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Post Natal Depression

Introduction

Post-Natal Depression (now often referred to as 'PND') means becoming depressed after having a baby. Sometimes this is easy to explain - the baby is unwanted or abnormal. Mostly, though, the depression makes no obvious sense: 'I was so looking forward to having this baby, and now I feel utterly miserable. What's the matter with me?' 'The labour went beautifully - much better than I expected, and everyone's been marvellous, especially Jim. So why aren't I over the moon?' 'I was so afraid there'd be something wrong with her, but she's perfect. So why aren't I enjoying her? Perhaps I'm not cut out to be a mother?'

These women are not ungrateful or unmotherly: they are experiencing one of the most common complications of childbirth, from which too many women still suffer unnecessarily in silence - Post-Natal Depression.

How common is it?

Very! Again and again it has been found that no less than one in ten women suffer depression after childbirth. This blight on the experience of motherhood is therefore one of the most common illnesses following childbearing. It can go on for months, or even years, yet if treated soon enough it can be nipped in the bud.

Symptoms

Depression

This is the most common symptom of PND. It means feeling low, unhappy and wretched for much or all of the time. Sometimes the depression is worse at particular times of the day, like mornings or evenings. Sometimes there are good days and bad - which are the more disappointing because the previous good day raised hopes of getting better.

Sometimes it can seem that life is not worth living, at a time when it should be at its most joyous.

Irritability

Often accompanies the depression. It can be shown towards any other children, and occasionally the baby, but most of all the partner, who may well wonder what on earth is wrong!

Fatigue

All new mothers get pretty weary, but the depressed mother is so utterly exhausted that she may think that there is something physically wrong with her.

Sleeplessness

However, when at last she gets to bed she may find that she cannot fall asleep - or if she does, that she wakes early, even if her partner is feeding the baby that night.

Loss of appetite

Depressed mothers usually haven't the time or the interest to eat, and this contributes to feeling irritable and run down. Some women, though, eat too much, for comfort, but then feel guilty and uncomfortable about getting fat.

Loss of enjoyment (or 'You're no fun anymore!')

What used to be a pleasure is unappealing, what used to be of interest is a bore. This may be especially true of sex. Some women regain interest in sex (if they ever lost it) before the 6 weeks post-natal examination, but PND usually takes any enthusiasm away. The partner who seeks to share the comfort and excitement of intercourse meets reluctance or a rebuff. This puts further strain on the relationship.

Not coping

PND causes a feeling of having too little time, doing nothing well and not being able to do anything about it. A new routine, to cope with the baby as well as everything else, is hard to establish.

Anxiety

Is acute. Often it takes the form of being afraid to be alone with the baby, who might scream the place down or not feed or choke or be dropped or harmed in some other way. Some depressed mothers perceive the baby as 'it', instead of feeling that they have given birth to the loveliest, most adorable creature in the world they feel detached from their infant. They can't see that it's all that beautiful - indeed, they may find it a rather strange, mysterious little being, whose thoughts (if any) can't be fathomed and whose unpredictable needs and emotions have somehow to be satisfied. The task of a new mother who hasn't yet 'fallen in love' with her baby is extra difficult. The love comes in the end, but usually when the baby is older and more interesting.

However, PND may develop even when love is strong. The mother then worries desperately in case she should lose her precious baby through infection, mishandling, faulty development or a 'cot death'. Snuffles cause her terrible worry, she frets over how much weight has been (or not been) gained, she is alarmed if the baby is crying or if it is too silent - has its breathing stopped? So she wants constant reassurance from her partner, the Health Visitor, the doctor, her family, the woman next door - anyone, really.

Anxiety may also make the mother concerned about her own health. She may panic when her pulse races and her heart thumps and then she may feel she has heart disease or be on the brink of a stroke. She feels so drained - is there some dreadful illness, and will she ever have any energy again? Her feelings are so odd and unusual - is she going mad? (The answer is NO!).

The terror of being left alone with all this can cause even the most capable woman to cling desperately to her partner, not wanting him to go to work.

Aren't all women like this after having a baby?

Thank goodness, no! Many women - at least one in two - feel a bit weepy, flat and unsure of themselves on the third or fourth day after having a baby. This is the 'Baby Blues', which soon passes. Of course, many women are weary and a bit disorganised when they get home from hospital, but they usually feel on top of the situation in a week or so. But for mothers with PND things get worse and worse.

When does it happen?

Most cases of PND arise within a month of the birth, but sometimes depression appears up to six months later.

Why does it happen?

We don't know enough about why women get PND to be sure who will or won't suffer it. Probably there isn't a single cause, but a number of different stresses may have the same consequence, or may act together. We know that among these 'risk factors' are:

However, a woman can suffer from PND when none of these apply and there is no obvious reason at all.

What about hormones?

It seems likely that PND is related to the huge hormone changes which take place at the time of giving birth, but this evidence is still lacking. Levels of oestrogen, progesterone and other hormones to do with reproduction, which may also affect emotions, drop suddenly after the baby is born, but no real differences have been found in the hormone changes of women who do and do not get PND. Some women, though, may be more vulnerable to such changes than others.

Do women with PND harm their babies?

No, they don't. They may feel like it (as, to be honest, do many mothers even without PND on occasion - 'I feel that if he goes on screaming I'll pick him up and throw him out of the window!') and they worry very much in case they should actually harm their babies, but they never do.

Women who do 'batter' their babies (the proper term is non-accidental injury, or NAI) have often been emotionally damaged by ill-treatment when they themselves were children.

Rarely, however, a baby is injured or even killed by a mother who is severely mentally disturbed at the time. This is a tragic consequence of puerperal psychosis, a very serious (but very treatable) mental illness which usually comes on within days of giving birth. The mother may be deluded that her baby is evil or, feeling suicidal, she may decide to take the baby's life with her own. This is called infanticide, rather than murder. Puerperal psychosis arises only after one birth in 500, and infanticide is fortunately very rare.

What can be done?

A great deal, but first the PND must be recognised.

Many depressed mothers don't realise what is wrong with them, and are ashamed to admit that they are less than thrilled by new motherhood. They may think that if they say how they feel the baby may be taken away (it won't be). Some doctors and Health Visitors are good at spotting PND, because they know about it and look out for it, but others overlook or ignore it, or say, wrongly 'Oh, that's just the Baby Blues'.

Now that there is a greater awareness of depression in general, PND should be missed less often. A questionnaire with only 10 questions is now widely used and is helping Health Visitors and GPs to spot the disorder - it's called the Edinburgh Scale.

Once the condition is suspected, the mother is encouraged to say how she has really felt since she had the baby. If she says that she has felt miserable, irritable, incompetent, frightened and not all that keen on her baby this is accepted with compassion and understanding, not alarm and reproaches.

It helps many a mother to be told 'You've got PND'. At last she knows her enemy. She can be reassured that she is not a freak or a bad mother, and that many others are in the same boat. PND is very common and anyone can get it (like flu). She can then be told that she will get better, but it may take time, and that arrangements will be made to see that she is supported until she has recovered.

It is now important to bring the partner into the picture, so that he can understand what has been going on (he, too, has been suffering from PND!) and be helped to be helpful. He is usually best placed to give support, provided that he has goodwill and gets a bit of support himself. If this is the first baby he may have been feeling pushed aside by the new arrival. If he then feels resentful without grasping how much his partner needs his support and encouragement, he may withdraw and add to her problems. He too may be hugely relieved by the diagnosis and guidance about what to do. Practical help with the baby, sympathetic listening, patience, affection and being positive will go a long way: they will be much appreciated even when at last the depression is over.

What about talking treatments?

The opportunity to 'off-load' to a sympathetic, understanding, uncritical listener - who could be a friend, a relative, a volunteer or a professional - can be a great relief and release. Many general practices now have a counsellor, and trained Health Visitors have been shown to be helpful to groups of depressed mothers.

More specialised psychological treatments, such as psychotherapy ('Let's try to understand this depression in terms of what has happened to you in the past') and cognitive therapy ('We're going to help you to feel more positive about yourself') are sometimes appropriate, and may be arranged through the GP with, say, community psychiatric nurses, psychologists or psychiatrists.

What about tablets?

Doctors don't always dismiss their patients who have emotional problems with a prescription! However, sometimes the nature of the depression is such that one of the antidepressant drugs will help a lot. These drugs:

Hormones appeal to many women more than antidepressants, because they seem more 'natural'. However, the evidence that they work is less impressive, and they are not necessarily harmless, e.g. if there is a previous history of blood clots.

Progesterone is best as a suppository, while oestrogen is now sometimes applied in skin patches. There is no doubt that many women feel that they have benefited greatly from hormone treatments, but it has yet to be shown that this is more than a 'placebo' effect - that is produced by hope rather than the treatment itself.

What is the outlook if PND is not treated?

Most women will get better anyway, after weeks, months or even a year or two. However, this means a lot of suffering. PND gets the experience of new motherhood off to a bad start, and strains the relationship with the baby's father. So the shorter it lasts, the better. It is very important to diagnose and treat PND as soon as possible.

Can PND be prevented?

Yes. There are three kinds of prevention: stopping it happening in the first place; nipping it in the bud; and stopping things from getting worse. This leaflet has been mainly concerned with the second form: spotting PND and treating it quickly.

We don't know enough yet about PND to prevent it in the first place, but certain principles make sense:

DON'T try to be a superwoman: having a baby may be a full-time occupation, so try to reduce commitments during your pregnancy. (If you are at work, make sure you get regular and sufficient nourishment and put your feet up in the lunch hour);

DON'T move house (if you can help it) while you are pregnant or until the baby is six months old;

DO make friends with other couples who are expecting or have just had a baby; among other things, this could lead to a baby-sitting circle;

DO identify someone to whom you can confide, it helps so much to have a close friend you can turn to. (If you can't easily find someone, try the National Childbirth Trust or MAMA - their local groups are very supportive before and after childbirth);

DO go to ante-natal classes - and take your partner with you!

If you have suffered PND before, that doesn't mean that you will do so again. However, it is only sensible to keep in touch with your GP (and, after the birth, your Health Visitor) so that should there be any signs of recurrence, treatment can start at once.

After the baby has arrived:

DO take every opportunity to get your head down. Try to learn the knack of cat-napping. Your partner can give the baby a bottle-feed at night, using your own expressed breast milk if you like.

DO get enough nourishment. Healthy foods like salads, fresh vegetables, fruit, fruit juices, milk and cereals are all nice, packed with vitamins and don't need much cooking.

DO find time to have fun with your partner. Try to find a baby sitter and get out together for a meal, a show, to see friends or just visit to the pub;

DO let yourself and your partner be intimate, even if you don't yet feel like sex: at least kiss and cuddle, stroke and fondle. This will comfort you both and lead all the sooner to the return of full sexual feeling.

DON'T blame yourself or him: life is tough at this time, and tiredness and irritability on both sides can lead to quarrels. But 'having a go' at each other may weaken your relationship when it needs to be at its strongest;

DON'T be afraid to ask for help when you need it. It may be up to doctors and Health Visitors and midwives to diagnose PND, rather than the mothers themselves. But those who have learnt about it from ante-natal classes (and leaflets like this) could help by asking themselves, their partners and the professionals whether they could be depressed.

FINALLY even if the PND is well established by the time it is recognised, support, counselling and medication will often make a big difference and will speed eventual recovery: it's never too late!
 


Copyright:  Royal College of Psychiatrists, 1998
Cartoons by Professor Tom Barnes
Leaflet last revised: June 1997

Online edition updated with minor amendments July 2001