Postnatal depression

What is postnatal depression?

Having a baby is a very emotional experience. New mothers often feel tearful and their mood may feel low. There are three causes of low mood after childbirth:

• Baby blues. It is very common and essentially normal to have these. Symptoms include being weepy, irritability, anxiety and feeling low. Baby blues usually start around the 3rd day but usually go by the 10th day after childbirth. They do not usually need any medical treatment. Baby blues are not discussed further in this leaflet.

• Postnatal depression (PND). This occurs in about 1 in 10 mothers. It usually develops within the first four weeks after childbirth. However, it can start several months following childbirth. Symptoms, including low mood, last for much longer than with baby blues. Treatment is advised. Most of this leaflet is about this common form of depression.

• Postnatal (puerperal) psychosis. This is an uncommon but severe form of mental illness. It may involve a low mood but there are a number of other features. See the Postpartum Psychosis leaflet for more.

The baby's father may also develop depression in the weeks after a baby is born. See also the leaflet on Depression.

Postnatal depression symptoms

The symptoms are similar to those that occur with depression at any other time. They usually include one or more of the following. In postnatal depression, symptoms are usually there on most days, for most of the time, for two weeks or more.

• Low mood. Tends to be worse first thing in the morning, but not always.

• Not really enjoying anything. Loss of interest in self and baby.

• Lack of motivation to do anything.

• Often feeling tearful.

• Feeling irritable a lot of the time.

• Feelings of guilt, rejection, or not being good enough.

• Poor concentration (like forgetting or losing things) or being unable to make a decision about things.

• Feeling unable to cope with anything.

• Thoughts of being dead, or in more severe cases, thoughts of suicide.

Some people also have thoughts about harming their baby. These thoughts are common (almost half of all new mothers experience them) but can be very distressing to experience. If things are very bad, people with postnatal depression may have ideas of harming or killing themselves, and might feel that they are going to act on those thoughts. It's really important to seek help if this is the case.

People with postnatal depression might also have less energy, disturbed sleep, poor appetite and a reduced sex drive. However, these are common and normal for a while after childbirth and, on their own, do not necessarily mean that someone is depressed.

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Why should you do anything about postnatal depression?

Postnatal depression often gets better within a few months. However, without treatment, roughly one third of women with depression remain unwell by one year after childbirth. There are many good reasons to get help for postnatal depression:

• Treatment can help people with postnatal depression recover more quickly.

• Postnatal depression can cause problems in relationships, jobs and life in general.

• Women with postnatal depression can be too unwell to look after themselves, and their babies, compared to what they could do if they were well. Being depressed can affect the relationship between mother and baby. There is evidence that untreated mental health problems in parents can lead to problems with child development that are noticeable when children grow up.

Some women are able to hide their postnatal depression. They care for their baby perfectly well and appear fine to those around them. However, they suffer the condition as an internal misery. It's really important that they seek help.

What causes postnatal depression?

The exact cause is not clear. It does not seem to be due to hormone changes after the birth of a baby. Many experts think that postnatal depression is the same condition as depression that occurs at any other time in life. Any mother can develop postnatal depression, but women are more prone to develop it just after childbirth. The main cause seems to be stressful events after childbirth, such as feelings of isolation, worry and responsibility about the new baby.

Things that increase the risk of developing postnatal depression include:

• Mental health problems in the past (such as a history of depression, previous postnatal depression, bipolar disorder or schizophrenia).

• Mental health problems during pregnancy, including depression or anxiety.

• A family history of depression.

• Poor social support from partners, friends, and family.

• Relationship problems with a partner.

• Physical health problems during pregnancy or during birth (such as a difficult labour).

• Problems with the baby's health, such as: being born early (pre-term), having serious health problems, or needing to spend time in neonatal intensive care after birth.

• Having an unplanned pregnancy.

• Being unemployed or having money troubles.

• Misusing drugs or alcohol - now, or in the past.

• Having to spend a long time trying for a baby before becoming pregnant.

• Depression in the father of the baby.

• Other major life events happening at the same time (like bereavement, or moving house).

In practice, it's often difficult to find any one specific cause for postnatal depression.

How long does postnatal depression last?

Postnatal depression lasts different amounts of time for different people. More than half of women with postnatal depression recover within three to six months. Roughly one third of women still have symptoms of depression after a year, and about 13% of women after two years. Some of those women continue to experience depression for a long time and may need long-term treatment.

Postnatal depression can return after future births. About one in four women with postnatal depression will experience at least one further episode.

How is postnatal depression diagnosed?

A doctor, midwife or health visitor will usually check for depression in all women who have recently given birth. They often ask the following two questions (this may be during postnatal checks or visits):

• During the past month, have you often been bothered by feeling down, depressed, or hopeless?

• During the past month, have you often been bothered by having little interest or pleasure in doing things?

If the answer to either question is 'yes', this should lead to them asking further questions, to see if postnatal depression is present. They may also ask you two questions to get an idea of anxiety levels:

• During the past month have you been feeling nervous, anxious, or on edge?

• During the past month have you not been able to stop or control worrying?

Based on the answers to these questions - or, if there are other reasons for concern - clinicians would then proceed to ask more questions to fully assess for depression or anxiety. Sometimes, standardised questionnaires are used, which give a 'score' that shows how likely depression is.

It is very important that people who feel low are truthful about how they are feeling. Being depressed does not mean that someone is a bad parent. It also doesn't mean that their baby needs to be taken away. It's extremely rare for this to happen - one of the most important parts of treating postnatal depression is to keep mother and baby together as much as possible, to allow the bond between mother and child to develop.

If postnatal depression is suspected, women are usually referred to their GP so that the diagnosis can be confirmed. In some areas, midwives and health visitors might also refer directly to a specialised perinatal mental health team. The diagnosis of postnatal depression is usually made by a clinician by talking to the person affected, and sometimes getting information from other people who know them.

Tests are not usually needed. However, sometimes doctors may do a blood test to make sure there is not a physical reason for the symptoms, such as an underactive thyroid gland or anaemia.

Some people initially don't recognise that they are depressed. However, their partner, or a family member or friend may notice that they are different, and may not understand why. Sometimes a friend or family member may suggest seeing a doctor, because they are worried about postnatal depression.

Postnatal depression treatment

The type of treatment that is best for each person depends on various things, including:

• How severe the depression is, and what symptoms are present.

• The impact of symptoms on people's ability to function (to look after themselves and their baby).

• Whether they have had depression or other mental health problems in the past. What has worked best before might be the best option again, if this is the case.

• The likely waiting time for any of the treatments.

• People's current situation, including the level of support they have from their partner, friends, and family.

• People's own preferences once the options and the pros and cons of them have been explained fully.

• In the case of medication, the possible effects on the baby if breastfeeding.

Treatment decisions should be made together between the person with depression and their healthcare professional. The following are some of the treatments available. More than one treatment may be suggested in some cases.

Support and advice

Understanding and emotional support from family and friends can help recovery. It is often best for people to talk to close friends and family to explain how they feel, rather than bottling up their feelings. People who are feeling depressed may also benefit from some help from family and friends in caring for their baby. This may give them some time off to rest and/or to do some things for their own self-care. Support and help from a health visitor can also help. Women who are feeling depressed should tell their health visitor,as they may be able to talk things through with them, including discussing the options for getting help.

Independent advice about any social problems may be available and of help (money issues, childcare, loneliness, relationships, etc). Health visitors usually know about what is available in your area. They also may know which self-help or support groups are available. Women with postnatal depression can be surprised to find that many other women feel the same way as them. Self-help groups are good at providing encouragement and support, as well as giving advice on how best to cope.

Antidepressants

Antidepressant medication is often prescribed for postnatal depression, especially if the depression is moderate or severe. Symptoms such as low mood, poor sleep, poor concentration, and irritability are often eased with an antidepressant. This may then allow people to function more normally, and increase their ability to cope better with theirnew baby.

There are several types of antidepressants, including tricyclic antidepressants (for example, imipramine, lofepramine) and selective serotonin reuptake inhibitors (SSRIs) - for example, paroxetine and sertraline. They all have pros and cons. For example, they differ in their possible side-effects. SSRIs are used more commonly than tricyclic antidepressants, as they generally have fewer side-effects.

Some antidepressants come out in breast milk. The amounts are very small and are unlikely to cause any harm to the baby. However, for mothers who are breastfeeding, doctors offer medicines that have good safety records for breastfeeding. Other drugs, especially new drugs, have fewer data to show that they are safe, and are usually avoided as a precaution. Paroxetine and sertraline are two drugs that are generally recommended as good options for breastfeeding women to use.

If mothers are breastfeeding a baby that has health problems (such as kidney or liver problems), or they were premature, then doctors will usually consult a specialist paediatrician (children's doctor) first to ensure that antidepressants are safe.

Psychological treatments

Another treatment option is to be referred to a psychologist or other professional for psychological treatment. There are various types, but their availability on the NHS can vary in different parts of the country. Psychological treatments include the following:

• Cognitive behavioural therapy (CBT). This is a combination of cognitive therapy and behavioural therapy. See the separate leaflet called Cognitive Behavioural Therapy (CBT).

• Guided self-help. This is based on the same ideas as CBT. People doing this are given some reading or video or computer-based information. They then go through this, reading, watching or listening to it at their own pace. They are able to talk to a therapist regularly, either face-to-face, or on the phone, who can help them work through it.

• Interpersonal therapy. This type of psychological talking therapy can help to identify any problems in relationships with family, friends, partners and other people, and see how these may relate to depression and other problems.

• Other types of therapy, including problem-solving therapy and psychodynamic psychotherapy, may also be used to treat postnatal depression.

Psychological treatments are sometimes not practical for women with postnatal depression, due to the time commitments required. There may also be a waiting list. However, women with postnatal depression should start treatment within a month of referral at most. This is the guidance from the National Institute for Health and Care Excellence (NICE).

Some research suggests that a combination of an antidepressant plus a psychological treatment such as CBT may be better than either treatment alone.

Other treatments

St John's wort (hypericum)

This is a herbal antidepressant that can be bought from pharmacies, without a prescription. St John's wort should not be used during pregnancy and when breastfeeding, because there are not enough data to show that it is safe. It interacts with certain other types of medication and can have side-effects. The amount of active medicine has been found to vary from brand to brand. For these reasons, national guidelines do not recommend St John's wort for the treatment of depression, including postnatal depression.

Specialist and hospital-based treatments

If postnatal depression is severe, or does not get better with treatment, people may be referred to a specialist mental health team. They may be able to suggest other treatments such as specialist medication. Occasionally, admission to hospital may be needed - for example, if people are very unwell, or it's thought that staying at home would be unsafe. Ideally, this is to a specialised mother and baby unit so that mother and baby can stay together.

Will it happen again?

Postnatal depression can occur again after another baby. About one in four people with postnatal depression go on to experience another episode later. However, people who've had postnatal depression before tend to be more aware of the signs, making it more likely to be detected early if it happens again. They may also be offered extra support and monitoring before and after birth to help keep them well.