Depression

Depression at any time can be devastating for women and their families. More women suffer than many people imagine. Find out more about depression in pregnancy and postnatal (after birth) depression. Read women’s stories. Discover answers to common myths, access an expert interview and find links to the research that Wellbeing of Women are funding to try and understand more about this devastating illness.

Women have a lifetime risk of depression of about 1 in 4 and it is most prevalent during their reproductive years. Much emphasis has been placed on the detection and treatment of postnatal depression however antenatal depression not uncommon and about half of postnatal depression appears to start during pregnancy.

 

 

Overview

This is an overview of depression in pregnancy and the postnatal period. Depression can affect women at any point in their lives. The tips and treatments below focus on pregnancy and the postnatal period but can equally be applied to any time in a woman’s life. Please also see our section on mental health.

 

DEPRESSION IN PREGNANCY

Pregnancy is a major psychological, as well as physiological, event:

With an excess of chronic life stressors, women may find themselves unable to cope with the additional demands of pregnancy.

Risk factors include:

·         Previous depression or postnatal depression.

·         History of premenstrual dysphoric disorder.

·         Family history of psychiatric illness around pregnancy.

·         History of childhood abuse.

·         Socio-economic factors - low income, single motherhood, poor support, large number existing children

·         Unplanned pregnancy.

·         Domestic violence or relationship conflict.

·         Young age.

Presentation

The symptoms of antenatal depression are as for depression in general.  (See our section on Mental Health).

Identifying antenatal depression can be difficult - women are reluctant to acknowledge 'difficult' emotions many of the symptoms such as fatigue can also be attributed to the pregnancy itself. Guidelines recommend that at the first booking appointment in pregnancy, women should be asked 2 questions:

·         During the past month, have you often felt bothered by feeling low, depressed or hopeless?

·         During the past month, have you often been bothered by having little interest or pleasure in doing things?

If the woman answers 'yes' to either of the above, then a third question should be asked:

·         Is this something you need or want help with?

Management

The woman's health and the potential fetus' development need to be considered when deciding on treatment bearing in mind the effects of medication on the fetus and the risk of an untreated mental illness.

As in depression, treatment can include guided self-help, talking therapies such as Cognitive Behavioural therapy or antidepressant medication.

Antidepressants

When a health professional prescribes antidepressants to a pregnant woman or a woman who intends to become pregnant the risks should be discussed – there are potential risks to both the mother and the unborn fetus.

 

POSTNATAL DEPRESSION

Postnatal depression is a type of depression some women experience after they have had a baby. Postnatal depression is more common than many people realise and cases can often go undiagnosed.

It is estimated around one-in-seven women experience some level of depression in the first three months after giving birth.

 

It usually develops in the first four to six weeks after childbirth, although in some cases it may not develop for several months.

It's very important to understand that postnatal depression is an illness. Having it does not mean the woman does not love or care for her baby.

Postnatal depression can be lonely, distressing and frightening, but there are many treatments available.  Provided postnatal depression is recognised and treated, it is a temporary condition from which recovery is possible.

Myths

Many myths surround the condition. These include:

·         Postnatal depression is less severe than other types of depression. In fact, postnatal depression is as serious as other types of depression.

·         Postnatal depression is entirely caused by hormonal changes. Postnatal depression is actually caused by many different factors.

·         Postnatal depression will soon pass. Unlike the "baby blues", the symptoms of postnatal depression persist for months if left untreated and in a minority of cases can become a long-term problem.

Symptoms

Postnatal depression can affect women in different ways.

Key symptoms:

·         persistent feeling of sadness and low mood

·         loss of interest and no longer enjoying activities that used to give pleasure

·         feeling tired all the time (fatigue)

Other symptoms:

·         disturbed sleep

·         poor concentration and decision making

·         low self-confidence

·         change in appetite – decrease or increase

·         feeling very agitated or alternatively very apathetic (can’t be bothered)

·         feelings of guilt and self-blame

·         suicide and self-harming thoughts

·         Some women feel unable to look after their baby, or feel too anxious to leave the house or keep in touch with friends.

·         Frightening thoughts - some women with postnatal depression have thoughts about harming their baby. This is quite common, affecting around half of all women with the condition.

Seeking help for postnatal depression does not mean you are a bad mother or unable to cope.

Spotting the signs in others

It's important for partners, family members and friends to recognise signs of postnatal depression at an early stage. Warning signs include:

·         Frequent crying for no obvious reason.

·         Difficulties bonding with their baby.

·         Self- neglect – for example, not washing or changing clothes.

·         They seem to have lost all sense of time – often unaware if 10 minutes or two hours have passed.

·         Loss of all sense of humour

·         Persistent worrying that there is something wrong with their baby, regardless of reassurance.

If you think someone you know has postnatal depression, encourage them to open up and talk about their feelings to you, a friend, GP or health visitor.

Postnatal depression needs to be properly treated and isn't something you can just snap out of.

Postnatal psychosis

A rarer and more serious mental health condition that can develop after birth is known as postnatal psychosis, thought to affect around 1 in 1,000 women.

Symptoms:

·         bipolar-like symptoms – feeling depressed one moment and very happy the next

·         believing things that are obviously untrue and illogical (delusions) – often relating to the baby, such as thinking the baby is dying or that either the mother or the baby have magical powers

·         seeing and hearing things that are not really there (hallucination) – this is often hearing voices telling the woman to harm the baby

Postnatal psychosis is regarded as an emergency. If you are concerned someone you know may have developed postnatal psychosis, contact your GP immediately. If this is not possible, call NHS Direct on 0845 46 47 or your local out-of-hours service.

If you think there is a danger of imminent harm to you, your partner or your baby, call your local A&E services and ask to speak to the duty psychiatrist. 

Causes of postnatal depression

The causes are not completely clear. It is most likely postnatal depression is the result of a combination of factors including:

·         depression during pregnancy

·         a difficult delivery

·         lack of support at home

·         relationship worries

·         money problems

·         having no close family or friends around

·         physical health problems following the birth, such as urinary incontinence (loss of bladder control), or persistent pain from an episiotomy scar or a forceps delivery

Simply having a baby can be a stressful and life-changing event that can trigger depression.

It can take months before people begin to cope with the pressures of being a new parent. This is true even for those who already have children.

In addition, some babies are more difficult and demanding than others, and don't settle so easily. This can lead to exhaustion and stress.

Who's at risk

Factors that can increase the risk of having postnatal depression include:

·         a family history of depression or postnatal depression

·         having experienced depression or postnatal depression previously, or other mood disorders such as bipolar disorder

Diagnosing postnatal depression

The GP should be able to diagnose postnatal depression through taking a history.

The GP may carry out a blood test to exclude physical reasons for symptoms like tiredness and low mood:

·         thyroid testing to exclude and underactive thyroid gland

·         blood count to check for anaemia (lack of red blood cells which can lead to tiredness).

Treatment

It can take some time to recover fully from the condition.

Support and advice

The most important first step in managing postnatal depression is recognising the problem and taking action to deal with it. The support and understanding of a partner, family and friends plays a big part in recovery.

Support and advice from social workers or counsellors can be helpful. Self-help groups can also provide good advice about how to cope with the effects of postnatal depression.

Exercise

Exercise has been proven to help depression, and is one of the main treatments for mild depression.

Psychological treatments

Psychological therapies are usually recommended as the first line of treatment for mild-to-moderate postnatal depression for women with no previous history of mental health conditions.

·         Guided self-help

The GP can suggest self-help manuals that also contain information on using cognitive behavioural techniques to help combat feelings of helplessness.

The GP may also give details about an interactive computer programme, available via the internet, called "Beating the Blues". This again takes a cognitive behavioural approach to battling depression.

·         Talking therapies

Talking therapies are used to encourage to talking through problems either one-to-one with a counsellor or with a group.

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) is a type of therapy based on the idea that unhelpful and unrealistic thinking leads to negative behaviour.

CBT aims to break this cycle and find new ways of thinking that can be more positive and beneficial.

CBT is usually provided in four-to-six weekly sessions.

Interpersonal therapy

Interpersonal therapy (IPT) aims to identify whether relationships with others may be contributing toward feelings of depression.

Again, IPT is usually provided in four-to-six weekly sessions.

·         Antidepressants

The use of antidepressants may be recommended in those with:

·         moderate postnatal depression and a previous history of depression.

·         severe postnatal depression

·         no response to counselling or CBT, or would prefer to try tablets first.

A combination of talking therapies and an antidepressant may be recommended.

Antidepressants work by balancing mood-altering chemicals in the brain. They can help ease symptoms such as low mood, irritability, lack of concentration and sleeplessness. This helps allow normal functioning and better coping with the new baby.

Contrary to popular myth, antidepressants are not addictive. A course usually lasts six-to-nine months.

Antidepressants take two-to-four weeks to start working, so it is important to keep taking them even if you don't notice an improvement straight away. It is also important to continue taking your medicine for the full length of time recommended by your doctor. If you stop too early, depression may return.

Between 50% and 70% of women who have moderate to severe postnatal depression improve within a few weeks of starting antidepressants. However, antidepressants are not effective for everyone.

Antidepressants and breastfeeding

The selective serotonin reuptake inhibitors (SSRI) types of antidepressants are usually recommended for women who are breastfeeding.

Tests have shown the amount of these types of antidepressants found in breast milk is so small it is unlikely to be harmful.

Side effects of SSRIs should pass once your body gets used to the medication.

Discuss feeding options with your GP when you're making decisions about taking antidepressants.

Many mothers are keen to continue breastfeeding because they feel it helps them to bond with their child and boosts their self-esteem and confidence in maternal abilities. These are important factors in combating symptoms of postnatal depression.

You may be referred to a mental health team if your postnatal depression is severe, or does not respond to treatment.  If it is felt your postnatal depression is so severe you are at risk of harming yourself or your baby, you may be admitted to hospital or referred to a mental health clinic. If you have support available from your partner or family, it may be recommended they care for your baby until you are well enough to return home.

If you do not have support available to help you care for your baby, or your mental health team feels separation from your baby would adversely affect your recovery, you may be recommended for transfer to a specialised "mother and baby" mental health clinic.

Prevention

When pregnant it is important to tell the GP about any previous depressive episodes. It is suggested a woman should speak to her GP if she has had postnatal depression in the past and is pregnant or considering having another baby.

Self-help measures can also be useful:

·         Ensure enough rest and relaxation as possible during pregnancy

·         Undertake regular gentle exercise.

·         Eat a healthy balanced diet and eat regularly

·         Don't try to do everything at once - set realistic goals.

·         Talk about worries with a partner, close family and friends.

Don't despair. Postnatal depression can affect anyone. You are not to blame.

Preventative treatment

If the risk of developing postnatal depression is thought to be especially high, the GP may recommend starting antidepressants as a precaution shortly or soon after giving birth.

 

Read Women's Stories

 

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".

 

If you would like to tell us your story so we can help and inform other women; there is more information available HERE

 

 

Expert Interview- Podcast

 

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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. 

Common Myths

 

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. 

Research

To find out about our research follow these links:
 

Useful Websites

 

 

 

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

Page last updated March 2013

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