Postnatal depression
The symptoms of postnatal depression normally start 1–2 months after birth, but can occur at any time within the first year of giving birth. Postnatal depression can develop gradually, suddenly or continue from depressive symptoms in pregnancy.
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Definition
Postnatal depression is a common mental health condition that affects over 1 in 10 women in the UK (Green, 2018). Symptoms normally start 1–2 months after birth, but can occur at any time within the first year of giving birth (Green, 2018). Postnatal depression can develop gradually, suddenly or continue from depressive symptoms in pregnancy. The duration varies, with some women experiencing symptoms for a few months; however, 24% of women with postnatal depression still have symptoms after 1 year (Stewart and Vigod, 2019). Risk factors for prolonged and severe postnatal depression symptoms include:
- younger age
- lower educational status
- history of mood disorders
- gestational diabetes (Putnick et al, 2020)
Postnatal depression should not be confused with the ‘baby blues’, which is a time-limited period of mood changes, usually starting a few days post birth and resolving within 2 weeks (Brown et al, 2021).
Severe postnatal depression is associated with poorer
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Symptoms
The symptoms of postnatal depression are the same as for depression, according to the International Classification of Diseases 10th edition (World Health Organization, 2019). Symptoms must last longer than 2 weeks and include:
- low mood
- loss of enjoyment and interest in usual activities
- poor concentration
- sleep disturbances
- tiredness
- low energy
- poor appetite or comfort eating
- weight changes
- agitation or slowed movement and thoughts (World Health Organization, 2019)
The symptoms of postnatal depression range from mild to severe, with a greater focus on the baby and adjustments to parenthood (Green, 2018). Postnatal depression is associated with:
- heightened anxiety
- persistent worries centred on the baby
- variable mood
- irritability
- feeling overwhelmed
- feelings of worthlessness or guilt
- beliefs that they are not a good enough parent
- low self-esteem and self-confidence (Slomian et al, 2019; Stewart and Vigod, 2019)
Severe and prolonged symptoms can lead to poorer outcomes for both the mother and child, including
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Aetiology
Although the exact cause of postnatal depression is not known, environmental, biological and genetic factors are thought to influence the development of symptoms (Payne and Maguire, 2019).
Environmental factors
Several environmental factors increase the risk of developing postnatal depression, including a history of mental health difficulties, poor coping skills and current stressors, such as financial or relationship difficulties (Payne and Maguire, 2019). Past trauma is another factor, as people who have experienced childhood abuse are three times more likely to develop symptoms (Payne and Maguire, 2019).
Hormonal factors
Abrupt changes in hormone levels following birth are thought to play an important role in the development of postnatal depression. Oestrogen and progesterone are associated with emotional and cognitive processing in the brain, and lower levels of these hormones correspond with increased irritability, anxiety and depressive symptoms (Trifu et al, 2019).
Genetic factors
Twin and family
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Diagnosis
Early detection and treatment of postnatal depression are important to reduce symptom severity, duration and the negative impacts. The National Institute for Health and Care Excellence (2020) guidelines for antenatal and postnatal mental health care recommend screening in primary care during the first post-birth contact by asking two questions:
- During the last month, have you often been bothered by feeling down, depressed or hopeless?
- During the last month, have you often been bothered by having little interest or pleasure in doing things?
If they answer yes to either question, a depression rating scale, such as the Edinburgh Postnatal Depression Scale or Patient Health Questionnaire, could be used. However, these tools are not essential and diagnosis can be made based on the symptoms listed above using a holistic assessment (National Institute for Health and Care Excellence, 2020). Assessment should include:
- mental health and pregnancy history
- current presentation
- drug and alcohol history
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Management
Treatment and management of postnatal depression is based on the National Institute for Health and Care Excellence (2020) guidelines and dependant on symptom severity and associated risks, along with considering the woman’s preferences. The National Institute for Health and Care Excellence (2020) recommends that all services involved in the woman’s care work collaboratively, including mental health services, health visitors and maternity services. Advice around self-care, exercise, sleep support and social networks to enhance support should be given to all service users (Stewart and Vigod, 2019).
Mild to moderate symptoms
The National Institute for Health and Care Excellence (2020) recommends guided self-help, which incorporates printed or digital material that can be delivered in person, via telephone or online. The interventions are based around cognitive behavioural therapy, which is a skills-based therapy aimed at understanding the link between thoughts and behaviours, behavioural activation (a goals-based motivational approach), problem solving
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NMC proficiencies
Nursing and Midwifery Council: standards of proficiency for registered nurses
Part 1: Procedures for assessing people’s needs for person-centred care
1. Use evidence-based, best practice approaches to take a history, observe, recognise and accurately assess people of all ages
Part 2: Procedures for the planning, provision and management of person-centred nursing care
3. Use evidence-based, best practice approaches for meeting needs for care and support with rest, sleep, comfort and the maintenance of dignity, accurately assessing the person’s capacity for independence and self-care and initiating appropriate interventions
11. Procedural competencies required for best practice, evidence-based medicines administration and optimisation
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Resources
Bauer A, Parsonage M, Knapp M et al. The costs of perinatal mental health problems. 2014. https://eprints.lse.ac.uk/59885/1/__lse.ac.uk_storage_LIBRARY_Secondary_libfile_shared_repository_Content_Bauer%2C%20M_Bauer_Costs_perinatal_%20mental_2014_Bauer_Costs_perinatal_mental_2014_author.pdf (accessed 23 October 2024)
Brown JVE, Wilson CA, Ayre K et al. Antidepressant treatment for postnatal depression. Cochrane Database Syst Rev. 2021;2(2):CD013560. https://doi.org/10.1002/14651858.CD013560.pub2
Green L. Postnatal depression. 2018. https://www.rcpsych.ac.uk/mental-health/mental-illnesses-and-mental-health-problems/post-natal-depression (accessed 23 October 2024)
Knight M, Bunch K, Patel R et al. Saving lives, improving mothers’ care. 2022. www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-2022/MBRRACE-UK_Maternal_MAIN_Report_2022_UPDATE.pdf (accessed 23 October 2024)
National Institute for Health and Care Excellence. Antenatal and postnatal mental health: clinical management and service guidelines. 2020. https://www.nice.org.uk/guidance/cg192 (accessed 23 October 2024)
National Institute for Health and Care Excellence. Depression – antenatal and postnatal. 2023. https://cks.nice.org.uk/topics/depression-antenatal-postnatal/ (accessed 23 October 2024)
NHS England, NHS Improvement. The perinatal mental health care pathways. 2018. https://www.england.nhs.uk/wp-content/uploads/2018/05/perinatal-mental-health-care-pathway.pdf (accessed 23 October 2024)
Payne JL, Maguire J. Pathophysiological mechanisms implicated in postpartum depression. Front Neuroendocrinol. 2019;52:165–180. https://doi.org/10.1016/j.yfrne.2018.12.001
Putnick DL, Sundaram R, Bell EM et al. Trajectories of maternal postpartum depressive symptoms. Pediatrics. 2020;146(5):e20200857.
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