Postnatal depression

Depression more persistent than 'maternity blues' occurs after 10-20 per cent of births. It tends to present later than puerperal psychosis. Many cases represent the continuation, exacerbation, or recurrence of depression that was present before the birth or even before the pregnancy: psychosocial factors are of particular importance.

A subgroup of women suffer depressive illness specifically related to childbirth, and their rates of depression at other times are not raised. Psychological difficulties in adjusting to motherhood, coping with the added responsibilities and changed social role, especially when there are social problems such as lack of support from the child's father or poor housing, may contribute to these depressive states. Minor hormone imbalance might also be involved.

Clinical features are not distinct from other depressive illnesses, and may include depression of mood, anxiety, panic attacks, fatigue, loss of libido, anorexia, and insomnia. Some of these symptoms are difficult to distinguish from the inevitable changes in sleep, eating pattern, and sexual function brought about by giving birth and caring for a child. Thoughts of hating or wishing to harm the baby are common, and should always sensitively be asked about; the mother will feel very guilty about any thoughts of this kind, and may be much helped by talking about them, and understanding that she is not alone in experiencing them. Actual harming of the baby is rare unless the mother is psychotic. The illness may last for months or years, especially if, as is often the case, it goes undetected and untreated. This chronic ill health in the mother is believed to hinder cognitive and emotional development in the child.

Case example

A 29-year-old professional woman lived comfortably with her husband and two small children. Her third pregnancy was unplanned, but the couple seemed to accept it well. Midway through the pregnancy, the husband was made redundant, and they began to experience some marital difficulties. During the third trimester, the patient became increasingly tearful and tired. She had a prolonged and painful labour, but the baby was well, and breast-feeding was established satisfactorily.

At home over the next 2 weeks, the health visitor noticed the patient became very distressed when her baby cried and seemed not to know what to do. She appeared mildly perplexed and was not taking much care of herself or her surroundings. On questioning, she confirmed that she could hardly sleep, she had little appetite, her weight was dropping fast, and she could not enjoy her baby as she had enjoyed the other two. She admitted feeling 'ugly' and 'dirty' (because of dribbling milk) and had considered leaving home because she was such a bad mother and wife. She scored 18 (high) on the Edinburgh Postnatal Depression Scale.

The health visitor called the GP, who visited the family and confirmed the diagnosis of depression, prescribed a tricyclic antidepressant (compatible with breast-feeding), and encouraged the health visitor to offer supportive counselling in addition to monitoring the baby's well-being.

Within 6 weeks the patient's mood had lifted, and she was restored to her former competent self, returning to work part-time while her husband stayed at home to look after the children. She continued on medication for another 6 months, during which time the couple came to accept their new circumstances and re-established a good emotional and sexual relationship.

Treatment includes a combination of the following:

• social support: training in childcare, contact with named midwives and health visitors, and introduction to other mothers of young children. Such measures in pregnancy have been shown to have preventive value, and health visitors given special training can provide valuable supportive counselling after the birth.

• antidepressant drugs

• psychotherapy: individual, marital, family, or group.

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