not ‘change your personality’. It simply corrects the chemical imbalances in your brain that are thought to be responsible for symptoms of depression and anxiety.  It is important to understand that women cannot ‘snap out’ of depression any more than they could snap out of diabetes.

Partners

Living with a woman suffering PND is difficult.  Partners too need a lot of support.  They often feel confused, lost and helpless.  It is important that partners be included by the health professionals treating women with PND.  Partners are much more supportive if they understand what the problem is and what they can do to help.

Where to go for help

If a woman does not feel the way she expected to feel after having a baby it is very important that she talk to her GP or Maternal and Child Health Nurse.  It could simply be that she is having trouble adjusting to the changes in lifestyle that occur when a baby is born and to the demands that a new baby makes.  If she is suffering PND it is important that she receive appropriate help as soon as possible.  PND is not something to be ashamed of.  It should be seen as one of the many complications of pregnancy and delivery.  With appropriate help women with PND do recover.

What helps

  • Emotional support (family, friends, outside services)
  • Practical help with housework and childcare
  • Psychological help (GP, psychologist, counselling, support groups, cognitive therapy)
  • Medical help (GP, psychiatrist, MCHN, antidepressant medication, hospitalisation – ideally in a mother-baby unit)

What we know about PND

  • PND can be mild or severe.
  • Symptoms of PND can begin during pregnancy (antenatal depression), suddenly after birth or gradually in the weeks or months following delivery.
  • PND occurs in all cultures and early signs are recognisable.
  • It is not a modern condition.  Each generation calls it something different.  What we call PND today may have been called a ‘nervous breakdown’ 50 years ago.
  • Symptoms can emerge at any time during the first year after birth but most cases have their onset within the first four months.
  • PND can happen to child-bearing women of all ages.
  • It can happen after miscarriage, stillbirth, normal delivery, or caesarean delivery.  Pregnancy is the common factor.
  • PND happens not only after a first baby.  It can occur after a third or fifth baby.  Sometimes it happens after a first baby only.  Sometimes it happens with a third baby, but not with the first two.  Sometimes it happens after each pregnancy.
  • A woman who has had PND has a 50% chance of recurrence with a subsequent pregnancy.
  • If a woman becomes pregnant again before recovering from PND, the condition will continue through the pregnancy and may worsen.  Women should delay another pregnancy until they have recovered completely.  It is wise to wait at least a year after discontinuing medication before falling pregnant again.
  • Help is available and with good support most women make a full recovery.