Some women get thoughts in pregnancy or after birth about harming themselves or their baby. These thoughts are caused by the condition and it is very important to tell some one about these feelings so help and support can be given.

Diagnosis

Early diagnosis is important, as there are simple treatments and straightforward things that can be done to help. The midwife, doctor or health visitor can assess the situation and advise on the correct help and support. It is important to remember that the health professionals are simply there to provide support and not to judge.

Treatment

Treatment depends on the severity of the depression and depends whether it occurs in pregnancy or the post-natal period. Health care professionals will assess the need and the level of support required. See our expert interview for more information. Treatments options include:

Self help:

• Eating a more healthy diet.
• Regular exercise.
• As much sleep and rest as possible by engaging family or friends to help with this.
• Family/friend support if possible by using an extended network to help with the challenges of pregnancy and new motherhood.
• Taking time out and making time for usual activities such as meeting friends, hobbies and trying to make an extended support network.
• Talking about feelings to a partner, family or friends.

Counselling:

There are different counselling options. A counsellor or specialist practitioner can provide general counselling sessions. These counselling measures can start to take effect even after just a few sessions.

Cognitive behaviour therapy (CBT):

Another option is CBT sessions with a psychologist or psychotherapist. See expert interview for more information.

Medications:

Less commonly medication such as antidepressants may be needed. These should be prescribed and supervised by a medical professional and assessed regularly. When taking medication it is still advisable to make the lifestyle changes described above, as these are important in general wellbeing. Many antidepressants are safe to take in pregnancy or whilst breastfeeding and with careful management they can be very effective.

It must be remembered that depression in pregnancy and the postnatal period is common but treatable and it is not the sufferer’s fault. There is help available to anyone who is struggling- so if this is you or your partner, please tell a doctor/midwife/nurse/support worker/ health visitor or anyone you can.

Prevention

Not all depression can be prevented, but adapting general lifestyle may help to control feelings and therefore help to reduce the risk.

In pregnancy and after birth it is important to;

• Talk openly about feelings.
• Maintain a healthy diet.
• Take regular exercise.
• Get as much sleep and rest as possible.
• Take all the support offered by family and friends.

It is extremely important to be open and honest about any feelings that concern you. This prevents problems becoming more serious and allows appropriate actions to be taken.

April’s story-

"I have been diagnosed with postnatal depression, but I didn’t think it would happen to me. Of course I was ecstatic and so excited to have my son Jack, but I found myself feeling low afterwards. After he was born I felt it was easier to stay in the house and not go out, then we wouldn’t have to face the world and I could protect him. This became worse over the weeks and I started to feel lower. My husband was fantastic and tried to help as much as he could, but I was not myself and it wasn’t working.

I struggled on. I thought that I could sort it out as I am usually so strong. It got to a point where I realised I needed more help to tackle it. I went to my doctor and started counselling with my Health Visitor which was helpful; it let me talk about everything I didn’t feel I could explain. This helped a lot but did not solve things. I am currently on medication and the two combined have really helped, I feel like I am getting back to my usual self. Medication is not for everyone but it is right for me in my situation.

My Message to other women is:  You are not the only one, don’t feel guilty and keep faith. Go and see someone about it and talk, it will get better".

This podcast was recorded in march 2012.

Depression in pregnancy and after birth: Text Version.

Hello and welcome to our podcast.  Today we’ll be speaking about depression in pregnancy and after birth. Depression can be devastating for mothers and their families. More women suffer than many imagine. Post natal depression can affect up to 1 in 8 new mums but it’s also important to be aware of depression of any kind including depression in pregnancy as well.

I would like to welcome Katherine Abel who is a psychiatrist and Professor and Director for the Centre for Women’s Mental Health at the University of Manchester.

Hi Katherine, thank you for joining us.

Could you explain a little bit more about what peri-natal depression is? I know that women can suffer during pregnancy and during the post natal period, as at any time in their lives.

Yes, over a woman’s lifetime about 21 percent of women will experience depression at some time. However, during their reproductive lives between the ages of about 15 and 44 they are most likely to develop a depressive illness, apart from when they are a lot older.

 Peri-natal depression is simply a way of thinking about depression that occurs either during pregnancy or in the first post natal year.  It may be, the research isn’t quite clear about this, that women who develop depression for the first time, only after they have had a child are more susceptible to childbirth, if you like, as a life event, a more stressful life event.  But for other women they may be just as likely to develop depression at any time in their lives and childbirth is just another time in their lives. Of course, for anyone having a new baby and particularly in our modern and hectic lives, it’s a stressful time and so that might be the reason why we are seeing an increase in the rates of peri-natal depression.

Why do some women suffer from this type of depression and I think you’ve partly answered that- it can be due to our stressful lives.

Yes, it may be that there’s something specific about childbirth for some women although it’s not really clear that that’s a biological phenomenon.   In peri natal psychosis and post natal puerperal psychosis, which is a different disorder, there is definitely a genetic component. There seems to be something specific in some women, some families, related to the events of childbirth and there may be a more biological phenomenon affecting the risk there.  However, for more simple depression which is common across women’s lives, it’s likely that psycho-social factors such as how much support you have, whether you’ve got a partner living with you, how old you are, are you a very young first time mum with no social support.  Was it an unwanted pregnancy?  Did you feel unwell during pregnancy?  Have you previously been unwell with depression?  We know that some of the risk factors of depression at any time are relevant also to post natal or peri natal depression, and in fact with post natal depression one of the most important risk factors is whether you’ve been depressed during pregnancy or whether you’ve been depressed during a previous pregnancy or, whether you’ve ever been depressed before in your life.  So some of the risk factors are common across depression at other times.

What signs should women look out for particularly? What signs tell them that maybe there’s a problem with depression?

The symptoms of depression in pregnancy overlap very much with symptoms that women would have normally as a part of pregnancy and it does make it more difficult and women need to be vigilant.  If you have a history of depression you are more likely to understand the symptoms that you get as a result of low mood and that could be, if you like a misjudgement of how good and how bad things are.  You know when you’re depressed things tend to think most things are terrible.  It’s difficult to have your mood lifted by things that would normally make people feel happier so you have a flattening and an inability to have your mood lifted and we call that ‘anhedonia’. But also you can have a more serious depression and you’ll have some features associated with the ‘drives’ as we call them, reduced sexual drive which also occurs when you get increasingly pregnant, and of course reduced appetite and reduced ability to sleep.  And again sleep disturbance of course is a common symptom of pregnancy.  So it’s difficult for women during pregnancy to make those distinctions but really it’s the tenacity of the low mood that is unable to be lifted and once it becomes more serious people can develop very unusual thoughts which might become psychotic.  In other words delusional beliefs about guilt, or things they’ve done, feeling they are a bad influence and might have a bad influence on others around them or indeed on the fetus.

When women are becoming seriously depressed during pregnancy they may stop eating altogether, they may try to harm themselves or the infant or develop suicidal thoughts and that’s clearly an extreme stage of the illness.

In the post natal period again there’s this overlap, so again sleeplessness as a result of the infant.  Mums describe it as a flattening and an inability to respond with joy to the infant’s stimuli so the infant, looking at them, and gazing at them, laughing so it’s very difficult for a new mum to enjoy being a new mum and that’s a terrible tragedy for both mother and the infant.  Many, many women, up to 90 percent develop baby blues in the first week and the midwives are aware of that, but women for some unknown reason to themselves become very tearful in the first week following childbirth.  But its women who become very severely low over that period and they don’t regain their mood, most women develop the blues and they recover quite quickly but in women who go onto develop post natal depression, the blues if you like, become entrenched and they can’t get over the event of childbirth particularly if it has been traumatic. They have difficulty bonding with the child; have a lack of desire of feeling of love towards the child.  All of those kinds of things, which are actually very specific signs that there is something wrong which needs picking up by friends and family.

Partner’s feelings can also be affected, can’t they? There’s often something that’s said that perhaps partners can suffer post-natal depression but is it more a reaction to their partner struggling?

Well of course there’s been a bit in the literature recently about paternal post-natal depression and I don’t want to downplay the role of the partner.  We know that it’s extremely important to have the support of the partner.  But it’s not likely from the better population studies that there’s something specifically related to post-natal depression for fathers.  What there is however, as you alluded to is the response quite naturally, of the father to his partner’s depression.  So what we find is that it’s most likely to predict the low mood in the father if the mother has post-natal depression.  So her being low is going to drag the dad down too, which of course is exactly what you don’t want when you’ve got one person to be rallying and looking after the other.  And we know this from this scenario of partners outside of childbirth, that if one partner becomes depressed that’s a big risk factor for the other partner subsequently to develop depression.

Could you tell us a little bit more about what are the possible treatments for women who find themselves depressed in pregnancy or in the post-natal period?

Yes sure.  One of the great anxieties for women during pregnancy is they don’t want to take medicines that might harm the fetes and of course that’s an anxiety for clinicians too.  The information is relatively poor because it’s difficult to do the kind of experiments you want.  You can’t randomise women to various treatments.  Having said that, it’s clear that the kinds of treatment options that are available for depression at any other time work perfectly well for women who are depressed during pregnancy, the problem is that you want to avoid medication if possible.  And that’s reasonable for the majority of women, up to 13% develop depression during pregnancy and they can’t go untreated. 

But for the majority of women the non medical treatments which are more support, psychological interventions at the level of the individual or guided self help, other self help treatment groups, support groups, family groups, one-to-one cognitive therapies, psychological therapies, all of those work for depression during pregnancy and can be tailored for the particular needs of the woman who is having a baby and her anxieties.  Of course if a woman becomes severely depressed, as we have discussed- suicidal, or really not getting better with the more simple treatments then what tends to happen is that you’ll add in a medication, a simple regime of one kind of treatment, one kind of therapy which could be an anti depressant.  There are some anti depressants, and you can have a look at those on various NHS websites and your clinician will guide you as to which are the most appropriate for you and which are not so appropriate for women during pregnancy.  The majority are probably safe for women and it’s as I said it’s a risk/benefit analysis that you and your clinician need to make about how well you are to sustain the fetus versus the risk  to the fetus of taking the medicine because some of these medicines do cross into the placenta and some far more than others.  It’s very important to have that conversation.

 Post-natally, it is slightly different as the fetus is no longer dependent on you for everything.  However, most women would like to breastfeed and we encourage women to breastfeed up to six months and that’s perfectly reasonable for a woman who needs to take a medicine.  Again, the same argument applies as to the woman who is pregnant.  If it’s mild to moderate depression then it’s usually perfectly amenable to either time, if it is very mild, or to psychological interventions. The same is relevant at other times but if it’s a more severe depression then treatment with medications is relevant then.  Most of those treatments can be safely administered, some better than others but again that can be discussed with your clinician.  One of the things is that women are often concerned that they have to stop breastfeeding.  That’s not the case, there are plenty of ways that you can time the regimen so that you take the medicine and feed the baby at the lowest blood level of medicine. You breastfeed and take the medicine afterwards and wait for a long time till its ok to feed again.  Anyway, there are all sorts of ways and it’s certainly not the case that it’s dangerous to treat mum during these times.

So as you say, there are options out there and women need to get the help they need and it’s about creating that balance that they need in getting the treatment.

Yes, and it’s about the risk/benefit analysis and it’s really important that mums and partners are engaged, if relevant in their discussions with their clinicians.

Is there anything that women can do to reduce their risk?

I mean with any mental health problem a lot of the risk is associated with who we are at the time as it were.  So the preventative measures occur way before the illness and so you want to have women who have social supports, if possible have a partner who is supportive around, who are slightly older mums, the thing is the slightly older mums go around being more supported and are partnered mums. I’m not saying they have to be married but if you have a more supportive partner around during pregnancy then you’re reducing your risk.  But it’s not just the partner, it’s the supportive network.

Any kind of support really.

Absolutely. If you have a great mum or family or somebody else that you can engage, a great friend perhaps. It doesn’t really matter where the support comes from as long as women have that support and feel they are engaged in some kind of network.  Really that’s probably, for the vast majority of us, that’s the most important thing.  We can’t change some of the risk factors, things like social class, genes that make us more susceptible because we have previously been more depressed or previously had a peri-natal depression.  You can’t necessarily change that.  There are things like booking early and seeing a midwife regularly and having good ante natal care that we think are protective. Part of that protection probably comes from having good obstetric outcomes because we know that a more traumatic, poor obstetric outcome both for the mother but also for the child makes the child more at risk, but you can’t change the fact for the mother if a child is born with malformations or anomalies. We know that this is a risk factor for postnatal mental illness and there are only certain thinks we can do to prevent those kind of anomalies.

This is obviously a very complex area as is any depression in general. Where do you feel there is a need for further research?

I think there are two elements to the research. One is relevant to how we want to change practice and the other more relevant to basic research and the origins of depression generally involving brain biology. I think it is certainly the case that we need to do more health services research. We have got very good recognition by most services of the risks of childbirth in relation to mental illness or mental health and we need to extend that to make sure that all professionals in obstetrics are picking up signs early of risk and vulnerability and the earlier you can pick things up the more likely you are to be able to intervene.

Access is incredibly important in terms of health service’s research. There are lots of very good interventions out there but if women don’t get those interventions or don’t come forward then they are not going to receive the effective therapies. I think there is a lot of work to be done in hard to access groups of women and again that relates to risk, so the poorer, younger more deprived, less supported women or women who are asylum seekers and English is not their first language, all of those women are at an increased risk of post-natal illness and they are less likely to access a lot of the preventative measures.  So more research is need into how best to make our effective interventions more accessible to hard to access groups.

From the brain biology perspective, certainly we are understanding far more these days about the biology of depression- the way that environment can alter the stress axis and our sensitivity to things that go on in our lives. All of us will know that some people just are more sensitive and get more stressed by a situation that may not bother you and that’s partly to do with the way we are built genetically but also partly to do with how our experiences in early life set up our stress systems. We know there is some interesting work being developed both in animals but also in humans looking at the effects on the control and regulation of the stress axis of various different environmental events. The way in which it is not about the genes you have got, but about the way they express themselves, the way the environment may alter the expression of those genes to make you more or less sensitive to stress levels.

Thank you Katherine it’s great to have your expert opinion on this. I know that we are focusing on quite a narrow subject here (pregnancy and postnatal depression) and women their families and everyone need to be aware of their mental health in general. What we are discussing here can translate to everyone’s lives, such as self help and tips etc.

Yes that is right and the other thing is that we hope in the future to talk a little bit more about more severe less common mental disorders that are also important for mother and child.

Thank you very much.

Pleasure. 

Discover the truth behind some of the myths surrounding pregnacy and postnatal depression.

I feel emotional in the first few weeks after birth and it must mean I will get postnatal depression.

No. Many women get a feeling after birth described as the ‘baby blues’, meaning being low or emotional after birth. This can affect up to 70 percent of women and is often a reaction to being tired and coping with a new baby. For most women this resolves as they adjust to new motherhood and get some more sleep! However, if these feelings become stronger or persist it is important to seek help as this may mean that postnatal depression is developing. 

If I am depressed and tell a healthcare professional I will be in trouble.

This is not the case at all. It is important to express feelings and healthcare professionals are there to help you to access the right treatment and support.

It’s my fault this has happened to me.

Pregnancy and postnatal depression, like depression any time, is an illness and it is not the sufferer’s fault.

Having pregnancy or postnatal depression in a first pregnancy or after a first child means that I will get it again.

After working through pregnancy or postnatal depression the vast majority of women will make a full recovery. During this coping strategies and techniques are learnt so it does not necessarily mean that you will suffer from depression again. However, be aware of the feelings and report them early if you start to feel them again in a subsequent pregnancy or postnatal period.

As a partner, friend or family member it’s my fault that she is suffering from depression.

This is not the case at all, while extra support and minimal stress is helpful, depression is a condition and it is no one’s fault. 

To find out about our research follow these links:
 

• The role of neurosteroids in stress and postnatal depression
   

• MIND: www.mind.org.uk

• Royal College of Psychiatrists: www.rcpsych.ac.uk

• Social care institute for excellence: www.scie.org.uk

• NHS Choices website also has a range of health information. This can be found at: www.nhs.uk