Postnatal depression

Abstract

The year after a baby is born is an important time in the life of any woman, and an essential period in the social and emotional development of a child. A significant number of women suffer from postnatal depression, however, only a small proportion of sufferers are diagnosed, and fewer are treated appropriately. Inadequate treatment has a detrimental effect on mothers and their families, and may lead to long-term problems in their children. Mental health problems, including suicide, are a leading cause of maternal death. Women who die due to mental illness in the postnatal period often have complicated social and medical problems. GPs are in an ideal position to detect and diagnose postnatal depression, initiate treatment and ensure referral to specialist perinatal mental health services when needed. GPs should be aware of red flag signs for postnatal mental health problems, and be able to coordinate between different services to detect and support women at high risk of harm.

The GP curriculum and postnatal depression

Clinical module 3.10: Care of people with mental health problems includes the learning objectives:

As a GP you should recognise the increased risk of mental health problems in the perinatal period and demonstrate how to assess and manage these appropriately in general practice

As a GP you should understand the stigma that can be associated with the label of a mental health problem

Mental health problems affect people throughout their lives, and as such, women may be affected by any mental health problem during pregnancy and the postnatal period. This article looks specifically at depression diagnosed perinatally, which is a time of significant risk.

Background

The American Psychiatric Association’s Diagnostic and Statistical Manual categorises postnatal depression (PND) as a major depressive episode with onset during pregnancy or the first-4-weeks postpartum (American Psychiatric Association, 2013). It is, however, generally acknowledged that symptoms of PND may present at any time in the first year after giving birth (Perfetti, Clark, & Fillmore, 2004). Around 50% of women describe labile mood and tearfulness in the early days after giving birth. This is often called ‘the baby blues’. It differs from depression as symptoms are transient and usually settle within 10 days of the birth (Henshaw, 2003).

There is some debate as to whether ‘PND’ is an entity separate from depression at any other time. Some small studies have pointed to a subgroup of women who develop mood symptoms related to the hormonal changes of pregnancy and the puerperium (Bloch et al., 2000; Cooper & Murray, 1995). Regardless of classification, PND is important as it occurs at such a crucial time for the mother and her infant.

A systematic review indicated a point prevalence of depression of 13% in the first 3 months postpartum (Howard et al., 2014). Not all women who are depressed after giving birth will have developed depression postnatally: some episodes of depression start in pregnancy and some before pregnancy.

Psychosis

A small number of women will develop postpartum psychosis, a new episode of psychosis in the early postnatal period. In most cases psychotic symptoms begin within 2 weeks of child birth and can progress rapidly. Severe mental illness is associated with risk of suicide, and there are long-term implications for mother–child bonding and the wellbeing of the family involved (Jones, Chandra, Dazzan, & Howard, 2014). Postpartum psychosis is a psychiatric emergency and requires immediate referral. Treatment should take place in a specialist Mother and Baby Unit.

Outcomes

Mothers

Mental health problems cause widespread morbidity and also significant mortality. PND causes great distress, and also impairs normal functioning, which in turn has an impact on family relationships. One in seven maternal deaths is by suicide, and suicide in the postnatal period is more often by violent methods. This may indicate that women who commit suicide after having a baby are sure about the intended consequences of their actions (Knight et al., 2015). Overall, 23% of women who die in the postnatal period have mental health problems; however, many of these women also have complicated social and medical problems implicated in their deaths (Knight et al., 2015).

Children

PND has important negative effects on the children of depressed mothers. There is good evidence that perinatal mental health problems are associated with a wide range of psychological and developmental difficulties in children. These associations are complicated, as it is hard to control for confounding factors such as genetic predisposition, and the impact of previous mental illness. Nevertheless, PND seems to be linked with difficulties in emotional regulation in the early years, symptoms of attention deficit hyperactivity disorder, insecure infant attachment and impaired cognitive development. The negative impact on children is not inevitable. Higher maternal socioeconomic status and better social support seem to moderate the impact of perinatal mental illness on children (Stein et al., 2014).

Poor detection rates

Despite the high prevalence of PND, only a small number of women are diagnosed and treated (Russell & Lang, 2013). Many women feel that the time after having a baby should be a happy one; however, it is often a time of significant stress coupled with severe sleep deprivation. Women with PND frequently choose not to disclose their feelings to health professionals. Some women are concerned that disclosing a mental health problem will lead to their baby being taken away or to judgments about their mothering ability (Russell & Lang, 2013). There is still significant stigma surrounding PND. Some GPs and health visitors may view PND as a social problem rather than a biomedical one, and be reluctant to diagnose and manage it (Chew-Graham et al., 2008).

Risk factors

PND may affect any new mother, but some factors increase the risk of developing depression postnatally. These are listed in Box 1. Many of these risk factors are not specific to the postnatal period, and highlight the fact that vulnerable women who have experienced violence and other medical and mental health issues are at the greatest risk of significant mental health problems after having a baby. There is a strong association between a history of domestic violence and PND, and this should be sensitively enquired about when considering a diagnosis of depression. Lack of support from a partner, marriage difficulties and poor social support are also risk factors for PND. History of any mental health problem before or during pregnancy is an important risk factor, and should be discussed and communicated to the whole team caring for a woman in the postnatal period (Howard et al., 2014). The relationship between breastfeeding and PND is complex. One longitudinal study showed a significant reduction in the risk of PND if the mother intended to breastfeed and subsequently did breastfeed; and an increase in risk if breastfeeding was stopped. However, in the same study, the risk of PND was increased if the mother did not intend to breastfeed, but in fact subsequently went on to breastfeed (Borra, Iacovou, & Sevilla, 2014).
Box 1.
Risk factors for postnatal depression.

• Poor social support

• Poor support from partner

• Domestic violence or a history of abuse

• Previous mental health problems

• Chronic medical problems

• Problems with breastfeeding where the mother intends to breastfeed

Screening

Due to low detection rates, if a woman does disclose feelings of depression, this should be taken seriously and addressed during the consultation. The 6-week check is an excellent opportunity to detect postnatal mental health problems, as almost all women attend this appointment with their babies.

It is important to have a low threshold for screening women. The National Institute for Health and Care Excellence (NICE) guidance recommends screening all women in the early postnatal period (NICE, 2014). The suggested screening questions are shown in Box 2.
Box 2.
Screening questions.

Recommended screening questions:

• 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?

Source: NICE (2014) .

Diagnosis

If the screening questions are answered positively, then further evaluation is necessary. The International classification of diseases, 10th revision (ICD-10), and the Diagnostic and statistical manual of mental disorders, fifth edition (DSM-5), recognise PND as a subgroup of major depression. Diagnosis is based on the criteria for major depression, and development within four (DSM-5) or six (ICD-10) weeks of delivery. The key features of depression are listed in Box 3.
Box 3.
Key features of depression.

• Low mood

• Reduced interest or pleasure in doing things

• Fatigue

• Poor concentration

• Sleep and appetite changes

• Feelings of worthlessness and guilt

• Thoughts of death or suicide

Source: NICE (2015) .

The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item questionnaire designed to screen for depressive symptoms in postnatal women. It is also validated for use antenatally (Kozinszky & Dudas, 2015). Although designed as a screening tool, NICE (2014) guidance recommends its use as part of a full assessment for PND. The questionnaire is shown below in Box 4. The EPDS is scored out of 30, and a score of over 10 indicates possible depression, although further careful clinical questioning is required to reach a diagnosis. Special consideration should be given to the final question, which asks about thoughts of self-harm. The patient health questionnaire 9 (PHQ9) can also be used to aid diagnosis, although it is not as well-validated in the postnatal period as the EPDS.
Box 4.
The Edinburgh Postnatal Depression Scale.

As you have recently had a baby, we would like to know how you are feeling now. Please underline the answer which best describes how you have felt in the past 7 days, not just how you feel today. Here is an example, already completed:

I have felt happy:

Yes, most of the time

Yes, some of the time

No, not very often

No, not at all

This would mean: “I have felt happy some of the time during the past week”. Please complete the other questions in the same way.

In the past 7 days:

1. I have been able to laugh and see the funny side of things:

As much as I always could

Not quite so much now

Definitely not so much now

Not at all

2. I have looked forward with enjoyment to things:

As much as I ever did

Rather less than I used to

Definitely less than I used to

Hardly at all

3. I have blamed myself unnecessarily when things went wrong:

Yes, most of the time

Yes, some of the time

Not very often

No, never

4. I have been anxious or worried for no good reason:

No, not at all

Hardly ever

Yes, sometimes

Yes, very often

5. I have felt scared or panicky for no very good reason:

Yes, quite a lot

Yes, sometimes

No, not much

No, not at all

6. Things have been getting on top of me:

Yes, most of the time I haven’t been able to cope at all

Yes, sometimes I haven’t been coping as well as usual

No, most of the time I have coped quite well

No, I have been coping as well as ever

7. I have been so unhappy that I have had difficulty sleeping:

Yes, most of the time

Yes, sometimes

Not very often

No, not at all

8. I have felt sad or miserable:

Yes, most of the time

Yes, quite often

Not very often

No, not at all

9. I have been so unhappy that I have been crying:

Yes, most of the time

Yes, quite often

Only occasionally

No, never

10. The thought of harming myself has occurred to me:

Yes, quite often

Sometimes

Hardly ever

Never

© 1987 The Royal College of Psychiatrists. Cox, J.L., Holden, J.M., & Sagovsky, R. (1987). Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782–786. Written permission must be obtained from the Royal College of Psychiatrists for copying and distribution to others or for republication (in print, online or by any other medium). Translations of the scale, and guidance as to its use, may be found in Cox, J. L., Holden, J., & Henshaw, C. (2014). Perinatal mental health: The Edinburgh Postnatal Depression Scale (EPDS) manual, second edition. London, UK: RCPsych Publications. www.rcpsych.ac.uk/usefulresources/publications/books/rcpp/9781909726130.aspx .

It is important to consider possible differential diagnoses before making a diagnosis of depression. Physical health problems, such as hypothyroidism, anaemia, infections like infectious mononucleosis, and fibromyalgia may be mistaken for depression in the postnatal period. Other mental health problems are also common, particularly anxiety and post-traumatic stress disorder. Severe mental health problems, such as puerperal psychosis, should be considered (NICE, 2015).

Treatment

Treatment depends on the severity of depression and prior mental health problems. Poor mental health care in the postnatal period is often associated with lack of continuity and coordination. A large number of professionals may be involved with women in the early postnatal period, including health visitors, midwives, obstetricians, mental health specialists, psychological therapy providers and emergency care providers. All professionals have a responsibility to ensure adequate communication between the team, and GPs are well placed to help facilitate this interaction. A summary of treatments by severity of depression is shown in Table 1.
Table 1.
Treatment by severity of depression.

Severity of depression Suggested treatment

Mild-to-moderate depression Corresponding to a score of 10–14 on PHQ-9 Facilitated self-help

Mild depression with a history of severe depression Consider antidepressant medication

Moderate or severe depression Corresponding to a score of 15 or more on PHQ-9 High intensity psychological intervention or Antidepressant medication if psychological treatment declined or A combination of medication and psychological therapy if response to medication or psychological intervention alone is inadequate

Source:* NICE (2014) .

Psychological therapies

Good social support is essential for families. It is useful to have a list of local resources, including Mums and Babies Groups, to give to new mothers. The members of the health visiting team are an invaluable resource who can highlight families they have concerns about, and also provide support and resources for women with depression. There are good online self-help resources for women with mild symptoms. ‘Two in Mind’ is a project that offers an online course based on cognitive behavioural therapy, which is specifically designed for new parents (Two in Mind, 2016). However, this is only available in Wales. Online courses not specifically aimed at perinatal symptoms are also available. Some resources for patients are listed in Box 5.
Box 5.
Further resources for patients and professionals.

Resource for health professionals

• RCGP. Perinatal Mental Health Resource. Retrieved from www.rcgp.org.uk/clinical-and-research/clinical-resources/perinatal-mental-health.aspx

Help for patients

• Two in Mind: www.twoinmind.org/enjoy-your-baby-online-course

• Living Life to the Full: www.llttf.com

• Your Baby: www.your-baby.org.uk

• Moodjuice: www.moodjuice.scot.nhs.uk

• The Association for Postnatal Illness: http://apni.org

Breastfeeding resources

• The Breastfeeding Network: www.breastfeedingnetwork.org.uk (This has a useful ‘Drugs in Breastmilk Helpline’ for enquiries about taking medications whilst breastfeeding)

• UK Drugs in Lactation Advisory service: www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Women who require a higher-intensity psychological intervention should be referred urgently to the intervention provider. NICE (2014) recommended treatment is started within 4 weeks of referral. If there is a delay in starting treatment, regular follow-up should be in place to offer ongoing support.

Pharmacological treatment

During pregnancy and breastfeeding, the risk-to-benefit ratio of any medication changes due to the limited evidence available about effects on the fetus and infant. A personalised approach is needed to help the woman decide if medication is the right treatment for her, and if so, which medication would be best.

Careful consideration should be given to treatment decisions in pregnancy. There is a paucity of evidence about the effects of antidepressant medication on the fetus. There is now evidence that psychiatric illness and its associated factors adversely affect the developing fetus. This is often not controlled for in studies looking at the effects of medication, which may lead to confounding (Chisolm & Payne, 2016). When making treatment decisions with women during pregnancy, the risk of relapse when stopping or changing medication, previous responses to medication, and the potential risks of the medication used must be taken into account. Selective serotonin reuptake inhibitors (SSRIs) seem to be the most widely used antidepressant in pregnancy. A recent review concluded that the risks of SSRIs in pregnancy, including risk of congenital malformation, miscarriage, preterm birth, and postnatal complications, are very modest. Ideally, patients would be provided with an indication of absolute risk increase, but due to the difficulty in interpreting the available data, it is hard to achieve this objective. There has been extensive debate about the role of SSRIs, particularly paroxetine, in congenital cardiovascular malformations. A review of the evidence indicated that this risk is small (2 per 1000 births affected by paroxetine use in the first trimester) (Chisolm & Payne, 2016). NICE guidance highlights the risk of discontinuation symptoms in patients and neonatal adaptation syndrome in babies exposed to any psychotropic medication, but particularly paroxetine and venlafaxine (NICE, 2015).

Postnatally, if the woman is not breastfeeding, treatment decisions are similar to those encountered when treating depression in the general population. For breastfeeding women, there are other factors to consider. If a woman is already taking an antidepressant that is effective for her, then continuing this is often the best option. There is very limited evidence about the effects on the infant from antidepressant ingestion via breast milk; however, exposure to medication via breast milk should be avoided in preterm and low-birth-weight infants, and in infants with significant health problems. In this situation, further advice should be sought and resources to do this are given in Box 5. Sertraline seems to be the most widely used antidepressant during breastfeeding, as levels in breast milk are low, it has a good safety profile in overdose and small studies of any long-term effects in infants are relatively reassuring (Sriraman, Melvin, & Meltzer-Brody, 2015). Doxepin, fluoxetine, citalopram and escitalopram should be avoided if possible (Scottish Intercollegiate Guidelines Network, 2012).

Another important consideration when prescribing to women both antenatally and postnatally is the issue of licensing. Most antidepressant medications are not licensed for use in pregnancy and breastfeeding, with the exception of fluoxetine, which is licensed for use in pregnancy. Prescribing a medication outside of its license increases the prescriber’s responsibility and may increase their liability if any harm is caused. Any off-license medication use should be fully discussed with the patient and correctly documented (Scottish Intercollegiate Guidelines Network, 2012).

When to refer

Most cases of PND will be managed in primary care, but some women do require referral. A small, but significant, number of women have serious mental health problems in the postnatal period. For these women, the best place for treatment is a specialist perinatal mental health Mother and Baby Unit. At present, there are not enough of these units to provide the care needed, but there is some political will to change this (Department of Health, 2016). The Confidential Enquiry into Maternal Deaths highlighted three key situations associated with maternal death that require urgent assessment (Knight et al., 2015). These are shown in Box 6.
Box 6.
Red flag symptoms requiring urgent assessment.

Women who report:

• New thoughts of violent self-harm

• Rapidly worsening mental symptoms

• Persistent feelings of estrangement from their baby

Source: Knight et al. (2015) .

Other reasons for referral include presentation with depression and a background of severe mental illness, diagnostic uncertainty or failure of treatment. Postpartum psychosis requires immediate referral. NICE recommend considering specialist advice before prescribing an antidepressant medication to a woman who is breastfeeding (NICE, 2015).

Mother–infant interaction

The first 2 years of life are significant in determining a child’s social and emotional development. There is good evidence that perinatal mental health problems are associated with a range of psychological and developmental disturbances in children (Stein et al., 2014). One of the symptoms of PND is a perceived lack of bonding with a much-wanted baby (Russell & Lang, 2013). Not all women with PND will have difficulties interacting with their children. Treating the underlying mental health problem should improve interactions, but other interventions to support responsiveness and bonding should be considered. Evidence suggests that support groups for mothers with PND and infant massage interventions are effective at improving interactions (Stein et al., 2014), and these may be available through the local children’s centre.

Key points

Depression affects a significant proportion of women in the year after giving birth

One in seven maternal deaths are due to suicide

GPs have an opportunity to detect and diagnose postnatal depression at the 6-week check

Treatment should be tailored to the needs of the individual woman, with a recognition that the risk-to-benefit ratio of drug therapy changes during pregnancy and breastfeeding

Consideration should also be given to supporting mother and infant attachment

Severity of depression	Suggested treatment
Mild-to-moderate depression Corresponding to a score of 10–14 on PHQ-9	Facilitated self-help
Mild depression with a history of severe depression	Consider antidepressant medication
Moderate or severe depression Corresponding to a score of 15 or more on PHQ-9	High intensity psychological intervention or Antidepressant medication if psychological treatment declined or A combination of medication and psychological therapy if response to medication or psychological intervention alone is inadequate

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, fifth edition.. Washington DC, USA: American Psychiatric Association.

Bloch

Schmidt

P. J.

Danaceau

Murphy

Nieman

Rubinow

D. R.

(2000) Effects of gonadal steroids in women with a history of postpartum depression. The American Journal of Psychiatry 157(6): 924–930. doi: 10.1176/appi.ajp.157.6.924.

Borra

Iacovou

Sevilla

(2014) New evidence on breastfeeding and postpartum depression: The importance of understanding women’s intentions. Maternal and Child Health Journal 19(4): 897–907. doi: 10.1007/s10995-014-1591-z.

Chew-Graham

Chamberlain

Turner

Folkes

Caulfield

Sharp

(2008) GPs’ and health visitors’ views on the diagnosis and management of postnatal depression: A qualitative study. British Journal of General Practice 58(548): 169–176. doi: 10.3399/bjgp08X277212.

Chisolm

M. S.

Payne

J. L.

(2016) Management of psychotropic drugs during pregnancy. BMJ 352: h5918, doi: 10.1136/bmj.h5918.

Cooper

P. J.

Murray

(1995) Course and recurrence of postnatal depression. Evidence for the specificity of the diagnostic concept. The British Journal of Psychiatry 166(2): 191–195. doi: 10.1192/bjp.166.2.191.

Department of Health. (2016). Prime Minister pledges a revolution in mental health treatment - Press release. Retrieved from www.gov.uk/government/news/prime-minister-pledges-a-revolution-in-mental-health-treatment.

Henshaw, C. (2003). Mood disturbance in the early puerperium: A review. Archives of Women’s Mental Health, 6(S2), S33–S42. doi: 10.1007/s00737-003-0004-x.

Howard

L. M.

Molyneaux

Dennis

C.-L.

Rochat

Stein

Milgrom

(2014) Non-psychotic mental disorders in the perinatal period. The Lancet 384(9956): 1775–1788. doi: 10.1016/S0140-6736(14)61276-9.

10.

Jones

Chandra

P. S.

Dazzan

Howard

L. M.

(2014) Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period. The Lancet 384(9956): 1789–1799. doi: 10.1016/S0140-6736(14)61278-2.

11.

Knight, M., Tuffnell, D., Kenyon, S., Shakespeare, J., Grey, R., & Kurinczuk, J. (2015). Saving Lives, Improving Mothers’ Care Surveillance of maternal deaths in the UK 2011–13 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–13. Maternal Infant and Newborn Clinical Outcome Review Programme. Retrieved from www.npeu.ox.ac.uk/downloads/files/mbrrace-uk/reports/MBRRACE-UK%20Maternal%20Report%202015.pdf.

12.

Kozinszky

Dudas

R. B.

(2015) Validation studies of the Edinburgh Postnatal Depression Scale for the antenatal period. Journal of Affective Disorders 176: 95–105. doi: 10.1016/j.jad.2015.01.044.

13.

NICE. (2014). Antenatal and postnatal mental health: Clinical management and service guidance. Retrieved from www.nice.org.uk/guidance/cg192.

14.

NICE. (2015). Clinical knowledge summary: Depression - antenatal and postnatal. Retrieved from http://cks.nice.org.uk/depression-antenatal-and-postnatal#!scenariorecommendation:21.

15.

Perfetti

Clark

Fillmore

C.-M.

(2004) Postpartum depression: Identification, screening, and treatment. Wisconsin Medical Journal 103(6): 56–63. Retrieved from www.wisconsinmedicalsociety.org/_WMS/publications/wmj/pdf/103/6/56.pdf.

16.

RCGP. Clinical module 3.10: Care of people with mental health problems. Retrieved from www.rcgp.org.uk/training-exams/gp-curriculum-overview/online-curriculum/managing-complex-care/3-10-mental-health-problems.aspx.

17.

Russell, S., & Lang, B. (2013). Perinatal mental health experiences of women and health professionals. A report 2013. Retrieved from www.tommys.org/file/Perinatal_Mental_Health_2013.pdf.

18.

Scottish Intercollegiate Guidelines Network. (2012). Management of perinatal mood disorders. Retrieved from hwww.sign.ac.uk/pdf/sign127.pdf.

19.

Sriraman

N. K.

Melvin

Meltzer-Brody

(2015) ABM clinical protocol 18#: Use of antidepressants in breastfeeding mothers. Breastfeeding Medicine 10(6): ). doi: 10.1089/bfm.2015.29002.

20.

Stein

Pearson

R. M.

Goodman

S. H.

Rapa

Rahman

McCallum

Pariante

C. M.

(2014) Effects of perinatal mental disorders on the fetus and child. The Lancet 384(9956): 1800–1819. doi: 10.1016/S0140-6736(14)61277-0.

21.

Two in Mind. (2016). Retrieved from http://www.twoinmind.org/enjoy-your-baby-online-course.