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A brief encounter with the paranormal: postnatal depression

Melissa came to my drop-in clinic one Monday morning. She had gone to bed the previous night and felt a tightness in her chest, which had increased until she felt unable to breathe. She had gone to hospital where she was nebulised and prescribed a Salbutamol inhaler, with advice to see her GP at the earliest opportunity. With no free appointments, she had arrived in my room ...

Janet Webb
BSc(Hons) RGN
DiPN(Lond)
Practice Nurse
Lindum Medical Practice
London

Visibly anxious, Melissa clutched her Salbutamol inhaler and perched on the edge of her chair to recount her story. She is slightly built, aged 32 and married with a six-week old baby girl. She is an occasional smoker with no previous pulmonary or atopic history, and no family history, currently on maternity leave from her clerical job. The dyspnoea had apparently started spontaneously. She had felt instant relief from the nebuliser therapy, and had gone back home and slept, woken normally that morning and her husband had gone to work, but she had used the inhaler six times since waking that morning in case the dyspnoea returned. It was still only 10.20am. 

I suggested using the inhaler only to relieve symptoms, as its effect tended to last between three and five hours, and that an ideal maximum would be eight puffs in 24 hours. It occurred to me that her apparent anxiety and tension could well be side-effects of that morning's six doses.1 Her peak flow exceeded predicted by 20 L/min and her blood pressure was normal, though her pulse was somewhat rapid, at 102 bpm.

There was no tachypnoea, she could complete long sentences, and no wheeze on auscultation. So: panic attack or bronchospasm from atopic asthma?2 I suggested bringing her back when she hadn't used the inhaler for at least four hours to do a reversibility test to exclude asthma.  

When Melissa returned, I spent the 15 minutes between her pre- and post-Salbutamol peak-flow readings gaining a clearer picture of her problem. She was still tense and anxious, despite not having used the Salbutamol all day. I asked if anything else was troubling her, anything on her mind that could have triggered the attack – I wondered now about postnatal depression.3 She was quiet for several seconds, averting her gaze and rubbing her hands. When she turned back, her bottom lip was trembling and the tears soon followed as she sobbed, "I just want to see my baby grow up. I don't want to die."
Supplying a wad of tissues, I tried to reassure her how completely normal that was. She went on to say that she knew something would go wrong, things had seemed too perfect; a loving husband with a good job, a new house, a nice car and now her perfect little girl.

After more sobbing she recounted an evening out the previous week with some workmates, the first since giving birth. They had had a pub meal, and then gone outside for a cigarette. She had taken their glasses back into the bar as the others had left, when another customer took her to one side, saying that she was a medium. She hoped Melissa would understand but had to tell her that she could "see" cancer in her, and that it would affect either her lung or throat. With that, she had gone, and Melissa was left to drive home. She hadn't mentioned the conversation to her husband Mark until the following evening, when he had dismissed the woman as a "nutter". Melissa had continued to worry, lying awake at night becoming increasingly upset until the crisis of that Sunday night.

There was, as expected, no reversibility to Salbutamol. I wondered whether the woman might simply be an avid antismoking campaigner who had noticed Melissa outside smoking. Melissa asked why she had singled her out, if that were the case.

I am a devout sceptic. I know how gullible people can be. Some years ago at a village fundraiser, I had been the fortune teller, and equipped with a glass paperweight (crystal ball) and a shawl, had charged 10p for my predictions of lottery wins and future love interest. A man came in and asked for a palm reading. Putting on my mystical voice I told him he worked hard but worried about money, but to stop worrying as everything was going to turn out well for him. I realised he was taking it seriously when he asked where I normally did readings. He refused to believe that I was making it all up as a bit of fun to raise funds. It all got a bit surreal.

I arranged an appointment for Melissa with a doctor, giving me chance to talk to him first. He agreed that statistically the woman was wrong – there are more people without cancer than with it – but what if? Would we be right to dismiss it if Melissa was worried enough? Would we make matters worse to proceed with investigations or leave her not knowing? He would offer her the choice of referral for X-rays and laryngoscopy.

Well, Melissa took up the offers and, as expected, had normal results. It's now five months since I first saw her. She's been on fluoxetine for four months, and had her first appointment with a clinical psychologist last week. Her relationship with Mark is deteriorating since she feels she is letting him down, and thinks he considers her to be crazy. She can't face going back to work. Melissa suspects Mark thinks she invented the woman in the pub; I can't deny having had similar thoughts myself, it seems so bizarre. I don't have any answers. At least she's stopped smoking!

References
1. BMA. British National Formulary 57, March 2009:193.
2. Family Practice Notebook. Asthma. Available from: http://www.fpnotebook.com/Lung/Asthma/Asthm.htm
3. Net Doctor. Postnatal Depression. Available from: http://www.netdoctor.co.uk/pregnancyandfamily/depressionpostnatal.htm