Microsoft word - post natal depression research 05.03.07.doc
Professionals tend to refer to this group of illnesses as "puerperal psychoses". "Puerperal" means the six weeks after having a baby and "psychosis" a serious mental illness. So "Puerperal psychosis" means a serious mental illness, developing in a woman shortly after she has given birth. This is often a shock, because there is no obvious reason why it should happen - it's not that the baby was unwanted, or that the pregnancy or birth were complicated or, as a rule, that there is anything wrong with the baby. Puerperal psychosis is rather rare and happens after only 1 in 500 births. It has been recognised for centuries - since the days of Hippocrates, the Greek physician who practised thousands of years ago. A woman is most likely to be affected if she has already experienced such an illness previously, or if someone in her family has suffered a mental illness, serious enough to have involved psychiatric treatment. It used to be thought that puerperal psychosis was a special mental illness, unlike those occurring at other times. However, it is now recognised to be manic-depression or schizophrenia - although somewhat altered by the baby's presence. There are three main illnesses that happen during this time. MANIA
A mother suffering from mania will be full of energy and confidence, even if she has never had a baby before. She will not rest, will tend to stay up all night, and will eat little, even though she is so active and talkative. She will tend to neglect her baby because she feels that she has so many other things to do - shopping, making plans, rearranging her home and her life. Though mostly cheerful and amusing, she may become very irritable if her unrealistic plans and impulses are - as is almost inevitable - thwarted. Both she and her baby are at serious risk of neglect. DEPRESSION
A seriously depressed mother is very different. She will be deep in misery, to the point of despair, and have little energy or initiative, although she may be restless with frantic agitation. Feelings of guilt, wickedness and worthlessness are common, as is the feeling that other people think this of her. She will eat very little and sleep poorly, with a tendency to wake up early in the morning (often at about 3am) feeling at her absolute worst. Not surprisingly, she may be suicidal. Rarely, a mother will kill her baby as well as herself. The law on infanticide recognises that a woman who kills her baby within a year and a day of giving birth may be mentally ill.
Schizophrenia is a remote dreamy state in which a mother's thoughts and feelings are muddled. She may believe that everything that happens around her, is in some special way connected with her. She may also hear voices talking to or about her and her baby, and believe that her baby is strange - a changeling, or the devil, or even a new Messiah. She may feel that she is under the influence of others who may wish her good or harm. This mixture of muddled thinking and strange ideas can make it difficult for other people to make sense of what she says. She may neglect her baby or do odd things with it or she may be fiercely protective, shielding it from people whom she thinks want to harm it. These different forms of mental illness sometimes merge or replace each other - mania may be followed by depression, or schizophrenia may have manic or depressive features. WHY DOES IT HAPPEN?
Puerperal psychosis is most likely to be due to the effect of the huge hormone changes which happen at the end of pregnancy and giving birth. The risk of developing this illness is highest around the time of the birth - especially during the first few days afterwards. Some women seem to be born with a tendency to develop puerperal psychosis, others may be vulnerable because of earlier experiences in their lives. CAN IT BE HELPED?
This kind of mental illness is serious, but it responds very well to the proper treatment and the outlook is excellent. The most important thing is that it is recognised sooner rather than later. This means that obstetricians, general practitioners, midwives and health visitors need to know both that psychosis happens, and how to recognise the warning signs - severe sleeplessness, extreme withdrawal or restlessness. When a woman is going to have a baby, it is very important that she is asked if she, or any members of her family, have experienced mental illness in the past. If there is any suspicion of such an illness developing, a psychiatrist needs to become involved. WHAT IS THE TREATMENT?
The psychiatrist is concerned with the welfare of the mother, baby and the immediate family. He or she will want to treat the mother in hospital, though in some parts of the UK it is possible to offer treatment at home - provided that the mother is not too disturbed - that is suicidal or irrational. If possible the baby will be admitted with the mother, so that the bonding between the two is not disrupted. They might be admitted to one of the country's few mother-and-baby units, or else to an ordinary acute admission ward with a nursery facility. Drug or physical treatment is always needed for puerperal psychosis. Speed is of the essence to ensure that the relationship between mother and baby is disturbed for as
little time as possible. The effects of psychological treatments are not usually evident for weeks, or more often months, whereas drug and physical treatments work within days or weeks. The usual medications used are anti-depressant and anti-psychotic drugs. The only physical treatment is electroconvulsive therapy (ECT) which although may sound alarming, is extremely effective in severe depression and may be life-saving. We can't just use hormones because we don't yet understand the ways in which the hormone changes work. However they may have some effect in preventing another puerperal psychosis in women who have already suffered one. Breast feeding is a powerful bond between mother and baby, so drugs which come through the breast milk should be avoided. Fortunately, anti-depressants appear in the breast milk in such tiny amounts, they need not stop that form of feeding and ECT is no barrier at all. However Lithium Carbonate which is the most powerful treatment for manic depression, does come through in breast milk, so if it is needed, bottle feeding may be necessary. HOW CAN OTHER PEOPLE HELP?
A serious mental illness such as puerperal psychosis, is a huge handicap to a new mother. It is important to help her in doing things with and for her baby, for example, feeding, washing, nappy changing and simple playing. The psychiatric team will do their best to help mother and baby come together happily, whilst reducing the risk of violence or neglect. Partners and families need support too, to stop them blaming themselves or feeling resentful, apprehensive or guilty. Other people may also be able to give support - the extended family, the GP or other members of the primary health care team, the health visitor, the community psychiatric nurse or psychiatrist, and social worker ( if there is thought to be any risk to the baby). There are also voluntary groups, like the Association for Post Natal Illness, whose members are women who have survived puerperal psychosis or post-natal depression, and who are ready to befriend and support other sufferers. HOW LIKELY IS IT TO HAPPEN AGAIN? The risk of having another puerperal psychosis is at least 1 in 5 - probably greater still in the case of manic-depression. Careful supervision is needed if a woman who has had such an illness, has another baby, especially in the early days after the birth. Treatment can then be given at once if there is any sign of the illness returning. However half the women who suffer a puerperal psychosis never become mentally ill again. 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. Sometimes, there may be an obvious reason, often there is none. It can be particularly distressing when you have so 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. How common is it?
Around one in every ten women have PND after having a baby. If untreated, it can last for months, or sometimes longer. 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. Sometimes, there are good days that make you hope that it is over. It can be very disappointing when they are followed by bad days. Sometimes, it can seem that life is not worth living. Irritable You may get irritable with other children and, occasionally, with your baby. You are most likely to get 'ratty' with your partner, who may well wonder what is wrong. Tired All new mothers get pretty weary, but depression can make you feel so utterly exhausted that you feel physically ill. Sleepless When, at last, you get to bed you find you can't fall asleep. You wake at the crack of dawn, even if your partner has fed the baby overnight. Not hungry Depressed mothers usually haven't the time or the interest to eat, and this can make you feel irritable and run down. On the other hand, if you find yourself eating for comfort, you may feel guilty and uncomfortable about getting fat. Unable to enjoy anything You find that you can't enjoy or be interested in anything. This may be especially true of sex. Some women get interested in sex again before the 6 week postnatal check-up, but PND usually takes away any desire or enthusiasm. Your partner may seek the comfort and excitement of intercourse, but you don't. This can put a further strain on the relationship. There are, of course, many other reasons for you 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 having a child. Unable to cope PND can make you feel that you have too little time, do nothing well, and that you can't do anything about it. It can be hard to establish a new routine to cope with the baby, as well as everything else. Anxious You may find that you are afraid to be alone with your baby. You may worry that he or she might scream, or choke, or be harmed in some way. 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. You may feel anxious even if you have strong loving feelings for your baby. You worry that you might lose him or her through infection, mishandling, faulty development or a 'cot death'. You worry about 'snuffles', or how much weight has been (or not been) gained. You worry if your baby is crying or is too quiet (has the baby stopped breathing?) 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 also worry about your own health. 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. Your tiredness may make you 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. Doesn't everybody get depressed after having a baby?
No. About half the women who give birth 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 the birth, but it can start up to six months later. What causes PND?
We don't know enough about why women get PND to be sure who will or won't suffer from it. There is probably no single reason, but a number of different stresses may add up to cause it. We know you are more likely to have PND if you:
have had depression (especially PND) before
lost your own mother when you were a child
have experienced several stresses in a short period of time. These could be
things like a bereavement, you or your partner losing a job, or housing and money problems.
In spite of this, you can still suffer from PND when none of these things have happened and there is no obvious reason. What about hormones?
In some cases, PND may have something to do with the huge hormone changes which take place at the time of giving birth. Levels of oestrogen, progesterone (and other hormones to do with conception and birth) drop suddenly after the baby is born. How exactly they affect your mood and emotions is not clear. No real differences have been found in the hormone changes of women who do and do not get PND. It may be that some women are more sensitive to these changes than others. Do women with PND harm their babies?
Very rarely. It is more likely (although still uncommon) if a mother has a more severe mental disorder, 'puerperal psychosis'. This is a very serious (but treatable) mental illness which usually comes on within a few days of the birth. The mother may become deluded and feel that her baby is evil. Rarely, she may feel so suicidal that she decides to take the baby's life with her own. Puerperal psychosis is much less common than PND: it occurs only after one birth in 500. It is fortunately very rare for a mother to kill her baby. 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. This is the case in PND. The problem is more likely to be you worry that you might harm your baby, rather than actually doing so. What can be done?
A great deal, but first the depression must be recognised. In the past it has often been overlooked or dismissed as the 'baby blues'. Many depressed mothers don't realise what is wrong with them. They feel ashamed to admit that they are less than thrilled by being a mother. They may think that if they say how they feel, then their baby may be taken away (this won't happen). Now that there is a greater awareness of depression in general, PND should be missed less often. A questionnaire, such as the Edinburgh Postnatal Depression Scale, can sometimes be used. This can help health visitors and GPs to spot PND.
Ways of helping yourself
Say how you feel:
If you feel miserable, irritable, incompetent, frightened and not all that keen on your baby, then tell someone. 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. Don't be frightened by the diagnosis: It can actually be a relief when someone tells you that you have PND. At last you know what is wrong, and that many others have had the same problem. You can be reassured that you will get better in time. It can help your partner, friends and family to know this as well. They will feel more able to help when 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 reveals that she has felt awful since the birth of her baby. Take time to listen sympathetically and make sure that she gets the help she needs. Try not to be shocked or disappointed by a diagnosis of PND. In a way, it is good news because we know it 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. It may be difficult for a while, but it is worth it. Make sure that you are clear about what is happening and that you 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 your 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. 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 spoils the experience of new motherhood, and will strain your relationship with your baby and partner. So the shorter it lasts, the better. It is advisable to diagnose and treat PND as soon as possible. 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. Psychotherapy can help you to understand the depression in terms of what has happened to you in the past. Cognitive Behavioural Therapy can help you to understand the depression in terms of how you think about yourself, the world and other people. 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. Other people have found that therapy puts a strain on their relationship with their partner. It is important to 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 scarce in some areas. There are long waiting lists, so you may not get any treatment for quite a while. What about tablets?
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 four to six months after you start to feel better. How do they work?
Antidepressants affect the activity of two chemicals in the brain, Serotonin (also called 5HT) and Noradrenaline. Do antidepressants have side effects?
Modern antidepressants are safe. They may cause nausea or an increase in anxiety in the early stages, 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. It should be safe to continue breast-feeding as there are antidepressants which do not pass into breast milk to any significant degree, so your baby should not be affected by them. Some people get mild withdrawal symptoms when they stop these medicines, so it's best to come off them slowly. For more information, see our factsheet 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. 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 will be willing to give advice. It is also sometimes helpful to talk over the options with your family or a close friend. It is important that you feel comfortable with the choice of help or treatment. Mothers with special needs
Mothers who have a previous history of mental health problems or physical or learning disability do face additional problems, or, equally challenging, additional scrutiny. They should get whatever help and reassurance they need to maintain their own well-being and that of their baby. Self-help
We don't yet know enough about PND to prevent it in the first place, but certain principles make sense:
DON'T try to be 'superwoman'. Try to do less during your pregnancy and
make sure that you don't over-tire yourself. If you are at work, 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
DO make friends with other couples who are expecting or have just had a
baby; among other things, this could lead to a baby-sitting circle.
DO find someone you can talk to. It helps so much to have a close friend you
can turn to. (If you can't easily find someone, try the National Childbirth Trust or MAMA - their local groups are very supportive both before and after childbirth).
DO go to ante-natal 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 and you can start treatment at once. After the baby has arrived:
DO take every opportunity to get your head down. Try to learn to 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 get enough nourishment. 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. Do not 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 may weaken your relationship when it needs to be at its strongest.
DON'T be afraid to ask for help when you need it. If you have learnt about
PND from ante-natal classes (and leaflets like this), you may spot the warning signs before anyone else.
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.
Written by Dr Hamish McAllister-Williams, MRC clinical scientist, senior
lecturer and honorary Consultant Psychiatrist.
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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 Murray L, Cooper PJ et al (2003) The British Journal of Psychiatry, Vol 182: 420-427
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(1987), Vol. 150 by Cox J L, Holden J M, Sagovsky R (www.wellmother.com/articles/edinburgh.htm)
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postpartum period using the Edinburgh Postnatal Depression Scale? Dennis C L (2004) Journal of Affective Disorders, Vol. 78, no. 2, p. 163-169
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(Cochrane Review). Lawrie T A, Herxheimer A, Dalton K in: The Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd.
Organisations that can help:
Association for Postnatal Depression 145 Dawes Road, Fulham, London SW6 7EB. Helpline: 020 7386 0868; http://www.apni.org/ 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, BM-CRY-SIS, London WC1N 3XX. Tel: 020 7404 5011 (line open 9.00 am to 10.00 pm, 365 days a year); www.cry-sis.com/index.asp Provides self-help and support for families with excessively crying and sleepless babies. Meet-A-Mum-Association (MAMA), 376 Bideford Green, Linslade, Leighton Buzzard, Beds LU7 2TY. Tel: 01525 21704; E-mail: Meet-A- Mum.Assoc@blueyonder.co.uk.; http://www.mama.co.uk/ ; Helpline: 020 8768 0123 (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, Alexandra House, Oldham Terrace, Acton, London W3 6NH. Enquiry line: 0870 444 8707; Breastfeeding line: 0870 444 8708; E-fax: 0870 770 3237; http://www.nctpregnancyandbabycare.com/. Advice, support and counselling on all aspects of childbirth and early parenthood. The Samaritans. Tel: 08457 909090 (UK) or 1850 609090 (Eire); E- mail:mailto:firstname.lastname@example.org; http://www.samaritans.org/. Provides confidential emotional support to any person who is suicidal or despairing. Books
Feelings after birth: The NCT Book of Postnatal Depression by Healther Welford (Book Production Consultants) Surviving Post-natal Depression: At home no-one hears you scream by Cara Aitken (Jessica Kingsley Publishers) Depression after childbirth: How to recognise, treat and prevent postnatal depression by Katherina Dalton (Oxford University Press)
GERIATRIC GYNECOLOGY Karen L. Miller, MD; Morton A. Stenchever, MD; Holly E. Richter, PhD, MD; Evelyn C. Granieri, MD, MPH, MSEd; William C. Andrews, MD, FACOG, FRCOG* Gynecologists play three roles in the health care of women aged 65 and over: surgeon,consultant and therapist for gynecologic disorders, and provider of primary and preventivehealth care. The research reviewed here addresse
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