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 might be unaware she is ill, because 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 more than 15% of women and 10% of men develop PND. Many women don’t 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’re feeling.
It’s very important for women and their partners to learn to recognise the signs and symptoms of PND so that they can ask for help as early as possible.
- PND occurs in all cultures and all socio-economic classes and can happen to child-bearing women of all ages.
- It is not a modern condition. Each generation calls it something different. What we call postnatal depression today might have been called a ‘nervous breakdown’ 50 years ago.
- It appears with mild, moderate or severe symptoms. It can begin during pregnancy (antenatal depression), suddenly after birth, or gradually in the weeks or months following delivery. Symptoms can emerge at any time during the first year after birth. Most cases have their onset within the first four months.
- It can happen after miscarriage, stillbirth, normal delivery or caesarean delivery. Pregnancy is the common factor.
- It happens mostly after the first baby but can occur after any other pregnancy.
- It can recur with a subsequent pregnancy. If a woman becomes pregnant again before recovering from PND, the condition will continue through the pregnancy and can worsen. If a woman has been taking medication, it’s wise to wait at least a year after discontinuing medication before falling pregnant again.
Contributing factors for PND
PND is caused by a combination of biological, psychological (spiritual) and social (cultural) factors. It results in a variety of symptoms and impacts on women’s lives in all these areas.
A different combination of these factors is responsible for each woman’s unique experience of PND. Strategies for managing postnatal depression towards recovery must address biological, psychological and social aspects of the woman’s life. This usually requires a combination of interventions.
PND exists within families and communities, not with the woman alone. Assessment and intervention need to consider the significant other people in her family.
- Genetic predisposition to developing depression
- Sudden changes in pregnancy hormones following delivery
- Nutritional deficiencies and sleep deprivation
- Difficult pregnancy or childbirth experiences
- History of premenstrual tension
- Previous experience of PND or family/personal history of mental health conditions
- Infertility and use of IVF for conception
- Difficult or traumatic birth (for example, unexpected interventions in the birth or an emergency caesarean)
- Problematic or unresolved relationship issues between the mother and her own mother
- Traumatic/abusive childhood (particularly sexual abuse)
- Unrealistic expectations of motherhood and of herself
- Certain personality types (perfectionist or controlling)
- Limited social and emotional skills (difficulties in effectively communicating)
- Past unresolved issues of grief and loss such as previous miscarriage
- Lack of family and community support
- Difficult relationship with partner – for example, the woman’s partner might be removed emotionally, work long hours or travel a lot
- Intrusive or difficult family relationships
- Social isolation and lack of transport
- Financial hardship
- Lack of close friends, particularly families with children
- Being of a younger or older age
- Stressful life events, such as a death in the family or job loss
Women experiencing some of these things should be encouraged to talk with their doctor and family. Every woman’s experience of PND is unique, and a health professional can help tailor an intervention that responds to a woman’s specific circumstances and experience.
Symptoms of PND
Symptoms can begin anywhere from 24 hours to several months after delivery. Women are more likely to seek help early when onset is abrupt and symptoms are severe. Sometimes symptoms are harder to separate from normal changes after having a baby. In this case, women can delay seeking help and PND can linger into the second year.
The following descriptions of PND symptoms come from women who have spoken to PANDA (Post and Antenatal Depression Association) or attended PND groups. They can also apply to a man’s experience 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. Sometimes they wake early in the morning. Others want to sleep all the time and have trouble getting up in the morning.
Appetite disturbance: women might feel totally uninterested in food. Sometimes they 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. Others feel sick at the thought of food.
Crying: a woman might feel sad and cry without apparent reason. Tears come easily day and night. Some women say, ‘I want to cry but can’t. I am crying on the inside’.
Inability to cope: daily chores, caring for the baby or self-care might seem impossible. Small demands a woman previously coped with might completely overwhelm her. A woman might feel like running away. She might feel overwhelmingly exhausted and very heavy physically and emotionally. She might also wish it would all go away.
Irritability: a woman with PND might snap at her partner or other children 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: a woman might 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. She might be anxious about her own health or her 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 anxiety’ might more accurately describe the way some women feel.
Negative obsessive thoughts: there can be little peace in the thought processes of a woman with PND. Small worries can consume her thought processes, interfering with her ability to listen, concentrate or remember. She might experience unrealistic fears, be afraid to let her partner go to work in case of a car accident, or be afraid to leave the baby with a friend in case something happens. No amount of reassurance or distraction can hold stop her thinking.
Fear of being alone: many women go out a lot or need their partner (or someone) at home with them at all times. This is because they’re afraid of being alone at home. The fear of something going wrong with the baby or a woman’s fear that she can’t cope with the baby on her own is overwhelming. Some feel incredibly lonely and go out to feel connected with other people. This takes an enormous amount of effort. Others feel they can’t be with other people and withdraw from family and friends, not answering the door or telephone.
Memory difficulties and loss of concentration: a woman might forget what she wanted to say mid-sentence. She might not be able to concentrate on simple tasks or take in new information. Organising herself and her family can become too difficult. Sometimes she doesn’t know where to start. Other times she might start everything at once. She might be unable to think creatively about her problems or find solutions – like reaching out to services that will help her.
Feeling guilty and inadequate: feeling guilty can be common for all mothers but more so for the mother with PND. Her thoughts and feelings constantly reinforce in her own mind that she is inadequate and a ‘bad mother’. She might be unable to take encouragement from the good things she has done or to feel affirmed by her relationship with her baby. Reassurance won’t stop her thinking and can discourage her from talking about how inadequate and guilty she feels.
Loss of confidence and self-esteem: a woman who enjoyed her job might panic at the thought of going back to it, no longer sure she’s able to do it. A woman who enjoyed entertaining might panic at the thought of visitors. She might feel unable to prepare a meal when she enjoyed doing so before the baby was born. Most women with PND have very low self-esteem regardless of how well they seem. Some describe their experience as a loss of a sense of who they are, a loss of sense of self.
PND is difficult to identify
Society makes it difficult for a woman to acknowledge that she might be experiencing PND. She is constantly confronted by messages about joy and bliss. These messages don’t often mention the challenges that come with motherhood. The media tends to reinforce the unrealistic expectations of motherhood. For example, it promotes celebrities who appear to be coping very well.
Added to this is the stigma of depression. PND is often being portrayed in a negative and sensational way. Women will put on a brave face and go to extraordinary lengths to hide how they feel. A woman who isn’t coping can feel very alone and can find it hard to come to terms with her feelings.
Effects of PND
PND doesn’t usually resolve itself fully without treatment. If PND isn’t identified or treated, the toll it takes on the woman, her baby, partner, family and extended relationships increases. A woman might also experience future episodes of depression and mental illness.
Many women with PND are very close to their babies despite how they feel. Others might struggle to connect with their babies if their PND is ignored. This can have an impact on the wellbeing of the baby.
With early identification and intervention, most women fully recover from PND and have no long-term effects.
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 successful treatment for many women with PND. It’s worth remembering that women can’t ‘snap out of’ depression, any more than they could ‘snap out of’ diabetes, and there are many misconceptions about antidepressants, how they work and what harm they might cause.
Rather than ‘changing your personality’, this type of medication aims to correct chemical imbalances in the brain thought to be responsible for symptoms of depression and anxiety. Antidepressants are not addictive. Some can be safely taken while breastfeeding and pregnant. You can seek objective help and advice from your doctor, a pharmacist or drug information line.
Living with a woman suffering PND is difficult. Partners too need a lot of support. They often feel confused, lost and helpless. It’s 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 doesn’t feel the way she expected to feel after having a baby, it’s very important that she talk to her GP or maternal and child health nurse.
It could simply be that she’s having trouble adjusting to the changes in lifestyle that occur when a baby is born and to the demands that a new baby makes. But if she’s suffering PND, it’s 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.