Clinical Review - Postnatal depression

By Dr K Thyarappa Praveen, specialty registrar in psychiatry at Broadway House, Bridgwater, Somerset, and Dr Sanju George, consultant and senior research fellow in addiction psychiatry, The Bridge substance misuse service, Birmingham and Solihull Mental Health NHS Foundation Trust

Many women with PND are undiagnosed and untreated
Many women with PND are undiagnosed and untreated

Section 1 Epidemiology and aetiology
Depressive disorder in women within 12 months of childbirth is referred to as postnatal depression (PND).

Although it is similar in symptomatology to depression outside the postnatal period, because of physiological, psychological and social factors unique to the postnatal period, PND is often thought of as a distinct clinical entity.

While prevalence figures vary, it is estimated to affect about one in eight women.1 It is a common cause of maternal morbidity, significantly affecting maternal functioning and quality of life, and is the leading cause of maternal mortality in the UK.2

Effect on relationships
PND can adversely affect maternal bonding, childcare, relationships with family and friends, and the child's emotional, cognitive and behavioural development.

Most women with PND present initially not in specialist perinatal psychiatric services, but in non-specialist settings, often primary care. More importantly, for a range of reasons such as lack of awareness, stigma, fear of their baby being taken away and other patientand clinician-related factors, many post-natally depressed women go undiagnosed and untreated.

This is worrying because there are effective psychological and pharmacological treatments, and better outcomes can be achieved if PND is treated early.

Most women can be successfully managed in primary care.3

Section 2 Diagnosis
It is essential to identify those who are at increased risk of PND but not yet depressed. Risk factors include prior history of depression or mental illness; low mood and anxiety during pregnancy; poor social support; and recent life events. It is crucial that these are looked for during assessment.

Women identified as being at risk for PND should be monitored and, if symptoms develop, referred for further assessment and management.

Two of the more common screening tools are the Edinburgh Postnatal Depression Scale (EPDS)4 and the Beck Depression Inventory (BDI-II).5

The EPDS, a 10-item self-report scale, is easy to use and quick to complete. Each item is scored from zero to three and a cut-off of 13 or more is most commonly used to detect severe depression.6

BDI-II is a 21-item self-completion scale with good sensitivity and specificity measures. Each item on the BDI-II is scored zero to three and a total score of 14-19 indicates mild depression, 20-28, moderate depression and more than 29, severe depression.

A comprehensive clinical interview, comprising a detailed medical, psychiatric, family, personal and social history, risk assessment (mother and baby) and overall assessment of the baby, is the cornerstone and should inform the formulation of a management plan.

The symptoms of depression are the same, whether they appear in the postnatal period or not (see box below).

Criteria for diagnosing depression

Major criteria

  • Low mood, lack of pleasure and low energy.

Minor criteria

  • Low self-confidence, thoughts of suicide or attempts, poor concentration, guilt feelings, loss of appetite, sleep disturbance and psychomotor agitation or retardation.

Making the diagnosis

  • For a diagnosis of depression, symptoms must be present continuously for a minimum period of two weeks.
  • For mild depression, four symptoms should be present, with at least two from the major criteria.
  • For moderate depression, six symptoms should be present, with at least two from the major criteria. For severe depression, eight symptoms should be present and all three major criteria should be present.
  • Depression may or may not present with biological symptoms such as early morning waking, weight loss, diurnal variation of mood, loss of libido, marked loss of appetite, marked loss of interest, lack of emotional reactivity and psychomotor retardation or agitation. The depressive episode is accordingly described as one with or without biological symptoms.

In this context, it is crucial to distinguish PND from postnatal blues, a common and normal transient condition, and postnatal psychosis, a rare and severe psychotic disorder occurring in the postnatal period (see box below).

POSTNATAL PSYCHIATRIC DISORDERS

POSTNATAL BLUES (BABY BLUES)

  • Prevalence: Up to one in two.
  • Symptoms: Restlessness, fatigue, tearfulness, anxiety.
  • Onset, duration and course: Symptoms peak four to five days postpartum, but condition rarely persists beyond 10 days.
  • Treatment modality and setting: Self-limiting; no treatment required.
  • Risk of recurrence: No clear evidence of increased recurrence.

 

POSTNATAL DEPRESSION

  • Prevalence: One in eight.
  • Symptoms: Pervasive low mood, lack of pleasure and energy, feelings of guilt, low self-confidence, agitation, anxiety, sleep and appetite disturbance, suicidal ideation.
  • Onset, duration and course: Symptoms persist for a minimum of two weeks. Usual onset is within one to six months of child birth. Course of illness may vary.
  • Treatment modality and setting: Psychological therapy, social support, antidepressant medication. Most patients can be managed in primary care and in the community. Severe depression may need inpatient treatment.
  • Risk of recurrence: Increased risk of recurrent depression.


POSTNATAL (PUERPERAL) PSYCHOSIS

  • Prevalence: One in 500.
  • Symptoms: May present as severe depression with symptoms of psychosis, such as hearing voices, muddled thinking, confusion or strange beliefs about the baby. May also present as mania, with symptoms such as increased energy, irritability, and less need for sleep and food. The patient may be overactive, overconfident and talkative. Rarely, it may present as a combination of the two or as a primary psychotic episode.
  • Onset, duration and course: Onset is usually in the first few days following childbirth. Course of illness may vary.
  • Treatment modality and setting: Antipsychotics, antidepressants, mood stabilisers and so on. Likely to need early inpatient management because of risk to mother and child.
  • Risk of recurrence: Up to half of patients may have recurrent episodes.

Section 3 Management
The type of intervention (support and monitoring, psychological and/or pharmacological treatments) and the setting in which it is provided depend largely on the severity of the PND.

The severity will also determine which professionals are involved in the care of the mother and the baby.

In some cases, dictated by the risk assessment, social services may also be involved. But it is important to remember that most postnatally depressed women can be successfully managed in primary care.

For women at risk of PND, some interventions have been shown to be particularly effective.

NICE guidance recommends offering brief individual psychological therapies, such as interpersonal therapy (IPT) or cognitive behavioural therapy (CBT) and social support through informal individual and/or group support.3

Antidepressants should only be considered if there is a past history of severe depression.

It is also recommended that such women be closely monitored and active liaison with perinatal mental health services be established.

For women with mild PND, non-pharmacological interventions, such as brief IPT or CBT, self-help strategies (exercise, computerised CBT) should be considered. For women with moderate depression, structured IPT or CBT should be considered.

NICE also recommends that pregnant and breastfeeding women needing psychological therapies should be started on such therapies within one month of initial assessment.3 Additionally, antidepressant medication could be considered for those who request it.

For women who have been experiencing severe depressive symptoms, antidepressant medication should be considered at an early stage after discussing the potential risks and benefits.

Referral to specialist perinatal mental health services should be considered if the patient is not responding to treatment, if there is a need for specialist prescribing, or if the patient develops puerperal psychosis and there are concerns about the welfare of the baby.

Section 4 Breastfeeding in postnatal depression
Breastfeeding is not contraindicated in women with PND, except in certain rare circumstances. However, it is important to bear in mind some general principles.7

Most antidepressants are excreted only in small amounts in breast milk and are unlikely to harm the baby.

This only applies provided the baby is mature and healthy with no renal or hepatic dysfunction.

SSRIs such as sertraline and paroxetine have a good safety profile.

Any decision regarding antidepressant treatment should only be taken jointly with the patient and after giving a full explanation of the benefits and potential risks.

At a practical level, the woman should be advised to take her antidepressant medication just before the baby's longest sleep cycle. The baby should be monitored for possible adverse reactions and if there is any doubt about prescribing, specialist advice should be sought.

Early detection
PND is common and most women present initially to the non-specialist. Effective screening and brief assessment can improve early detection rates.

Early intervention in the form of psychological and/or pharmacological treatments, often in primary care, can successfully treat most postnatally depressed women. Referral to specialist perinatal mental health services is required only in severe cases and for women not responding to routine treatment.

Resources

1. O'Hara MW, Swain AM. Rates and risk of postpartum depression: a meta-analysis. Int Rev Psych 1996; 8: 37-54.

2. Lewis G, Drife J. Why Mothers Die 2000-2002: The Sixth Report of Confidential Enquiries into Maternal Deaths in the United Kingdom. London, CEMACH/Royal College of Obstetricians and Gynaecologists, 2004.

3. NICE. Antenatal and postnatal mental health: clinical management and service guidance. CG45. London, NICE, February 2007.

4. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psych 1987; 150: 782-6.

5. Beck AT, Steer RA, Brown GK. Manual for Beck Depression Inventory-II. San Antonio, Texas, Psychological Corporation, 1996.

6. Gaynes BN, Gavin N, Meltzer-Brody S et al. Perinatal depression: prevalence, screening accuracy, and screening outcomes. Evidence Report/Technology Assessment (Summary) 2005; 119: 1-8.

7. Kohen D. Psychotropic medication and breast-feeding. Advances in Psychiatric Treatment 2005; 11: 371-9.

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