Postnatal Depression

New podcast: Postnatal depression - Louise's story
Louise is a young mother who developed postnatal depression (PND) following the eventful birth of her first child. Here, she discusses with Raj Persaud her experiences, and what it was like to be admitted to a Mother and Baby Unit.About this leafletThis leaflet is for anyone wants to know more about postnatal depression (PND for short). We hope it will be helpful to:

• women who have, or think they might have postnatal depression
• pregnant women who are worried about getting postnatal depression
• partners, family and friends.

The leaflet describes

• what it's like to have postnatal depression
• how to help yourself
• how partners, families and friends can help
• when to seek help from your GP or mental health services
• treatments
• further sources of help and information.

What is postnatal depression?

Postnatal Depression is a depressive illness which affects between 10 to 15 in every 100 women having a baby. The symptoms are similar to those in depression at other times. These include low mood and other symptoms lasting at least two weeks.  Depending on the severity, you may struggle to look after yourself and your baby. You may find simple tasks difficult to manage.

Sometimes there is an obvious reason for PND, but not always.  You may feel distressed, or guilty for feeling like this, as you expected to be happy about having a baby. However, PND can happen to anyone and it is not your fault.

It's never too late to seek help. Even if you have been depressed for a while, you can get better. The help you need depends on how severe your illness is. Mild PND can be helped by increased support from family and friends.

If you are more unwell, you will need help from your GP and health visitor.  If your PND is severe, you may need care and treatment from a mental health service.

When does PND happen?

The timing varies. PND often starts within one or two months of giving birth. It can start several months after having a baby. About a third of women with PND have symptoms which started in pregnancy and continue after birth.

What does it feel like to have PND?

You may have some or all of the following symptoms:

Depressed

You feel low, unhappy and tearful for much or all of the time. You may feel worse at certain times of the day, like mornings or evenings.

Irritable

You may get irritable or angry with your partner, baby or other children.

Tired

All new mothers get pretty tired. Depression can make you feel utterly exhausted and lacking in energy.

Sleepless

Even though you are tired, you can't fall asleep. You may lie awake worrying about things. You wake during the night even when your baby is asleep. You may wake very early, before your baby wakes up.

Appetite changes

You may lose your appetite and forget to eat. Some women eat for comfort and then feel bad about gaining weight.

Unable to enjoy anything

You find that you can't enjoy or be interested in anything. You may not enjoy being with your baby.

Loss of interest in sex

There are several reasons why you lose interest in sex after having a baby. It may be painful or you may be too tired. PND can take away any desire. Your partner may not understand this and feel rejected.

Negative and guilty thoughts

Depression changes your thinking:

• you may have very negative thoughts
• you might think that you are not a good mother or that your baby doesn't love you
• you may feel guilty for feeling like this or that this is your fault
• you may lose your confidence
• you might think you can't cope with things.

Anxious

Most new mothers worry about their babies' health. If you have PND, the anxiety can be overwhelming. You may worry that:

• your baby is very ill
• your baby is not putting on enough weight
• your baby is crying too much and you can't settle him/her
• your baby is too quiet and might have stopped breathing
• you might harm your baby
• you have a physical illness
• your PND will never get better.

You may be so worried that you are afraid to be left alone with your baby. You may need re-assurance from your partner, health visitor or GP.

When you feel anxious, you may have some of the following:

• racing pulse
• thumping heart
• breathless
• sweating
• fear that you may have a heart attack or collapse.

You may avoid situations, such as crowded shops because you are afraid of having panic symptoms.

Avoid other people

You may not want to see friends and family. You might find it hard to go to postnatal support groups.

Hopeless

You may feel that things will never get better. You may think that life is not worth living. You may even wonder whether your family would be better off without you.

Thoughts of suicide

If you have thoughts about harming yourself, you should ask your doctor for help. If you have a strong urge to harm yourself, seek urgent help (see below).

Psychotic symptoms

A small number of women with very severe depression develop psychotic symptoms. They may hear voices and have unusual beliefs. If this happens, you should seek help urgently (see below).

How does PND affect how I feel about my baby?

• You may feel guilty that you don't feel the way you expected to.
• You may or may not love your baby.
• You may not feel close to your baby.
• You might find it hard to work out what your baby is feeling, or what your baby needs.
• You may resent the baby or blame the baby for the way you feel.

Do women with PND harm their babies?

Depressed mothers often worry that they might do this, but it is very 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. If you do feel like this, tell someone.

Women often worry that if they tell someone how they feel, their baby may be taken away.  Actually your GP, health visitor and midwife will want to help you get better. This will mean that you can enjoy and care for your baby at home.

Doesn't everyone get depressed after having a baby?

Having a baby is a time of huge change.  It is common to feel many different emotions. Not everyone gets a depressive illness.

Over half of new mothers will experience the 'baby blues'. This usually starts 3 to 4 days after birth. You may have mood swings. You may burst into tears easily. You can feel irritable, low and anxious at times. You may also over-react to things.  It usually stops by the time your baby is about 10 days old. Women with baby blues do not need treatment. If it continues for more than 2 weeks, tell your health visitor or GP. They can check whether you have PND.

Other mental health problems around childbirth

Depression and anxiety are the most common mental health problems in pregnancy. They affect 10-15 in every 100 women. Depression in pregnancy can be helped in much the same way as postnatal depression. Women also experience a range of other mental health problems during pregnancy, just like at other times.

See our leaflet on mental health in pregnancy.

Postpartum (puerperal) psychosis

This is the most severe type of mental illness that happens after having a baby. It affects around 1 in 1000 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.

There are many symptoms that may occur.  Your mood may be high or low and there are often rapid mood swings. Women often experience psychotic symptoms. They may believe things that are not true (delusions) or see or hear things that are not there (hallucinations).

This illness always needs medical help and support. You may have to go into hospital. Ideally, this should be to a specialist mother and baby unit where your baby can go with you.

Women who have had previous episodes of severe mental illness, particularly bipolar disorder, are at a high risk of postpartum psychosis. Women, who have had a severe episode of illness following a previous delivery, are also at very high risk. Let your doctor or midwife know about this. You can discuss with them ways to increase the chances of you staying well.

Although puerperal psychosis is a serious condition, the vast majority of women make a full recovery.

Other mental health problems after childbirth

You may have had a mental illness before pregnancy. Your symptoms may get worse or return after your baby is born. Just as at other times, women can experience many types of mental health problems. If you are worried about any type of mental illness, discuss this with your GP. They can make sure you get the help and support you need.

What causes PND?

Many possible causes for PND have been suggested. 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 mental health problems, including depression before
• have had depression or anxiety during pregnancy
• do not have support from family or friends
• have had a recent stressful event - e.g. death of someone close to you, relationship ending, losing a job.

There may be a physical cause for your depression, such as an underactive thyroid. This can be easily treated.

PND can start for no obvious reason, without any of these causes. Also having these problems does not mean that you will definitely have PND.

Can postnatal depression be prevented?

We don't know enough about PND to prevent it in the first place. The following suggestions seem sensible and may help to keep you well.

• Don't try to be 'superwoman'. Try to do less and make sure that you don't get over-tired.
• Do make friends with other women who are pregnant or have just had a baby. It may be more difficult to make new friends if you get PND.
• Do find someone you can talk to. If you don't have a close friend you can turn to, try the National Childbirth Trust or The Pandas Foundation. Their local groups are very supportive both before and after childbirth.
• Do go to antenatal classes. If you have a partner, take them with you. If not take a friend or relative.
• Don't stop antidepressant medication during pregnancy without advice. Around 7 in 10 women who stop antidepressants in pregnancy relapse if they stop the medication.  You need to discuss the risks and benefits of continuing treatment in pregnancy and breastfeeding.
• Do keep in touch with your GP and your health visitor if you have had depression before. Any signs of depression in pregnancy or PND can be recognised early.
• Do make sure that you have treatment for depression in pregnancy. This may be a talking therapy or medication.
• Do accept offers of help from friends and family.

Recognising postnatal depression

The first thing is to recognise you have had a depressive illness. Don't dismiss it as the 'baby blues'. Don't assume it's normal to feel like this when coping with a baby.

There are lots of reasons why women delay seeking help. You may:

• not realise what is wrong
• worry about what other people think
• feel ashamed to admit that you are not enjoying being a mother.

Some women worry that their baby will be taken away.  In fact, you are doing what is best for your baby and for yourself by getting help for your PND. Doctors and health visitors want to get the care you need so you can look after your baby.

People are now more aware of depression in general. This means PND shouldn't be missed so often.

Doctors, midwives and health visitors usually ask new mothers about their mental health. They may ask you to fill in a questionnaire or ask the following 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?

It is important to answer these questions honestly so that you can be offered help if you need it. If your answers suggest you might have PND, you should see your GP. Your GP will need to ask more questions to confirm the diagnosis.

Where to get help

The help and treatment you need depends on how severe your PND is. Your GP and health visitor can help you decide what kind of help you need.

Everyone can try the self-help suggestions below.  If this is not enough, you might benefit from a talking therapy. For more severe depression, you may need medication, with or without talking therapy.  Your GP can advise you about these treatments.

A small number of women will need help from mental health services.  In some areas, there are perinatal mental health services. These are specialist services for pregnant women or women with a baby under a year old.  Your GP can refer you.  This is usually only needed for women with more severe illnesses.

Only a few women will need to go into hospital for treatment of PND. In that case, you should usually be admitted with your baby to a specialist Mother and Baby Unit.

Urgent help

If you cannot look after yourself or your baby, or if you have plans to harm yourself, you should be seen urgently by:

• your GP
• a mental health service - your GP can arrange this. You may already have a crisis number to call
• your local Emergency Department - open 24 hours.

Self-help

• Don't be frightened by the diagnosis. Many women have postnatal depression and you will get better in time. Your partner, friends or family can be more helpful and understanding if they know what the problem is.
• Do tell someone about how you feel. It can be a huge relief to talk to someone understanding. This may be your partner, a relative or friend. If you can't 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 some sleep or rest during the day or night. If you have a helpful partner, relative or friend, ask them to feed the baby at night sometimes. You can use your own expressed breast milk, or formula milk for this.  If you are on your own, try and rest when the baby sleeps.
• Do try to eat regularly, even if you don't feel like eating. Eat healthy food.
• Do find time to do things you enjoy or help you relax - e.g. go for a walk, read a magazine, listen to music.
• If you have a partner, do try to enjoy some time together. If you are a single mother, try to do something enjoyable with a friend or family member.
• Do go to local groups for new mothers or postnatal support groups. Your health visitor can tell you about groups in your area. You may not feel like going to these groups if your are depressed.  See if someone can go with you. You may find the support of other new mothers helpful. You may find some women who feel the same way as you do.
• Do let others help you with housework, shopping and looking after other children.
• Do some exercise. Ask your health visitor if there are any mother and baby exercise classes in your area.  Walking with your baby in the pram is good exercise. Regular exercise can boost your mood.
• Do use self-help books and websites.
• Do contact organisations that support women with Postnatal Depression.
• Don't blame yourself, your partner or close friends or relatives. Life is tough at this time, and tiredness and irritability can lead to quarrels. 'Having a go' at your partner can weaken your relationship when it needs to be at its strongest. The same can happen with other close family or friends who are trying to support you.
• Don't use alcohol or drugs. They may make you feel better for a short time, but it doesn't last. Alcohol and drugs can make depression worse. They are also bad for your physical health.

How partners, family and friends can help

• Don't be shocked or disappointed if your partner, friend or relative says she has postnatal depression. It is common and can be effectively helped.
• Make sure that you understand what postnatal depression is. Ask the health visitor or GP if you need more information.
• It's helpful just to spend time with someone who is depressed.  It is important to listen and to offer encouragement and support. Reassure her that she will get better.
• Take your partner, relative or friend seriously if she talks about not wanting to live or about harming herself. Make sure she seeks help urgently (see section above on Urgent Help).
• Encourage your partner, relative and friend to get the help and treatment she needs.  If you have any worries about treatment, discuss these with the doctor.
• Do all you can to help with the practical things. This includes feeding and changing the baby, shopping, cooking or housework.
• 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 help and support.
• Fathers can also get depressed after the birth of a baby. This may be more likely if the mother also has postnatal depression. If you are a father and think you may have depression, talk to your GP. It is important for you and your family that you get the help you need.

See our Partners in Care leaflet on Postnatal Depression.

Why is treatment important?

Most women will get better without any treatment within 3 to 6 months. 1 in 4 mothers with PND are still depressed when their child is one-year-old. However, this can mean a lot of suffering. PND can spoil the experience of new motherhood. It can strain your relationship with your baby and partner. You may not look after your baby, or yourself, as well as you would when you are well. PND can affect your child's development and behaviour even after the depression has ended. So the shorter it lasts, the better.

Which treatments are available?

The treatment you need depends on how unwell you are. You should be told about all the likely benefits and risks of treatment so you can make the best choice for you.

Treatment includes:

• talking treatments
• medication.

Talking treatments

Talking about your feelings can be helpful, however depressed you are. Sometimes, it's hard to express your feeling to someone close to you. Talking to a trained counsellor or therapist can be easier. It can be a relief to tell someone how you feel. It can also help you to understand and make sense of your difficulties.

Many general practices now have a counsellor. rained health visitors can offer counselling at home in some areas.

There are also 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. You can learn to change these thoughts which has a positive effect on other symptoms. Other psychotherapies can help you to understand the depression in terms of your relationships or what has happened to you in the past.

Some counselling and psychotherapy services will see you more quickly if you have recently had a baby. Ask your GP or health visitor about services in your local area.

Are there problem with talking treatments?

Talking treatments are usually very safe, but they can have unwanted effects. Talking about things may bring up bad memories from the past. This can make you low or distressed. Psychotherapy can put a strain on relationships with people close to you.

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. National guidelines state that women with PND should be seen within a month. In reality, there are often long waiting lists. This means you may not get any treatment for quite a while.

Medication

If you have a more severe depression, or it has not improved with support or a talking therapy, an antidepressant will probably help.

There are several types of antidepressants.  They all work equally well, but have different side-effects. They are not addictive. They can all be used in PND, but some are safer than others if you are breastfeeding. 

Antidepressants take at least 2 weeks to start working. You will need to take them for around 6 months after your start to feel better.

Are antidepressants safe in breastfeeding?

Make sure that your doctor knows that you are breastfeeding. For many antidepressants, there is no evidence that they cause problems for breastfed babies, so breastfeeding is usually possible.

However, the decision is an individual one for each woman. Some antidepressants have been used in breastfeeding for many years.  There is less information about newer medications.  You doctor can provide up-to-date information and advice.

To decide whether to breastfeed when taking an antidepressant, you need to think about:

• how severe your illness is (or has been in the past)
• treatments which have helped you before
• side-effects
• up-to-date information about the safety of medication in breastfeeding
• the benefits of breastfeeding
• whether your baby is very premature or has any health problems
• the impact of the untreated illness on your baby.

What about hormonal treatments?

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 thrombosis (blood clots in their veins).

Alternative remedies

St John's Wort is a herbal remedy available from chemists. There is evidence that it is effective in mild to moderate depression. It seems to work in much the same way as some antidepressants, but some people find that it has fewer side-effects. 

One problem is that St John's Wort can interfere with the way other medications work. If you are taking other medication, you should discuss it with your doctor. This is very important if you are taking the oral contraceptive pill. St John's Wort might stop your pill working. This can lead to an unplanned pregnancy.

There is not enough information to say that it is definitely safe in breastfeeding. Only small amounts get into breast milk, but do not assume that because it is 'herbal', it will be safe. Discuss the risks and benefits of treatment in breastfeeding with your doctor.

References

Antenatal and postnatal mental health: clinical management and service guidance. NICE CG192 (2014) National Institute for Health and Care Excellence: London.

Musters C, McDonald E, Jones L (2008) Management of postnatal depression. British Medical Journal, 337, 399-403.

Dennis CL, Hodnett ED (2007) Psychosocial and psychological interventions for treating postpartum depression. Cochrane Database of Systematic Reviews. Oct. Issue 4.

Organisations that can help

Association for Postnatal Illness

Helpline: 020 7386 0868. Provides telephone helpline, information leaflets and a network of volunteers who have themselves experienced PND.

Depression Alliance

Tel: 020 7407 7584; email: info@depressionalliance.org

Information, support and understanding for people who suffer with depression, and for relatives who want to help. Self-help groups, information, and raising awareness for depression.

Cry-sis

Helpline: 08451 228669. Provides self-help and support for families with excessively crying and sleepless and demanding babies.

Family Action
Tel: 020 7254 6251. Support and practical help for families affected by mental illness, including 'Newpin' services - offering support to parents of children under-5 whose mental health is affecting their ability to provide safe parenting.

Home Start

Tel: 0800 068 6368. Support and practical help for families with at least one child under-5. Help offered to parents finding it hard to cope for many reasons. These include PND or other mental illness, isolation, bereavement, illness of parent or child.

National Childbirth Trust

Helpline: 0300 330 0700. Support and information on all aspects of pregnancy, birth and early parenthood. Local groups and telephone helplines.

Netmums

A website offering support and information on pregnancy and parenting. There is a specific section on offering support. There is also information on local resources and support groups.

Pandas Foundation

An organisation that helps individuals and their families with pre- and postnatal depression advice and support. They also offer support to families in the antenatal period. Helpline (open 9am to 8pm): 0843 2898401.

The Samaritans

24-hour helpline 08457 90 90 90 (UK) or 116 123 (Ireland); Email: jo@samaritans.org.

Confidential emotional support for those in distress who are experiencing feelings of distress or despair, including suicidal thoughts.

Relate

Tel: 0300 100 1234. Relationship support including couple and family counselling. Face-to-face, telephone or online counselling.

The Wellspring Charity Foundation: Fighting UK Poverty

Produces an ante-natal and post-natal information pack.

Further Reading

Overcoming postnatal depression: a five areas approach by Christopher Williams, Roch Cantwell and Karen Robertson, Hodder Arnold (2009) Coping with postnatal depression by Dr Sandra Wheatley, Sheldon Press (2005) Surviving postnatal depression by Cara Aitken, Jessica Kingsley Publishers (2000) Feelings after childbirth: the NCT book of postnatal depression by Heather Welford, NCT Publishers (2002)

Produced by the Royal College of Psychiatrists' Public Education Editorial Board.

 

For a catalogue of public education materials or copies of our leaflets contact: Leaflets Department, The Royal College of Psychiatrists, 21 Prescot Street, London E1 8BB, Telephone: 020 3701 2252.

 

Charity registration number (England and Wales) 228636 and in Scotland SC038369.