Post-Natal Depression

Question 1

When is the postnatal period considered?

Answer 1

The postnatal period is generally considered to be the first 12 months after delivery.

Question 2

What % of mothers will develop a mental disorder in the postnatal period?

Answer 2

During this period, 10-20% of mothers will experience a mental disorder, the majority of which are depression or anxiety disorders.

Question 3

How soon after birth do the following conditions present?

Note: ‘baby blues’, postnatal depression and puerperal psychosis

Answer 3

There is a spectrum of postnatal mental health illness:

• Baby blues is seen in the majority of women in the first week or so after birth
• Postnatal depression is seen in about one in ten women, with a peak around three months after birth
• Puerperal psychosis is seen in about one in a thousand women, starting a few weeks after birth

Question 4

Why is it important to treat postnatal mental disorders?

Answer 4

As it is a formative time in development of the infant, especially in developing a secure mother-baby attachment, it is very important to detect and treat these mood disorders.

Question 5

Briefly describe the ‘baby blues’

Answer 5

The ‘baby blues’ is a normal phenomenon occuring in ~70% of mothers. It is self-limiting, usually disappearing within a few days.

The main symptoms are irritability, lability of mood and tearfulness.

They peak on the third or fourth postpartum day.

Both the frequency of the emotional changes and their timing suggest that maternity ‘blues’ may be related to re-adjustment in hormones after delivery.

No treatment is required except reassurance and general support.

Question 6

How may ‘baby blue’s present?

Answer 6

Baby blues affect more than 50% of women in the first week or so after birth, particularly first-time mothers. It presents with symptoms such as:

• Mood swings
• Low mood
• Anxiety
• Irritability
• Tearfulness

Question 7

What factors contribute to the ‘baby blues’?

Answer 7

Baby blues may be the result of a combination of:

• Significant hormonal changes
• Recovery from birth
• Fatigue and sleep deprivation
• The responsibility of caring for the neonate
• Establishing feeding
• All the other changes and events around this time

Question 8

How common is postnatal depression?

Answer 8

Postnatal depression occurs in ~10% of mothers.

Question 9

How long after birth does postnatal depression occur?

Answer 9

Two-thirds of cases develop within 12 weeks of delivery and, for some women, their symptoms are a continuation of an episode which began in pregnancy.

Question 10

What are the risk factors for postnatal depression?

Answer 10

The risk factors for postnatal depression are as for any depressive episode but with some additional factors such as:

• Previous depressive episodes or anxiety disorders
• Stressful life events during late pregnancy or after delivery (especially through relationship difficulties)
• Maternal age less than 25
• Single mothers
• Domestic violence
• Unwanted pregnancy
• Perinatal complications
• Difficulties in establishing breastfeeding
• Difficult infant temperment

Question 11

What are the clinical features of postnatal depression?

Answer 11

Postnatal depression is similar to depression that occurs outside of pregnancy, with the classic triad of:

• Low mood
• Anhedonia (lack of pleasure in activities)
• Low energy

Irritability, tiredness and anxiety may be more prominent than depressive mood and there may be prominent phobic symptoms.

Symptoms are undoutedly exacerbated by loss of sleep and by the hard work of looking after a baby.

Question 12

What scale is used to assess postnatal depression?

Answer 12

Edinburgh Postnatal Depression Scale

Question 13

What is the Edinburgh Postnatal Depression Scale?

Answer 13

The Edinburgh postnatal depression scale can be used to assess how the mother has felt over the past week, as a screening tool for postnatal depression.

There are ten questions, with a total score out of 30 points. A score of 10 or more suggests postnatal depression.

Question 14

What are the consequences of postnatal depression?

Answer 14

• Impact upon baby:
  
  • Impaired bonding with mother
  • Lower rates of breastfeeding
  • Poor infant nutrition
  • Lower rates of childhood vaccines
  • Higher risk of delayed development
  • Harm to baby/ infanticide (rare)
• Impacts upon mother:
  
  • Impaired bonding with infant
  • Increased rates of relationship discord
  • Self-neglect (e.g. poor nutrition)
  • Suicide (rare- 1/100,000 births)

Question 15

Briefly describe the treatment of postnatal depression

Note: mild, moderate and severe

Answer 15

Treatment is similar to depression at other times:

• Mild cases may be managed with additional support, self-help and follow up with their GP
• Moderate cases may be managed with antidepressant medications (e.g. SSRIs) and cognitive behavioural therapy
• Severe cases may need input from specialist psychiatry services, and rarely inpatient care on the mother and baby unit

Question 16

How common is postnatal psychosis?

Answer 16

Postnatal psychosis is rare, only occuring in about 0.1-0.2% of mothers.

Question 17

What other mental health condition is postnatal psychosis linked to?

Answer 17

It is highly associated with bipolar disorder.

The risk of postnatal psychosis in a mother who already has a diagnosis of bipolar disorder is 30-40%, while 50% of those without a prior psychiatric history later acquire a diagnosis of bipolar disorder, schizophrenia or schizoaffective disorder.

Question 18

What are the risk factors for postnatal psychosis?

Answer 18

• Previous serious major psychiatric disorder
• A family history of bipolar/ psychosis
• Primiparity

Question 19

What are the clinical features of postnatal psychosis?

Answer 19

Postnatal psychosis typically has an onset between two to three weeks after delivery. Women experience full psychotic symptoms, such as:

• Delusions
• Paranoia
• Hallucinations
• Depression
• Mania
• Confusion
• Thought disorder

Question 20

Briefly describe the assessment required for postnatal psychosis

Answer 20

Women with puerperal psychosis need urgent assessment and input from specialist mental health services.

A careful risk assessment should be undertaken, considering mother, baby and other dependents.

Question 21

What are the risks associated with postnatal psychosis?

Answer 21

The greatest risks are of self-neglect and/ or accidental neglect of the infant or other children.

Risks of suicide and infanticide are considerably increased but remain objectively low.

Question 22

How likely is it that postnatal psychosis will occur again with another pregnancy?

Answer 22

Recurrence of psychosis after subsequent delivereies is high, and family members/ professionals should monitor the mother closely in the postnatal period.

Question 23

Briefly describe the treatment of postnatal psychosis

Answer 23

Treatment is directed by specialist services, and may involve:

• Admission to the mother and baby unit
• Cognitive behavioural therapy
• Medications (antidepressants, antipsychotics or mood stabilisers)
• Electroconvulsive therapy (ECT)