Postnatal depression

In January 2016, the UK Prime Minister announced a £290 million investment into new specialist perinatal mental health services in an attempt to ensure that all women in the UK have access to specialist community services and psychiatric inpatient mother and baby units. Other countries have also invested in these specialist services.

Postnatal depression (PND) refers to the development of a depressive illness following childbirth and may form part of a bipolar or, more usually, a unipolar illness. PND is not recognised by current classification systems as a condition in its own right, but the onset of a depressive episode within four weeks of childbirth can be recorded via the perinatal-onset specifier in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5)¹. There is evidence to suggest that the DSM-5 specifier is too narrow; therefore, most clinicians consider depressive episodes occurring within 6-12 months of delivery to be PND².

The term "postnatal depression" should not be used as an umbrella term for all mental health problems following delivery. It is one of a number of under-recognised mental health problems which may occur in the postnatal period, others including a range of anxiety disorders, such as generalised anxiety disorder, obsessive-compulsive disorder, panic disorder, phobias, post‑traumatic stress disorder and social anxiety disorder³.

Depression can occur de novo, can be a recurrence of a depressive condition occurring prior to pregnancy, or be part of a wider problem - eg, bipolar disorder. Assessment and management are much like that of depression at any other time, the key differences being the implications of the illness and its management for the baby, and the risk of postpartum psychosis.

Epidemiology

Depression is under-recognised during pregnancy and postnatally. In pregnancy, depression and anxiety are the most common mental health problems, affecting around 12-13% of women, respectively and during the first year after birth, around 15-20% of women experience depression and anxiety³.

Examination of UK GP records shows screening was recorded in only 13% of patient records and a study using GP records reported an estimated rate of missed cases of 31-46%, suggesting there is still a diagnosis gap for perinatal depression in general practice⁴. Research suggests that women from black and ethnic minority groups have their perinatal mental health needs missed more than white women⁵.

Aetiology

The strongest risk factors appear to be:

• Previous history of mental health problems.

• Psychological disturbance during pregnancy.

• Poor social support.

• Poor relationship with partner.

• Baby blues.

• Recent major life events.

Other risk factors include:

• Unplanned pregnancy.

• Unemployment.

• Not breastfeeding.

• Antenatal parental stress.

• Antenatal thyroid dysfunction.

• Longer time to conception.

• Depression in the father of the child.

• Having two or more children.

• Current, or history of, substance misuse.

• Neonatal low birth weight or illness, stillbirth and sudden infant death syndrome (SIDS).

Weak associations have also been found for:

• Obstetric complications.

• History of abuse.

• Low family income.

• Lower occupational status.

There is no convincing evidence that hormonal changes cause PND.

Presentation

PND presents with the same symptoms as those of depression in other circumstances. However, take into account that some of the symptoms associated with depression can be normal in the early postnatal period (sleep disturbance, tiredness, anxiety about the baby). Symptoms of depression include:

• Low mood.

• Loss of enjoyment and pleasure.

• Anxiety.

• Disturbed sleep.

• Loss of appetite.

• Poor concentration..

• Low self-esteem. Worthlessness and inappropriate feelings of guilt.

• Low energy levels.

• Loss of libido.

• Thoughts of death/suicidal thoughts

The National Institute for Health and Care Excellence (NICE) warns that health professionals should be aware that women may be unwilling to disclose symptoms of depression and other mental health problems or reluctant to engage³. This may be due to fear of stigma, fear the baby may be taken into care, concern that they will be perceived as a poor mother, the nature of the condition or problems with alcohol or substance dependence.

Diagnosis³

At booking and at postnatal checks, all health professionals should consider mental health screening questions.

Consider asking the following questions to screen for depression:

• 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?

Consider asking the following two questions about anxiety:

• 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?

If the answer is "yes" to any of these questions, or if there is clinical concern, further assessment is required. This may be by the use of a formal assessment tool, such as the Patient Health Questionnaire (PHQ-9), the Edinburgh Postnatal Depression Scale or the Generalised Anxiety Disorder Scale (GAD-7).

Assessment

NICE advises that assessment of any mental health problem in either pregnancy or the postnatal period should include the following³:

• Past history or family history of any mental health problem. Also any current or past treatment for a mental health problem and response to any treatment.

• Physical well-being and history of any physical health problem.

• Alcohol and drug misuse.

• The woman's attitude to and experience of the pregnancy.

• The mother-baby relationship.

• Relationships and social networks.

• Living conditions and social isolation.

• Domestic violence and abuse, sexual abuse, trauma, or childhood maltreatment.

• Housing, employment, and economic and immigration status.

• Responsibilities as a carer for other children and young people or other adults.

Management³⁶

General principles

• Empowerment. Involve women in decisions about their care. Partners, family and carers should also be involved, if the woman agrees. Reassure the woman that PND is not uncommon, and be optimistic about its resolution. Give her all the information she needs to make informed decisions about treatment, and acknowledge her central role in the decision-making process. Ensure adequate contact and support networks. For patients who lack capacity, follow the Department of Health guidelines and the code of practice accompanying the Mental Capacity Act.

• Communication. Good communication is important - the woman, her relatives and carers should be given information in a form that is culturally appropriate and takes account of any physical disabilities that present an obstacle to comprehension (eg, deafness). Communication between all health professionals involved is vital for integrated care. Develop an integrated care plan.

• The wider family environment. Consider the needs of other children, dependent adults, and the effect the illness may have on relationships with partners. The welfare of the baby must always be borne in mind.

• Adolescents. Bear in mind local and national guidelines concerning confidentiality and the rights of the child. When obtaining consent, issues that may need to be considered include Gillick competence, child protection concerns, current mental health legislation, and the Children Act.

Management strategy

Mild to moderate depression
Consider facilitated self-help strategies (as per NICE guidelines on depression)⁷.

Mild depression with a history of severe depression
Consider an antidepressant.

Moderate or severe depression
Consider:

• High-intensity psychological intervention such as cognitive behavioural therapy (CBT).

• Antidepressant treatment if:

  • Risks are understood and accepted, particularly if breastfeeding.

  • The woman declines psychological therapy.

  • Psychological therapies have failed.

• High-intensity psychological intervention in combination with antidepressant therapy.

Psychological treatments

• There is evidence that psychological therapies are of benefit with strongest evidence for CBT and interpersonal psychotherapy⁸. NICE guidelines advise psychological therapies are first-line consideration in most cases.

• Facilitated self-help strategies are described in NICE depression guidelines and are based on the principles of CBT⁷. They should be supported by a trained practitioner, over a 9- to 12-week period, either face-to-face or by telephone.

• High-intensity psychological treatments such as CBT or interpersonal psychotherapy must be delivered by appropriately trained practitioners.

• Psychological treatments should be provided promptly (within one month at most, and assessment should take place within two weeks of referral).

Pharmacological therapy - issues to consider and discuss in choosing treatment

Seek advice from a specialist perinatal mental health team, where available; or from secondary psychiatric care.

• The current uncertainty about the benefits, risks and harms of treatments for mental health problems in pregnancy and the postnatal period.

• The likely benefits and risks of each treatment, taking into account the severity of depression.

• Benefits of breastfeeding.

• Potential benefit of antidepressant drugs and the impact of relapse and recurrence if the drugs are stopped. Potential risk of harm to mother and baby if depression is not treated.

• Evidence of response to a particular antidepressant for that individual woman

• For a mother who is successfully treated for depression during pregnancy, it might be better to continue the same antidepressant postpartum because stopping or switching the drug might lead to relapse.

• Maternal side-effects of drugs - sedation might affect a mother's ability to care for the child, particularly at night.

If choosing a selective serotonin reuptake inhibitor (SSRI), tricyclic antidepressant (TCA), or (serotonin-) noradrenaline reuptake inhibitor [(S)NRI] in the postnatal period²:

• The choice of drug should be based on the woman's previous response to medication and the risk profile for her and her baby.

• Note that no psychotropic medication has a UK marketing authorisation specifically for women who are breastfeeding and informed consent should be obtained and documented.

• The lowest effective dose should be prescribed, but ensure that depression is adequately treated.

• The risk of discontinuation symptoms in the woman should be taken into account.

• A single drug should be used, if possible, rather than two or more drugs.

Management of severe depression

Women who have ideas of either suicide or of harming the baby, should be referred immediately for urgent psychiatric assessment. Child protection procedures may need to be invoked.

A few mothers have depression that is too severe to be managed solely in primary care and will require the involvement of a psychiatrist; sometimes needing compulsory admission using the Mental Health Act. Dedicated "mother and baby units" offer the ideal environment but are not available in all areas. Care needs to be delivered and monitored by a multidisciplinary team linking closely with social services and family mental health services.

Prognosis

Whilst women are at generally low risk of suicide during pregnancy, it is a significant cause of maternal death in the year following birth in the UK. Improving awareness of perinatal mental health problems, in all their diversity, is important.

Depression occurring postnatally is often self-limiting within a few months; however, about one third of women are still unwell one year after childbirth, and about 13% after two years².

Complications

Postpartum depression has repercussions beyond physical harm to the child. The condition also affects mother-infant bonding and often the child is treated inappropriately with a very negative attitude⁹. This can have a significant impact on the growth and development of the child. Children born to mothers with postpartum depression have been found to exhibit marked changes in behaviour, altered cognitive development and early onset of depressive illness. Negative influences of mothers' depression are seen in their language skills and intelligence quotients (particularly in boys). However, these effects are not universal. It is only seen when the mother is unable to engage actively with the infant.

Postpartum psychosis

Postpartum (or puerperal) psychosis is more often associated with bipolar disorder or with schizophrenia, but may occur with severe depression.

Prevention³

Women should be proactively screened for mental health problems, and high-risk patients identified. It is advised that when women present for booking and at the postnatal check, health professionals (including midwives, obstetricians, health visitors and GPs) should ask questions to screen for depression and anxiety (as in the 'Diagnosis' section, above). At the first contact they should also ask about:

• Past or present severe mental illness including schizophrenia, bipolar disorder, psychosis in the postnatal period and severe depression.

• Previous treatment by a psychiatrist/specialist mental health team including inpatient care.

• A family history of severe perinatal mental illness in a first-degree relative.

Women identified as at high risk of developing severe depression, or with a history of severe mental illness, should be referred to secondary care mental health services.