Postnatal depression

It is important to clarify who is responsible for managing postnatal depression, advises Dr Carolyn Chew-Graham.

Postnatal depression is a non-psychotic depressive episode meeting standardised diagnostic criteria, beginning in or extending to the postnatal period. It affects 8-15 per cent of women and can result in long-term adverse consequences for maternal mood and infant development.1

An episode of major depression may have detrimental consequences for relationships and reduce confidence in parenting. Only severe cases are referred beyond primary care.

Postnatal depression should not be confused with 'baby blues', which is the tearfulness that commonly occurs in the first few days after delivery. The recently published NICE guidelines for antenatal and postnatal mental health use the term 'perinatal mental disorder', recognising that symptoms may begin in the antenatal period, and outline the potential role of all healthcare professionals in the detection of depression.2

It is important to distinguish postnatal depression from postnatal blues

Making the diagnosis
There is no evidence that mild-to-moderate depression is any more common after childbirth than in the postpartum population, nor are the clinical features or management any different.3

The role of the GP is to assess the woman in the same way as any patient in whom depression is suspected. It may be that the woman volunteers feelings of sadness and low mood, but the GP needs to be aware of the need to explore depressive symptoms in appointments antenatally, at the postnatal check, in routine baby checks and appointments for the child (particularly if the child is presented frequently).

Depressive symptoms such as low mood, poor concentration, anxiety, guilt, low confidence or sleeping problems must be explored. The GP must take a relevant history, including the duration and severity of symptoms, previous history of depression, and the outcome of any treatment and the presence of any co-morbidities.

The GP may, following exploration of symptoms, use the Patient Health Questionnaire 9 (a self-administered diagnostic tool) to assess severity of depression. Any risk posed to the mother or baby should also be assessed.

Screening
It has been suggested that health visitors should screen for postnatal depression using the Edinburgh Postnatal Depression Scale (EPDS, see box on page 33). How widely the EPDS is used by health visitors is not known, but there may be confusion between health visitors and GPs about whose responsibility it is to make the diagnosis of, and manage, women with postnatal depression.4

The NICE guidelines suggest that health professionals should be screening women for depression during pregnancy and for the first year after birth using the questions that are used in consultations with patients with chronic conditions (see box above).

Management
The NICE guidelines stress the need for a trusting relationship between clinician and mother and the provision of culturally sensitive information to women, including discussion of the impact of the disorder and its treatment on the health of the woman and baby.

Management options include psychological interventions (talking treatments) and/or antidepressants. Evidence for the effectiveness of psychological interventions is limited, but it is thought that women may prefer talking treatments to medication.5

It is recognised that availability of psychological therapies may be limited and so may restrict what GPs can offer to women. GPs can, however, refer women to the many useful websites, self-help groups run by health visitors or the voluntary sector, and GPs should familiarise themselves with what is available locally. Some primary care mental health teams will offer short-term intervention for women with mild-to-moderate postnatal depression and some PCTs commission innovative services to support women postnatally, with a broader psychosocial approach and the offer of childcare facilities. Referral to Sure Start programmes may be appropriate, but evaluation of such programmes has been disappointing.5

Antidepressants
When prescribing antidepressants, it is important to take account of patient preference, as well as past experience of treatment, and special issues such as breastfeeding and sedation.

Careful monitoring of symptoms, side-effects, suicide risk and risk to baby should be routine, especially early in treatment. First-line treatment should be an SSRI rather than a tricyclic antidepressant because they are less toxic in overdose and less likely to be discontinued because of side-effects.

If the woman is breastfeeding, fluoxetine is not recommended because of its long half-life and higher levels in breast milk, although harmful effects on breastfed babies have not been detected in case reports. There is most experience with sertraline and citalopram in breastfeeding mothers, and women can be reassured that no harmful effects have been reported.

Implications for practice
Practices might want to consider postnatal depression as a topic for in-house training. Consider who has responsibility for the management of postnatal depression, what services are available in your area, whether you provide women with enough information, and whether you have training needs yourselves.

Unless practices take ownership of the management of postnatal depression, then commissioning will follow NICE guidelines, which suggest the establishment of a specialist multidisciplinary perinatal service in each locality.

Such specialised services may, of course, improve care through service provision as well as the introduction of protocols and care pathways, educational initiatives and training for primary care teams. It could, however, lead to fragmentation of care and further reduce the role of the GP in the management of women with postnatal depression. 6

  • Dr Chew-Graham is a GP, senior clinical lecturer in primary care, at the University of Manchester and RCGP clinical champion for mental health

Detection of postnatal depression
At a woman's first contact with primary care, at her booking visit and postnatally - usually at 4-6 weeks and 3-4 months - healthcare professionals (including midwives, obstetricians, health visitors and GPs) should ask two questions to identify possible depression:

  • During the past month, have you often been bothered by feeling down, depressed or hopeless?
  • During the past month, have you often been bothered by having little interest or pleasure in doing things?
  • A third question should be considered if the woman answers 'yes' to either of the initial questions: Is this something you feel you need or want help with?

EPDS questions and scoring

  • I have been able to laugh and see the funny side of things.
  • I have looked forward with enjoyment to things.

Answered with one of the following: 0 Yes, quite often; 1 Sometimes; 2 Hardly ever; 3 Never

  • I have blamed myself unnecessarily when things went wrong.
  • I have felt worried and anxious for no very good reason.
  • I have felt scared or panicky for no very good reason.
  • Things have been getting on top of me.
  • I have been so unhappy that I have had difficulty sleeping.
  • I have felt sad or miserable.
  • I have been so unhappy that I have been crying.
  • The thought of harming myself has occurred to me.

Answered with one of the following: 0 Never; 1 Hardly ever; 2 Sometimes; 3 Yes, quite often;

A score over 12 may indicate postnatal depression.

References

1. Hay D, Pawlby S, Sharp D et al. Intellectual problems shown by 11-year-old children whose mothers had postnatal depression. J Child Psychol Psychiatry 2001; 42: 871-90.

2. NICE. Antenatal and postnatal mental health. Guideline 45. DoH 2007.

3. O'Hara M W, Swain A M. Rates and risk of postnatal depression: a metanalysis. Int Rev Psychiatry 1996; 8: 37-54.

4. Chew-Graham C A, Chamberlain E, Turner K et al. General Practitioners' and Health Visitors' views on the diagnosis and management of postnatal depression: a qualitative study. Br J Gen Pract 2008, 58: 169-76.

5. Belsky J, Melhuish E, Barnes J et al. Effects of Sure Start local programmes on children and families: early findings from a quasi-experimental, cross-sectional study. BMJ 2006; 332: 1,476.

6. Derrett C, Burke L. The future of primary care nurses and health visitors: Increasing fragmentation threatens the primary healthcare teams. BMJ 2006; 333: 1,185-6.

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