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 outcomes for the mother and child, along with an estimated £74 000 in health and economic costs per episode, the majority of which relates to the impact on the child (Bauer et al, 2014). Therefore, accurate assessment and prompt treatment are crucial. With the right treatment and support, women can go on to recover and resume usual levels of functioning.
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 poor maternal physical and mental health, poor attachment and bonding with the child and relationship difficulties with partners. Children of mothers with postnatal depression are more likely to experience difficulties with social, emotional and cognitive development (National Institute for Health and Care Excellence, 2023). Suicidal thoughts can be common in up to 20% of women with postnatal depression (Stewart and Vigod, 2019). Suicide is a leading cause of death in the year following pregnancy (Knight et al, 2022) and is associated with more severe symptoms (Slomian et al, 2019).
There are several factors that increase the risk of developing postnatal depression, including:
- past history of postnatal depression, depression or anxiety
- history of or current harmful substance use
- poor relationships and lack of social support
- baby with health difficulties or needing neonatal care
- difficulties conceiving
- unplanned pregnancy
- having two or more children (National Institute for Health and Care Excellence, 2023)
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 studies suggest a genetic component, as postnatal depression can run in families. Several genetic differences found in general depression are also seen in postnatal depression (Stewart and Vigod, 2019). Genetic variants in postnatal depression affect oestrogen receptors and how serotonin is made and transported within the brain. Genes linked to stress response and depressive symptoms are also thought to influence the development of postnatal depression (Payne and Maguire, 2019).
The onset of postnatal depression is associated with differing aetiological factors. Onset within 4 weeks of birth is more closely associated with genetic factors; symptoms that resolve within 6–8 weeks are more likely because of hormonal factors; and later-onset symptoms are more closely linked with the aetiology of general depression (Stewart and Vigod, 2019; Trifu et al, 2019).
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 and current use
- birth experience
- family and social history
- thorough risk assessment
Where appropriate, families and support networks should be involved (National Institute for Health and Care Excellence, 2020).
Diagnosis can be challenging. Some women may not wish to disclose symptoms because of stigma or fear of the consequences (National Institute for Health and Care Excellence, 2020). Differential diagnoses must be ruled out. These include normal changes in emotions and functioning, the ‘baby blues’, adjustment reactions involving an identifiable stressor or depressive symptoms as a result of medical conditions. Women can commonly experience low iron levels or thyroid dysfunction following birth, which can also cause depressive symptoms. Common comorbidities include anxiety and obsessive-compulsive or trauma-related symptoms (Stewart and Vigod, 2019).
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 and psychoeducation. The intervention is delivered across six to eight sessions.
Moderate to severe symptoms
The National Institute for Health and Care Excellence (2020) recommends referral for high-intensity psychological intervention, such as cognitive behavioural therapy, or medication if this is the person’s preference, they decline psychological interventions or have not benefitted from them.
If there is limited response from either psychological interventions or medication alone, the next step would be to combine both.
Women with a history or new onset of complex or severe postnatal depression should be referred to a specialist perinatal mental health team for assessment and treatment (NHS England and NHS Improvement, 2018). Perinatal mental health teams support women from late pregnancy until 1-year post birth with recovery-focused interventions.
Medication
The National Institute for Health and Care Excellence (2023) recommend taking an individualised approach to prescribing medication for postnatal depression based on:
- symptom severity
- risk vs benefit of treatment options
- previous treatments and response
- availability of support networks
There are no medications specifically licensed for postnatal or breastfeeding women in the UK. Clinicians must follow prescribing guidelines and seek specialist advice where required. In a Cochrane review, Brown et al (2021) found that selective serotonin reuptake inhibitor antidepressants were effective for symptoms of postnatal depression, but there was not enough evidence to compare these antidepressants to determine which worked best.
When prescribing antidepressant medication for women who choose to breastfeed, the National Institute for Health and Care Excellence (2020) recommends thorough discussion of the benefits of breastfeeding along with the risks of untreated or suboptimal treatment for postnatal depression and the potential risk of using medications while breastfeeding. Treatment plans that support the woman to breastfeed, where this is her wish, should be agreed.
Crisis care
If there are urgent or emergency mental health needs or concerns that the mother or child is at risk, a referral to a crisis resolution team or mental health liaison team should be made (NHS England and NHS Improvement, 2018). The aim of this intervention is rapid access to a mental health and risk assessment to guide a suitable, intensive treatment pathway.
Mother and baby units
A voluntary or involuntary mother and baby unit admission may be needed where there are severe symptoms and risk of harm to the mother (such as suicide attempts), risk of harm to the baby or others, or severe neglect. Mother and baby units support the mother with both her mental health treatment and parenting role by employing both staff specialised in perinatal mental health care and nursery nurses. Mothers can be admitted with babies up to 1 year old (Royal College of Psychiatrists, 2018).
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
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. https://doi.org/10.1542/peds.2020-0857
Royal College of Psychiatrists. Mother and baby units. 2018. https://www.rcpsych.ac.uk/mental-health/treatments-and-wellbeing/mother-and-baby-units-(mbus) (accessed 23 October 2024)
Slomian J, Honvo G, Emonts P, Reginster JY, Bruyère O. Consequences of maternal postpartum depression: a systematic review of maternal and infant outcomes [published correction appears in Womens Health (Lond). 2019;15:1745506519854864. https://doi.org/ 10.1177/1745506519854864]. Womens Health (Lond). 2019;15:1745506519844044. https://doi.org/10.1177/1745506519844044
Stewart DE, Vigod SN. Postpartum depression: pathophysiology, treatment, and emerging therapeutics. Annu Rev Med. 2019;70:183–196. https://doi.org/10.1146/annurev-med-041217-011106
Trifu S, Vladuti A, Popescu A. The neuroendocrinological aspects of pregnancy and postpartum depression. Acta Endocrinol (Buchar). 2019;15(3):410–415. https://doi.org/10.4183/aeb.2019.410
World Health Organization. International statistical classification of diseases and related health problems (ICD). 2019. https://www.who.int/standards/classifications/classification-of-diseases (accessed 23 October 2024)