About this leaflet
This leaflet is for anyone who suffers from
postnatal depression (PND for short). We hope it will also be
helpful to family and friends, and to anyone who wants to know more
about this problem. The leaflet describes what it's like to have
PND, ways of helping yourself and some of the treatments available.
There are references to research information and suggestions for
further reading and help.
What is PND?
Postnatal Depression is what happens when you
become depressed after having a baby. There may be an obvious
reason, but often there is none. It can be particularly distressing
when you have looked forward to having your baby through the months
of pregnancy. You may feel guilty for feeling like this, or even
feel that you can't cope with being a mother. It can last for weeks
or several months. Mild PND can be helped by increased support from
family and friends, more severe PND will need help from your GP,
health visitor or, in some cases, mental health professionals.
How common is it?
Around 1 in every 10 women has PND after
having a baby. Without treatment it can last for months, or rarely
years.
What does it feel like to have PND?
Depressed
You feel low, unhappy and wretched for much or
all of the time. You may feel worse at particular times of the day,
like mornings or evenings. Occasional good days give you hope but
they are followed by bad days which make you despair.
Irritable
You may get irritable with other children,
occasionally, with your baby, but most often with your partner. He
or she may well not understand what is happening.
Tired
All new mothers get pretty weary, but
depression can make you feel so utterly exhausted that you feel
physically ill.
Sleepless
Even though you are tired, you can't fall
asleep. You wake at the crack of dawn, even if your partner has fed
the baby overnight.
Not hungry
You lose your appetite and forget to eat,
which can make you feel irritable and run down. Some people eat for
comfort and then feel bad about putting on weight.
Unable to enjoy anything
You find that you can't enjoy or be interested
in anything.
Sex
Your partner may want the comfort and intimacy
of sex again – but you're just not interested. Of course, there are
other reasons to lose interest in sex after having a baby - it may
be painful, you may be too tired, or you may be just trying to
adjust to the new situation - but PND will take away any desire or
enthusiasm. If your partner does not understand this, they may feel
rejected.
Unable to cope
PND can make you feel that you have no time,
can't do anything well, and that you can't do anything about it.
You may find it hard to organise a routine with your baby.
Guilty
Depression changes your thinking and makes you
see things negatively. You may feel guilty, useless or that you are
responsible for feeling like this.
Anxious
You may worry so much that your baby might
scream, or choke, or be harmed in some way that you are afraid to
be alone with him or her. Instead of feeling close to your baby,
you may feel detached. You can't work out what your baby is
feeling, or what your baby needs.
Even if you have strong loving feelings for
your baby, you can still feel anxious. Most new mothers worry about
their baby’s health, but PND can make this overwhelming. You may
worry:
- That you might lose your baby through an
infection, mishandling, faulty development or a 'cot death'
- About 'snuffles', or how much weight your
baby is putting on
- If your baby is crying or is too quiet, or if
they have stopped breathing
- That you might harm your baby
- About your own health
You may find that you need reassurance all the
time from your partner, the health visitor, the GP, your family or
a neighbour. You may feel panicky - your pulse races, your heart
thumps and you may feel that you have heart disease or are on the
brink of a stroke. You may wonder if you have some dreadful
illness, or if you will ever have any energy again. The fear of
being left alone with all this can cause even the most capable
person to cling desperately to their partner, not wanting to be
left alone.
Other mental health problems around childbirth
Depression in pregnancy
This is more common than people think and can
be helped in much the same way as postnatal depression.
Puerperal psychosis
This is a serious condition that affects
around 1 in 500 women and starts within days or weeks of
childbirth. It can develop in a few hours and can be
life-threatening, so needs urgent treatment. Other people will
usually notice it first. You start to say strange things and become
excitable and unpredictable. You may have rapid mood swings,
strange or bizarre beliefs and may hear voices. This always needs
medical help and support. You may have to go into hospital, but
your baby should go with you.
It is more likely to happen if you, or someone
in your family has had PND, or bipolar disprder (manic depression).
Let your doctor or midwife know about this so you can have
treatment to reduce the risk of it happening. Although puerperal
psychosis is a serious condition, full recovery is possible with
the proper treatment.
Doesn't everybody get depressed after having a baby?
No. About half of new mothers will feel a bit
weepy, flat and unsure of themselves on the third or fourth day
after having a baby. This is known as the 'baby blues', and it
passes after a few days.
When does PND happen?
Most cases of PND start within a month of
giving birth, but it can start up to six months later.
What causes PND?
We don't know enough to be sure who will or
won't get it. There is probably no single reason, but a number of
different stresses may add up to cause it. You are more likely to
have PND if you:
- have had depression (especially PND)
before
- do not have a supportive partner
- have a premature or sick baby
- lost your own mother when you were a
child
- have had several recent life stresses -
bereavement, unemployment, housing or money problems
Even so, PND can start for no obvious reason,
without any of these stresses. And having these problems does not
mean that you will definitely have PND.
What about hormones?
Levels of oestrogen, progesterone (and other
hormones to do with conception and birth) drop suddenly after the
baby is born. It's not clear exactly how they affect your mood and
emotions. No real differences have been found between women who do
and do not get PND, and research does not suggest that this is a
major reason for depression. Hormone changes may be more important
in the baby blues and puerperal psychosis.
Do women with PND harm their babies?
Depressed mothers often worry that they might
do this, but it is rare. Occasionally, through utter tiredness and
desperation, you might feel like hitting or shaking your baby. Many
mothers (and fathers) occasionally feel like this, not just those
with PND. In spite of having these feelings at times, most mothers
never act on them. The problem is more likely to be a crippling
worry that you might harm your baby. If you do feel like this, tell
someone. Your health visitor or doctor will be able to help.
Women with special needs
Mothers who have a mental illness or a
physical or learning disability, do face extra difficulties.
Professionals should try to make sure that they get the help and
support they need to stay well and look after their baby.
What can be done?
The first thing is to recognise the depression
for what it is – and not to dismiss it as the 'baby blues'.
You may not realise what is wrong, or feel
ashamed to admit that you are less than thrilled by being a mother.
You may worry that, if you do, your baby may be taken away – but
your doctor, health visitor or midwife are most concerned with
helping you get better so you can enjoy and care for your baby at
home.
People are now more aware of depression in
general, so PND shouldn't be missed so often. A questionnaire, such
as the Edinburgh Postnatal Depression Scale, can be used to
help health visitors and GPs to spot PND.
Self-help
We don't yet know enough about PND to prevent
it in the first place, but certain principles make sense:
During pregnancy:
- DON'T try to be 'superwoman'. Try to do less
and make sure that you don't get over-tired. If you are working,
make sure you get regular meals and put your feet up in the lunch
hour.
- DON'T move house (if you can help it!) while
you are pregnant or until the baby is six months old.
- DO make friends with other women or couples
who are expecting or have just had a baby; among other things, this
could lead to baby-sitting arrangements.
- DO find someone you can talk to. If you don't
have a close friend you can turn to, the National Childbirth Trust
or MAMA - their local groups are very supportive both before and
after childbirth (see page 17).
- DO go to antenatal classes - and take your
partner with you.
- DO keep in touch with your GP and your health
visitor if you have suffered PND before. Any signs of PND can be
recognised early.
After the baby has
arrived:
- DO tell someone about how you feel. Many
other women have gone through the same experience. If you don't
feel you can talk to your family or friends, talk to your health
visitor or GP. They will know that these feelings are common and
will be able to help.
- DO take every opportunity to get your head
down. See if you can cat-nap. Your partner can give the baby a
bottle-feed at night. If you like, you can use your own expressed
breast milk for this.
- DO eat well. Healthy foods like salads, fresh
vegetables, fruit, fruit juices, milk and cereals are all nice,
packed with vitamins and don't need much cooking.
- DO find time to have fun with your partner.
Try to find a baby-sitter and get out together for a meal, a show
or to see friends.
- DO let yourself and your partner be intimate
if you can: at least kiss and cuddle, stroke and fondle. This will
comfort you both and lead to the return of full sexual feelings
sooner. Don't feel guilty if this takes some time.
- DON'T blame yourself or your partner: life is
tough at this time, and tiredness and irritability on both sides
can lead to quarrels. 'Having a go' at each other will weaken your
relationship when it needs to be at its strongest.
- Don't be frightened by the diagnosis. You
know what is wrong, that many others have had the same experience
and that you will get better in time. Your partner, friends or
family can be more helpful and understanding if they know what the
problem is.
Ways for other people to help
- Don't be shocked or disappointed if your
wife, partner, sister or girlfriend confesses that she has felt
awful since the birth of her baby. Take the time to listen and make
sure that she gets the support and help she needs.
- Try not to be shocked or disappointed by a
diagnosis of PND - it is common and can be effectively helped.
- Do all you can to help with the practical
things that need to be done, while your partner does not feel up to
doing them - shopping, feeding and changing the baby, or
housework.
- Make sure that you are clear about what is
happening. Get advice on how to help, especially if you are the
mother's partner. Make sure that you have some support yourself. If
this is a first baby, you may feel pushed to one side, both by the
baby and by your partner's needs. Try not to feel resentful. Your
partner needs your support and encouragement. Practical help with
the baby, sympathetic listening, patience, affection and being
positive will go a long way. Your partner will appreciate this even
when the depression is over.
Getting Help
Doctors and nurses should regularly ask about
the mental health of mothers to be. So, they may ask three
questions:
- During the last month, have you been bothered
by feeling down, depressed or hopeless?
- During the last month, have you been bothered
by having little interest in pleasure or in doing things?
- Is this something you feel you need or want
help with?
If you are referred for psychological help
while pregnant, you should be seen within a month. Professionals
should take into account the needs of your partner and any children
you have. There should be a specialist service – a “perinatal”
mental health service – for women who are pregnant or who have
given birth.
What if I don't want treatment?
Most women will get better without any
treatment after a period of weeks, months or sometimes longer.
However, this can mean a lot of suffering. PND can spoil the
experience of new motherhood, and strain your relationship with
your baby and partner. So the shorter it lasts, the better. It's
important to get help as soon as possible, to relieve the
depression, to support your relationship with your baby, and to
help your baby’s development in the long run. You should be told
about all the likely benefits and risks of treatment so you can
make the best choice for you.
What about talking treatments?
It can be a great relief just to talk to a
sympathetic, understanding, uncritical listener - this could be a
friend, a relative, a volunteer or a professional. Many general
practices now have a counsellor, and trained health visitors can
help treat PND.
There are more specialised psychological
treatments. Cognitive Behavioural Therapy can help you to see how
some of your ways of thinking and behaving may be making you
depressed – and help you to change them. Other psychotherapies can
help you to understand the depression in terms of your
relationships or what has happened to you in the past. These can be
arranged through your GP with a community psychiatric nurse, a
psychologist or a psychiatrist.
Are there problems with these treatments?
These treatments are usually very safe, but
they can have unwanted effects. Talking about things may bring up
bad memories from the past and this can make you low or distressed.
Psychotherapy can put a strain on a relationship with their
partner.
Make sure that you can trust your therapist
and that they have the necessary training. Another problem with
talking therapies is that they are still hard to get in some areas.
There are long waiting lists, so you may not get any treatment for
quite a while.
What about medication?
If you have a more severe depression, or it
has not improved with support and reassurance, one of the
antidepressant drugs will probably help. Antidepressants take two
weeks or so to start working and should be taken for around six
months after you start to feel better.
How do they work?
It is not entirely clear, but antidepressants
affect the activity of two chemicals in the brain, serotonin (also
called 5HT) and noradrenaline.
Do antidepressants have side effects?
Some may cause nausea or an increase in
anxiety at first, but these usually wear off. Others can make you
sleepy or give you a dry mouth. Make sure that your doctor knows
that you are breast-feeding. For many antidepressants, there is no
evidence that they cause problems for breastfed babies, so
breastfeeding is usually possible. However, such a decision is an
individual one for each woman and your doctor can provide
additional advice. Some people get withdrawal symptoms when they
stop these medicines, so it's best to come off them slowly. For
more information, see our fact sheet on antidepressants.
Hormones have been suggested as a treatment
for PND. However, there is little evidence that they work, and they
have their own dangers, particularly if you have had thromboses
(blood clots in the veins) of any sort.
Are there alternatives?
There is some evidence that regular exercise
can boost your mood and help you to feel less isolated. You may
find it easier to do this with other people.
So which treatment is best?
Everyone can try the simple measures outlined
in this leaflet. Talking treatments and antidepressants are equally
effective, but antidepressants are more likely to be recommended if
the depression is severe or has gone on for a long time. They also
work a bit quicker than talking treatments. Talking treatments and
antidepressants can be given together. Your GP or health visitor
can give information and advice.
FINALLY, even if you have been depressed for a
while, support, counselling and medication can all help you to get
better. It's never too late.
References
Antidepressant treatment for post-natal
depression (2001) Hoffbrand S., Howard L. and Crawley H.,
Cochrane Review.
This article compares antidepressant
treatment and counselling, find it at:
www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD002018/pdf_fs.html
Depression in postpartum and
non-postpartum women: prevalence and risk factors (2002)
Eberhard-Gran, M. et al. Acta Psychiatrica Scandinavica, Vol
106, 426-433.
Controlled trial of the short- and
long-term effect of psychological treatment of post-partum
depression 2: Impact on the mother-child relationship and child
outcome (2003) Murray L. et al. British Journal of
Psychiatry, Vol 182: 420-427
Edinburgh Postnatal Depression Scale
(EPDS) (1987) Cox J. L., Holden J. M., Sagovsky R., British
Journal of Psychiatry, Vol. 150 : 782-786
Find this article at:
www.wellmother.com/articles/edinburgh.htm
Antenatal and postnatal mental health:
clinical management and service guidance. NICE Clinical Guideline
45. (2007) National Institute for Clinical Excellence:
London
Find this document at:
www.nice.org.uk/CG45
Can we identify mothers at risk for
postpartum depression in the immediate postpartum period using the
Edinburgh Postnatal Depression Scale? (2004) Dennis C.
L., Journal of Affective Disorders, Vol. 78, no. 2, p.
163-169
Oestrogens and progestogens for preventing
and treating postnatal depression (1999) Dennis, CL., Ross,
LE., Herxheimer, A. Cochrane Database of Systematic
Reviews, Issue 3. The Cochrane Collaboration, John Wiley &
Sons, Ltd.
Find this article at:
www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001690/pdf_fs.html
Organisations that can help
Association for Postnatal
Depression
Helpline: 020 7386 0868 (10am-2pm Mon, Weds
& Fri, 10am-5pm, Tues & Thurs).
Provides support to mothers suffering from
post-natal illness. It exists to increase public awareness of the
illness and to encourage research into its cause and nature.
CRY-SIS
Helpline: 020 7404 5011 (line open 9.00 am to
10.00 pm, 365 days a year)
Provides self-help and support for families
with excessively crying and sleepless babies.
Meet-A-Mum-Association
(MAMA)
Helpline: 0845 120 3746 (7.00 pm to 10.00 pm
weekdays)
Self-help groups for mothers with small
children and specific help and support to women suffering from
postnatal depression.
National Childbirth
Trust
Enquiry line: 0870 444 8707; Pregnancy and
Birth Line: 0870 444 8709: Breastfeeding line: 0870 444 8708.
Advice, support and counselling on all aspects
of childbirth and early parenthood.
The
Samaritans
Tel: 08457 909090 (UK) or 1850 609090 (Eire);
Email: jo@samaritans.org.
Provides confidential emotional support to any
person who is suicidal or despairing.
Further Reading
Websites
Living Life to the Full
www.livinglifetothefull.com/elearning
An online mental health lifeskills course
supported by the Scottish Executive Health Department
Produced by the Royal College of Psychiatrists' Public Education
Editorial Board.
Updated August 2007
Series Editor: Dr Philip Timms
Expert Review: Dr R. Cantwell and Dr M Oates
Editorial Board: Dr Ros Ramsay, Dr Martin Briscoe, Deborah
Hart
User and Carer Input: Royal College of Psyciatrists'
Committee of Patients and Carers
Illustration: Lo Cole/Inkshed.co.uk
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© August 2007 Royal College of Psychiatrists.
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