Postnatal Depression - Baby Blues

Postnatal depression is also known as postpartum or perinatal depression. It is a more serious type of depression than the “baby blues”. The baby blues, unless persistent, usually do not require treatment and are normal reactions to the hormonal changes and stress after delivery. It is thought that postnatal depression can occur at any time up to one year after delivery; however, evidence suggests that there is no general consensus^[1].

Research evidence suggests that postnatal depression affects 10 to 20% of newly delivered women^[2]. It is debated however, that these figures should be treated with caution, as they are representative of DSM IV diagnosis that was found among a selective population of middle-class Caucasian women. A more detailed review of the literature shows that the reported figures vary between countries, and even within a country, from 0.5% to over 60%^[3]. Therefore, it is proposed that factors such as culture, socioeconomic status, genetics, ethnicity and style of reporting may contribute to the diversity^[4].

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It is suggested that symptoms are quite varied and can include factors such as a depressed mood, tearfulness, lack of drive and enjoyment, social withdrawal, insomnia, poor appetite, impaired concentration, and feelings of uselessness and helplessness are common symptoms. Some sufferers may be emotionally detached from their infant and show no affection towards family members. Some women may feel self-worthless and isolated due to the physical and emotional stress during delivery and the dilemma in meeting the demands of infant care and other family members. Sufferers may also feel as if they are inadequate mothers, causing them to have feelings of guilt and embarrassment.

Bodily symptoms, such as wound pain, headache and back pain, are also prevalent. Some women even have ideas about self-harm and suicidal plans or there might be the presence of ideas about or acts of infant-harm^[5]. Although it is imperative to check whether a depressed mother wants to harm her baby, it is just as important to ask if she has ever lost her temper with the baby; for example, when the baby cries. This may bring about a disclosure of, for instance, the mother thrusting a pillow on the baby on occasions when she has been distressed by the baby’s inconsolable crying. While the purpose of the deed may not have been infanticidal, it is nonetheless dangerous and has an essential relevance to risk assessment and treatment plan^[6].

As already mentioned, it is generally recognised that postnatal depression is caused by a combination of biological and psychosocial factors. There is evidence that genetic factors may contribute to as much as one third of the aetiology of postnatal depression^[7]. A recent study also showed that siblings of women who had suffered with postnatal depression had increased risk of suffering from the condition^[8]. Hormones, such as oestrogen and progesterone, have commonly been suggested as potential biological causes; however, it is important to note that no conclusive evidence exists as yet as to the role of these hormones in postnatal depression^[9].

In contrast, research into the psychosocial reasons for postnatal depression has produced more reliable results. A large scale study summarised significant individual but not mutually exclusive psychosocial causes for postnatal depression. These are: a history of depression that is not necessarily associated with pregnancy, coexisting life stressors, lack of social support, marital dissatisfaction, personal vulnerability such as an anxiety-prone personality and poverty. It is also important to note that women who have postnatal depression in previous pregnancies are more preponderant to the illness compared to those who have never had postnatal depression. Between one sixth and one half of women with a previous history of postnatal depression could have another episode in subsequent pregnancies^[10]. It is suggested that it is also well established that antenatal depressive symptoms are the best predictor of postnatal depression^[11]. Research has shown that a substantial proportion of “postnatal depression” actually begins during pregnancy. A study following a group of women through pregnancy to the postnatal period revealed that levels of antenatal depression are “on a par” with those of postnatal depression^[12].

Research evidence has reported a correlation of stress during pregnancy and preterm delivery and low birth weight. Both are suggested to be associated with long-term neurological and developmental impairments, mental and cognitive dysfunctions, diabetes, cardiovascular disease, schizophrenia and other somatic disorders. There is growing evidence of the adverse impact of postnatal depression on the emotional, behavioural and cognitive development of the newborn^[13]. Longitudinal studies in the United Kingdom showed that newborns of women with postnatal depression are more likely to have impairment in terms of socio-emotional and cognitive developments^[14]. Mothers suffering from postnatal depression are more likely to exhibit behaviours such as intrusiveness, withdrawal and disengagement that would impact the children negatively. Postnatal depression symptoms are also a consistent predictor of negative parenting behaviour. It is suggested that problems in infants may be reduced or prevented if maternal depression is prevented and treated early^[15].

It is posited that postnatal depression generally responds well to treatment. Mild depression can be treated with psychological counselling and social interventions, whereas more severe cases might benefit from antidepressants^[16]. As mentioned, it is important to remember that postnatal depression is associated with psychosocial stressors and these can be improved with counselling and social interventions. For instance, mild postnatal depression may be improved by the family providing more assistance and support for the new mother. Cognitive behavioural counselling and interpersonal therapy have been shown to be useful in treating mild cases of postnatal depression^[17]. In more severe cases, pharmacotherapy is needed to expedite the recovery. Antidepressants with fewer sedative side-effects are the drugs of choice for non-breastfeeding mothers, allowing them to continue to look after the newborn at night time. When the mother is breastfeeding, the uncertain neuro-behavioural risks of antidepressants need to be carefully considered. It is also important to consider the mother and her family’s wishes in tailoring the treatment. Current evidence shows that intense psychological treatment can be as effective as antidepressants; however, it is much more time-consuming and expensive^[18]. Arguably, this could be why there is preponderance towards psychotropic drug therapy as the answer to treating postnatal depression.

Postnatal depression affects up to 1 in 5 women postpartum. Symptoms are wide-ranging and individuals are affected to varying degrees from mild depression to severe depression involving suicidal thoughts and infant harm. The aetiology is a combination of biological and psychosocial factors and a genetic component has been found to exist that predisposes women to the condition. Similarly, having a mother or other maternal relatives who have suffered from postnatal depression predisposes one to the condition. There is evidence that postnatal depression can effect the development of neonates and that treatment for the condition could be beneficial in terms of reducing its impact on child development. Response to treatment is usually good with mild cases responding to counselling and cognitive behavioural therapy. However, more severe cases may need treatment with antidepressants.

References

Altshuler LL, Cohen LS, Moline ML. The expert consensus guideline series: treatment of depression in women, Postgraduate Medicine, 2001, 109, 1-7

Beck CT. A meta-analysis of predictors of postnatal depression, Nursing Research, 1996, 45, 297-303

Benette HA, Einarson A, Taddio A. Prevalence of depression during pregnancy: systematic review, Obstetrics Gynecology, 2004, 103, 698-709

Cooper PJ & Murray L. Fortnightly review: postnatal depression, British Medical Journal, 1998, 316, 1884-1886

Cooper P, Murray L, Wilson A and Romaniuk H. Controlled trial of the short and long-term effect of psychological treatment of post-partum depression: 1. Impact on maternal mood, British Journal of Psychiatry, 2003, 182, 412-419

Goodman J. Postpartum depression beyond the early postpartum period, Journal of Obstetric, Gynecologic and Neonatal Nursing, 2004, 33(4), 410-420

Evans J, Heron J, Francomb H. Cohort study of depressed mood during pregnancy and after childbirth, British Medical Journal, 2001, 323, 257-260

Halbreich U. Guest editorial: postnatal disorders: multiple interacting underlying mechanisms and risks factors, Journal of Affective Disorders, 2005, 88, 1-7

Henshaw C and Elliott S. Screening for Perinatal Depression, 2005, London: Jessica Kingsley

Howard LM. Postnatal depression, Clinical Evidence, 2004, 11, 1872-1885

Marcus SM, Flynn HA, Blow FC, Barry KL. Depressive Symptoms among Pregnant Women Screened in Obstetrics Settings, Journal of Women’s Health, 2003, 12(4), 373-380

MilgromJ, Gemmill A, Bilszta J, Hayes B, Barnett B, Brooks J, Ericksen J, Ellwood D, Buist A. Antenatal risk factors for postnatal depression: A large prospective study Journal of Affective Disorders, 2008, 108(1-2), 147-157

Murphy-Eberenz K, Zandi PP, March D. Is perinatal depression familial? Journal of Affective Disorders, 2006, 90, 49-55

Righetti-Veltema M, Bousquet A, Manzano. Impact of postnatal depressive symptoms on mother and her 18-month-old infant, European Child and Adolescent Psychiatry, 2003, 12, 75-83

Treloar SA, Martin NG, Bucholz KK. Genetic influences on post-natal depressive symptoms: findings from an Australian twin sample, Psychological Medicine, 1999, 29, 645-654

Zonana J and Gorman JM. The neurobiology of postnatal depression, CNS Spectrums, 2005, 10, 792-799

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Footnotes

^[1] Goodman (2004) p415

^[2] Howard (2004) p1872

^[3] Benette et al (2004) p700

^[4] Halbreich (2005) p4

^[5] Marcus et al (2003) p373

^[6] Henshaw and Elliott (2005) p23

^[7] Treloar et al (1999) p645

^[8] Murphy-Eberenz et al (2006) p51

^[9] Zonana and Gorman (2005) p793

^[10] Beck (1996), p301

^[11] Milgrom et al (2008) p145

^[12] Evans et al (2001) p257

^[13] Righetti-Veltema et al (2003) p80

^[14] Cooper and Murray (1998) p412

^[15] op cit p1

^[16] Cooper et al (2003) p415

^[17] ibid

^[18] Altshuler et al (2001) p2