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Postnatal Depression and Social Exclusion.

What is Post Natal Depression ?

Postnatal depression is a discrete clinical entity which appears to have a number of different aetiological factors. It does not appear to be greatly influenced by geography (Affonso et al 2000), or culture (Oates et al, 2004). A typical rate for detection of postnatal depression is quoted as about 13% of postnatal women (O’Hara et al 1996). It classically arises during the first three months post partum but the spread of onset is wide. (Cooper & Murray 1995)

One of the prime factors is considered to be the sudden postnatal drop in progesterone levels in the post partum days. (Nappi et al 2001) The placenta is responsible for the vast majority of circulating progesterone during pregnancy and it’s delivery is effectively responsible for the precipitate drop in levels post partum.

There may also be other related hormonal changes including the fluctuations in prolactin levels (Hendrick et al 1998) and falling oestrogen and cortisol levels. (Halari et al. 2004)

Symptoms can initially include irritability, tearfulness, insomnia, hypochondriasis, headache and impairment of concentration. There is a maximal incidence of these symptoms on about the fifth post partum day and these can progress to frank depressive symptoms over a variable period. (Ramsay et al 1995). There are various tools that can be used to measure the degree of depression and these include the Edinburgh postnatal depression scale,(Cox et al 1987), The Stein scale for maternity blues, (Stein 1980) and the Beck depression rating inventory. (Beck et al 1961)

Key issues affecting vulnerable patients

There have been a number of studies that look at the effectiveness of treatment of postnatal depression. One of the most recent publications (Dennis 2005) provides a meta-analysis of the factors which influence the outcome in the condition. The author concluded that the only strategy that was shown to have “a clear preventative effect” was intensive post-partum support from the healthcare professionals involved in the case. Curiously, this was found to be more effective than similar regimes which included an ante-natal component as well.

The morbidity associated with postnatal depression has a number of potential consequences not only for the mother, but also the child and the rest of the family as well. (Oakley et al 1996)

One of the most significant is the fact that one episode of postnatal depression is the greatest predictor (or risk factor) for another episode after subsequent pregnancies. The children are likely to have difficulties because of possible problems with bonding and the mother’s possible negative perceptions of the behaviour of the children. (Cooper & Murray 1997)

Some studies have shown that mothers with postnatal depression have derived beneficial help from social support during pregnancy. (Ray et al 2000). It would therefore appear that the key issues in this area are identification of the predictive factors that make postnatal depression more likely and then the provision of prompt supportive measures if those factors are established.

Local resources for support

Apart from the more “traditional “ resources of the primary healthcare team of the General Practice the Midwife and the Health Visitor, some centres have tried experiments with postnatal support worker provision (Morrell 2000). This particular study found that the patients found an high level of satisfaction with the service – but no more so than with the services provided by the rest of the primary healthcare team. Analysis of the results showed that the postnatal support worker helped to achieve higher levels of breast feeding, but had little impact on the severity or frequency of postnatal depression.

One significant factor that was found, however, was that support from a partner was a significant positive factor in preventing severe postnatal depression.

Communication strategies

Several recent studies have shown that healthcare professionals often fail to spot the signs of postnatal depression. (Bick et al 1995). Making the diagnosis is obviously the prerequisite of establishing a treatment regime so it is clearly vital for all healthcare professionals to be on their guard for warning signs – sleep disturbance, irritability, mood swings and irrationality. (Ramsay et al 1995)

Reflection and reflective practice is a vital part of effective nursing. (Gibbs 1998) . Each healthcare professional should ideally reflect upon their management of each individual case to decide whether they were communicating optimally with the patient and that they were fully receptive to all that was on the patient’s agenda. Communication is a two-way modality.

Bulman (et al.2004) points to the need to understand, at a deeper level, just what it is the message that the patient is taking away from any interaction. Communication is therefore vital in the strategy to empower and educate the vulnerable patient.

Role of midwife and Health Visitor

The new mother is often at the centre of an emotional rollercoaster. The sudden culmination of nine months of expectation results (frequently) in a flurry of support from healthcare professionals and family, which then rapidly evaporates and the mother is left to deal with the new situation which is frequently stressful. (Kitzman et al 1997)

The midwife can obviously help by preparing the ground in the antenatal period and offering support in the immediate postnatal period. (Dennis 2005). The health visitor is probably better placed to be aware of any developing warning signals that postnatal depression is developing, as they are likely to be in contact with the patient during the “high risk period”. (Cooper & Murray 1995).

It has been suggested that encouragement of the mother to attend the health visitor clinic rather than to have home visits is a positive way of encouraging social inclusion. (Seeley et al 1996)
Studies which have looked at the cost-effectiveness of using community postnatal support service workers have shown no benefit over the more traditional midwife and Health Visitor support. (Morrell et al 2000)

References

Affonso DD, De AK, Horowitz JA, Mayberry LJ. 2000
An international study exploring levels of postpartum depressive symptomatology.
J Psychosom Res 2000;49: 207-16.

Beck AT, Ward CH, Mendelson M, Mock J, Baugh J. 1961
An inventory for measuring depression.
Arch Gen Psychiatry 1961;4:561-71.

Bick D, MacArthur C. 1995
The extent, severity and effect of health problems after childbirth.
Br J Midwifery 1995; 3: 27-31

Bulman & Schultz 2004
Reflective Practice in Nursing
The Growth of the Professional Practitioner Third Edition
Edited By: CHRIS BULMAN, School of Health Care, Oxford Brookes University
SUE SCHUTZ, Oxford Brookes University 2004

Cooper & Murra 1995
Course and recurrence of postnatal depression. Evidence for the specificity of the diagnostic concept
The British Journal of Psychiatry 166: 191-195 (1995)

Cooper P, Murray L. 1997
Prediction, detection, and treatment of postnatal depression.
Arch Dis Child 1997;77: 97-9

Cox JL, Holden JM, Sagovsky R. 1987
Detection of post-natal depression. Development of the 10-item Edinburgh post-natal depression scale.
Br J Psychiatry 1987;150:782-6.

Dennis C-L. 2005
Psychosocial and psychological interventions for prevention of postnatal depression: systematic review
BMJ, Jul 2005; 331: 15.

Gibbs, G (1998)
Learning by doing: A guide to Teaching and Learning methods
EMU Oxford Brookes University, Oxford. 1998

Halari, V. Kumari, R. Mehrotra, M. Wheeler, M. Hines, and T. Sharma 2004
The Relationship of Sex Hormones and Cortisol with Cognitive functioning in Schizophrenia
J Psychopharmacol, September 1, 2004; 18(3): 366 - 374.

Hendrick, L. L. Altshuler, and R. Suri 1998
Hormonal Changes in the Postpartum and Implications for Postpartum Depression
Psychosomatics, April 1, 1998; 39(2): 93 - 101

Kitzman H, Olds DL, Henderson CR, Hanks C, Cole R, Tatelbaum R, et al. L 1997
Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing.
JAMA 1997; 278: 644-652

Nappi, F. Petraglia, S. Luisi, F. Polatti, C. Farina, and A. R. Genazzani 2001
Serum Allopregnanolone in Women With Postpartum "Blues"
Obstet. Gynecol., January 1, 2001; 97(1): 77 - 80.

Oakley A, Hickey D, Rajan L. 1996
Social support in pregnancy: does it have long-term effects?
J Reprod Infant Psychol 1996; 14: 7-22.

Oates MR, Cox JL, Neema S, Asten P, Glangeaud-Freudenthal N, Figueiredo B, et al. 2004
Postnatal depression across countries and cultures: a qualitative study.
Br J Psychiatry Suppl 2004;46: s10-6.

O'Hara M, Swain A. 1996
Rates and risk of postpartum depression—a meta-analysis.
Int Rev Psychiatry 1996;8: 37-54.

Ramsay. R and T. Fahy 1995
Recent Advances: Psychiatry
BMJ, July 15, 1995; 311(6998): 167 - 170.

Ray KL, Hodnett ED. 2000
Caregiver support for postpartum depression. In: Cochrane Collaboration,ed. Cochrane Library. Issue 1.
Oxford: Update Software, 2000.

Seeley S, Murray L, Cooper PJ. 1996
The outcome for mothers and babies of health visitor intervention.
Health Visitor 1996;69:135-138.

Stein GS. 1980
The pattern of mental change and body weight in the first post partum week.
J Psychosom Res 1980;24:1165-71.


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