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Postnatal depression: what is it?

The arrival of a new baby is usually a happy event, but it can also be a stressful time during which many adjustments have to be made. Many women are not aware that mood changes are common after childbirth and vary from mild to severe. In fact, in the year after childbirth a woman is more likely to need psychiatric help than at any time in her life.

There are three recognised mood disorders in the postpartum period.

At one end of the spectrum is ‘baby blues’, affecting about 80 per cent of new mothers, almost expected by all mothers. It usually occurs between the third and tenth day after birth. Symptoms include tearfulness, anxiety, mood fluctuations and irritability. The ‘blues’ are transient and will pass with understanding and support.

At the other end of the spectrum is puerperal or postnatal psychosis. This affects one in 500 mothers, usually in the first 3 to 4 weeks after delivery. Postnatal psychosis is a serious condition. The mother herself may be unaware she is ill, as her grasp on reality is affected. Symptoms include severe mood disturbance (either marked elation or depression or fluctuations from one to the other), disturbance in thought processes, bizarre thoughts, insomnia, and inappropriate responses to the baby. There is risk to the life of both mother and baby if the problem is not recognised and treated. Postnatal psychosis requires a hospital stay. With appropriate treatment, women suffering from postnatal psychosis fully recover.

Between the ‘blues’ and psychosis lies postnatal depression (PND). More than 15 per cent of women develop postnatal depression. Many women do not know that postnatal depression can occur unexpectedly after delivery and typically blame themselves, their partners or their baby for the way they feel. Some try hard to ‘snap out of it’ without understanding that women with PND have little control over the way they are feeling. It is very important for women and their partners to learn to recognise the signs and symptoms of postnatal depression so that they can ask for help as early as possible.

Postnatal depression

• Postnatal depression occurs in all cultures and all socio-economic classes, and can happen to child-bearing women of all ages.
• Postnatal depression is not a modern condition. Each generation calls it something different. What we call PND today may have been called a ‘nervous breakdown’ 50 years ago.
• Mild, moderate, or severe symptoms can begin during pregnancy (antenatal depression), suddenly after birth, or gradually in the weeks or months following delivery. Symptoms can emerge at any time during the first year after birth, but most cases have their onset within the first 4 months.
• Postnatal depression can happen after miscarriage, stillbirth, normal delivery, or Caesarean delivery. Pregnancy is the common factor.
• Postnatal depression happens mostly after a first baby, but can occur after any other pregnancy.
• Postnatal depression has a 50 per cent chance of recurrence with a subsequent pregnancy. If a woman becomes pregnant again before recovering from postnatal depression, the condition will continue through the pregnancy and may worsen. It is wise to wait at least a year after discontinuing medication before falling pregnant again.

Bio-psycho-social postnatal depression and recovery

Postnatal depression should be viewed as a bio-psycho-social condition that has an impact on the woman’s biological, psychological (spiritual) and social (cultural) wellbeing. Factors that contribute to postnatal depression come from all these areas and result in a variety of symptoms. A different combination of factors is responsible for each woman’s unique experience of postnatal depression. Strategies for managing postnatal depression towards recovery must address all bio-psycho-social aspects of the woman’s life. This usually requires a combination of interventions.

Postnatal depression exists within families and communities, not with the woman alone. Assessment and intervention need to consider the significant other people in her family.

Contributing factors for postnatal depression

Biological

• Genetic predisposition to depression.
• Sudden changes in pregnancy hormones following delivery.
• Nutritional deficiencies and sleep deprivation.
• Difficult or complicated pregnancy or childbirth experiences.
• A history of pre-menstrual tension.
• Previous experience of postnatal depression, or family/personal history of other mental health conditions.

Psychological

• Infertility and use of in-vitro fertilisation (IVF) for conception.
• A difficult or traumatic birth (including unexpected interventions, e.g. emergency Caesarean section).
• A traumatic or abusive childhood (particularly sexual abuse).
• Unrealistic expectations of motherhood and of herself.
• Certain personality types (perfectionist or controlling).
• Limited social and emotional skills (difficulties in effectively communicating).
• Problematic or unresolved relationship issues with own mother.
• Past unresolved issues of grief and loss such as previous miscarriage.

Social

• Lack of family and community support.
• Difficult relationship with partner — removed emotionally, works long hours or travels.
• Intrusive or difficult family relationships.
• Social isolation and lack of transport.
• Financial hardship.
• Lack of close friends, particularly families with children.
• Being a younger or older age.
• Stressful life events such as a death in the family or job loss.

Women experiencing some of these things should be encouraged to talk with their doctor and family. It is important that the individual meaning and response to these factors are discussed and assessed.

Symptoms

Symptoms can begin anywhere from 24 hours to several months after delivery. When onset is abrupt and symptoms severe, women are more likely to seek help early. When the symptoms are harder to separate from the normal changes after having a baby, treatment may be delayed, if it is ever sought, and postnatal depression can linger into the second year.

The following descriptions of the postnatal depression symptoms come from women who have spoken to PANDA or attended postnatal depression groups.

Sleep disturbance unrelated to baby’s sleep needs

Most women with a young baby fall asleep as soon as they are able to. Women with postnatal depression can lie awake for hours feeling anxious while the baby sleeps. Some have trouble falling asleep or wake early in the morning. Others want to sleep all the time and have trouble getting up in the morning.

Appetite disturbance

Women may feel totally uninterested in food and say, ‘I force myself to eat because I am breastfeeding, but I don't taste anything.’ Some overeat in an attempt to control their anxiety. Some feel sick at the thought of food.

Crying

A woman may feel sad and cry without apparent reason. Tears come easily day and night. Some say, ‘I want to cry but can't. I am crying on the inside.’

Inability to cope

Daily chores, caring for the baby and herself may seem insurmountable to women with PND. Small demands she previously coped with may make her completely overwhelmed. She may talk about feeling like running away, wishing it would all go away, feeling overwhelmingly exhausted and very heavy, physically and emotionally.

Irritability

She may snap at her partner or other children without cause. Partners often say, ‘I can't do anything right. If I fold nappies she complains I do it the wrong way. If I don't help, I'm being unsupportive.’

Anxiety

She may feel a ‘knot in the tummy’ most of the time and panic without cause. Some experience heart palpitations so severe they fear they are having a heart attack. They may be anxious about their own or their baby's health even after being reassured that nothing is wrong. Many women describe anxiety as their most obvious symptom and reject the term postnatal depression. They deny being depressed. The term ‘postnatal anxiety’ might more accurately describe the way some women feel.

Negative obsessive thoughts

There can be little peace in the thinking processes of a woman with PND. Small worries can become consuming thought processes that interfere with her ability to listen, concentrate or remember. She may be afraid to let her partner go to work in case he has a car accident or be fixated on something bad happening to the baby. No amount of reassurance or distraction can hold her thinking at bay.

Fear of being alone

Many women go out a lot or need their partner (or someone) at home with them at all times because they are afraid of being alone at home. The fear of something going wrong with the baby or her own perceived inability to cope with the baby on her own is overwhelming. Some feel incredibly lonely and go out to feel connected with other people. This takes an enormous amount of effort. Others feel they cannot be with other people and withdraw from family and friends, not answering the door or telephone.

Memory difficulties and loss of concentration

A woman may forget what she wanted to say mid-sentence. She may not be able to concentrate on simple tasks or to take in new information. Organising herself and her family can become too difficult. Sometimes she doesn’t know where to start or she starts everything at once. Her ability to think creatively about her problems and to find solutions disappear, including what will help her feel better and finding services to help her.

Feeling guilty and inadequate

Feeling guilty can be a common feeling for all mothers but more so for the mother with postnatal depression. Her thoughts and feelings constantly reinforce in her own mind that she is inadequate and a bad mother. She may be unable to take encouragement from the good things she has done or to feel affirmed by her relationship with her baby. Reassurance will not dissuade her thinking and can discourage her from talking about how inadequate and guilty she feels.

Loss of confidence and self-esteem

A woman who enjoyed her job may panic at the thought of returning to it, no longer sure she is able to do it. A woman who enjoyed having family and friends over may panic at the thought of visitors. She may feel unable to prepare a meal which she enjoyed doing before the baby was born. Most women with postnatal depression have very low self esteem regardless of how well they seem. Some describe their experience as a loss of sense of who they are, a loss of sense of self.

Postnatal depression is difficult to identify

Society makes it difficult for a woman to acknowledge that she may be experiencing PND. She is constantly confronted by messages about joy and bliss but that rarely include the challenges that come with motherhood. The media tends to reinforce the unrealistic expectations of motherhood, for example promoting celebrities who appear to be coping exceptionally well.

Added to this is the stigma of depression with postnatal depression often being portrayed negatively and sensationally. Women will put on a brave face and go to extraordinary lengths to hide how they feel. A woman who is not coping can feel very alone and can find it very hard to come to terms with the way she is feeling.

Effects of postnatal depression

If postnatal depression is not identified or treated the toll it takes on the woman, her baby, partner, family and extended relationships increases. It does not usually resolve itself for full recovery without treatment, and the woman may experience future episodes of depression and mental illness.

Many women with postnatal depression are very close to their babies despite how they feel. For others, if postnatal depression is ongoing they may struggle to connect with their baby. This can have an impact on the wellbeing of the baby. With early identification and intervention most women fully recover from postnatal depression and there are no long-term effects.

Treatments

All women with postnatal depression need emotional support from family and friends. Some women find psychological treatments helpful especially if they have experienced traumatic events in their childhood or more recently.

Antidepressant medication is a successful part of treatment for many women. There are many misconceptions about antidepressants, and women who could benefit from them may refuse to take them because they are afraid the medication is harmful. Antidepressants are not addictive and some can be safely taken while breastfeeding and pregnant.

This type of medication does not ‘change your personality’, it corrects the chemical imbalances in the brain that are thought to be responsible for symptoms of depression and anxiety. It is important to understand that women cannot ‘snap out of’ depression any more than they could ‘snap out of’ diabetes.

Partners

Living with a woman suffering postnatal depression is difficult. Partners too need a lot of support as they often feel confused, lost and helpless. It is important that partners be included by the health professionals treating women with postnatal depression. Partners are much more supportive if they understand what the problem is and what they can do to help.

Where to go for help

If a woman does not feel the way she expected to feel after having a baby it is very important that she talk to her doctor or maternal and child health nurse. It could simply be that she is having trouble adjusting to the changes in lifestyle that occur when a baby is born and to the demands that a new baby makes. If she is suffering postnatal depression it is important that she receive appropriate help as soon as possible. Postnatal depression is not something to be ashamed of. It should be seen as one of the many complications of pregnancy and delivery. With appropriate help, women with PND do recover.

 

Last Reviewed: 01 October 2007

myDr, 2007. Reproduced with the kind permission of the Post and Ante Natal Depression Association (PANDA).
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