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Postnatal depression: a priority for service development

Cheryll Adams
D(Nurs) MSc BSc(Hons) RN RHV Dip Man
Independent Adviser, Nursing Health Visiting and Community Health Policy and Practice
Honorary Senior Visiting Lecturer
City University

One of the casualties from the recent reduction in health visitor numbers has been the closing of services run by health visitors for depressed mothers. Cheryll Adams discusses the reasons why this may be counterproductive

The common figures given for the incidence of postnatal depression (PND) are 10-15%, or an average of 13% of mothers.1 This debilitating condition may not only affect the mother, but also her children and her partner. In the longer term we now know it can also have a significant impact on the economy. However, while incidence measures PND at a point in time, it doesn't consider how many mothers may be affected by depression in the first year of their child's life.

Surveys of mothers by parenting website Netmums and the Family and Parenting Institute would suggest that the number of mothers actually suffering some degree of PND in the first year of a child's life is very much higher - possibly as much as 52%.2,3 This higher prevalence has been supported by the millennium cohort study, which found 32.6% of mothers reporting that they had suffered depression.4

It is essential to understand that postnatal depression is different from the common, but much milder, and normally insignificant “baby blues”, occurring a few days after the baby's birth. It is also different from the much more severe, but uncommon puerperal psychosis, which is marked by psychotic episodes, again, usually shortly after birth, and which always requires urgent medical treatment. Other, not uncommon, emotional disturbances can also occur in the postnatal period, such as anxiety and post-traumatic stress disorder, these tend to receive less attention in the popular media than does postnatal depression.

Causes
Many symptoms of PND are reported, but mostly they are symptoms that can be associated with any normal depression. Today, postnatal depression is frequently thought of as depression occurring at a vulnerable time in the mother's life, often triggered by circumstances related to becoming a parent. For example, the baby may be initially unwanted - perhaps arriving at an inconvenient time in the mother's life (or career); it may be causing restrictions on the mother's lifestyle that she finds unacceptable; or its arrival may expose difficulties in the relationship between parents. However, there are many different reasons why a mother becomes depressed, including the infant having unsettled behaviour.
Risk factors for postnatal depression include:

  • Previous psychiatric history or a family history of depression.
  • Antenatal depression.
  • Relationship difficulties.
  • Recent traumatic events, such as a very difficult delivery or the loss of a loved one.

Typically, the incidence of PND peaks at around three to four months post birth, but it may occur at any time during the first postnatal year, and we now know that depression is not uncommon in the antenatal period.5 There is also increasing evidence that there is a significant incidence of depression in new fathers, frequently secondary to the mother's
depression.

Effects
Untreated postnatal depression may have an impact, not only on the mother, but also on her baby, children, partner and, ultimately, if effects become long term, on the economy. The effect on the economy is as a result of increasing the fiscal spend for health and wellbeing, and reducing both the mother's and the child's later contributions to the economy
and society.

As well as experiencing the symptoms of the illness, the depressed mother may find her whole quality of life affected, disrupting and disturbing social opportunities, her parenting capacity and her relationship with her partner. Unsurprisingly, postnatal depression is frequently identified as a factor when children are found to be neglected.

Cohort research studies have demonstrated that the babies of mothers who are persistently depressed during their early years are more likely to have behavioural problems, cognitive delays, to express violence as teenagers, and to themselves be vulnerable to emotional illness.6-8 These problems relate to the mother's difficulty in responding to her child's emotional needs while she is depressed.

Treatment
If this is such an important and expensive condition when it is left untreated, which services should be in place to support mothers? Clearly, many mothers will attend their GP when they are depressed and are likely to be offered antidepressants, which can be an effective treatment, although we know compliance is poor. Some GPs can also offer counselling which is a more popular treatment. However, the real challenge is that many depressed mothers will not be aware that they are depressed, will suffer from agoraphobia as a result of the depression and will not attend their GP until their depression is in a more advanced and destructive form. There is also evidence to suggest that, often, the presence of PND is not detected by GPs when the mother attends for other reasons.
It is very important that services are in place to detect PND as early as possible. Research has confirmed that detecting and managing PND within a universal health visiting service is a very effective management strategy.9 A recent study also suggests that a good-quality health visitor service is a more cost-effective approach to managing mild-to-moderate depression than simply relying on primary care support.10
 
However, the normal methods for detecting PND are not simple. The difficulties lie in the words “screening” and “assessment”. The National Screening Committee is clear that there is, currently, no suitable method of screening women at population level for the presence of PND.

The National Institute for Health and Clinical Excellence (NICE) guideline, Antenatal and postnatal mental health, recommends the use of two initial screening questions (Whooley questions) to detect possible depression in any mother; but this advice was decried by experts in the field.11 The reason for the controversy is the presence of so-called false positives and false negatives when you attempt to screen a population for the presence of PND. To be an effective screening tool these should be minimal, otherwise it will pick up some individuals inappropriately and miss others with the condition.

A more accurate way to identify PND is through holistic assessment, which is strengthened when the assessing professional already knows the mother and has a relationship with her. Not only does this allow for the mother to feel confident to disclose the truth about how she is feeling to a trusted professional, but it also allows the professional to compare her emotional health at any point in time to any other point in time, which enhances the assessment process.
 
The Healthy Child Programme states that all professionals in contact with new mothers should review their mental health regularly, as recommended by NICE.12 In particular, it recommends a formal assessment at four to six weeks and three to four months, to be followed by eight contacts for non-directive or other counselling, or other treatment, should the mother be found to be depressed.

The Community Practitioners' and Health Visitors' Association (CPHVA) published guidelines for the detection of postnatal depression by health visitors in 2002.13 They recommend use of the Edinburgh Postnatal Depression Scale as an assessment framework supported by the clinical interview, the tool commonly used to detect depression in primary care.14 There have been many examples of misuse of the Edinburgh Scale when it is used alone a screening tool, rather than a framework for detecting depression.

When a mother is found to be depressed what should happen next? There are a number of possible interventions that may be effective, and which should be based on patient preference and the severity of the depression. A mild depression may be self-limiting, or if the cause is clear, perhaps extreme tiredness, loneliness or a lack of confidence in the maternal role can easily be rectified by the health visiting or primary care team through access to the right support.

Moderate or severe depression will require more formal intervention in the form of counselling, family support and/or antidepressant medication. Many health visitors are trained to deliver a range of counselling interventions, in particular non-directive counselling and cognitive behavioural therapy. They are also skilled in helping the mother address some of the potential causes of the depression. They are also well placed to assess the impact of the depression on the family, particularly the mother-child relationship and to initiate additional supportive interventions as necessary.

It is important that the primary care team work closely together to determine the most appropriate intervention for each mother and family. Other helpful interventions can be attendance at therapeutic groups for the more seriously depressed mothers, or support groups for the more moderately affected. Exercise, such as walking or swimming is a very good method of managing depression once the individual can be motivated to undertake it. Learning baby massage will enhance the mother's relationship with her infant.

Conclusion
So what are the levers for improving services for depressed mothers? As discussed above, the NICE guidance and the requirements of the Healthy Child Programme are particularly helpful. Furthermore, addressing postnatal depression is now prioritised in the new government policy for public health, Healthy Lives, Healthy People.15 Increasingly, as more research is published, it seems likely that both the economic arguments, as well as the evidence of potential long-term effects on the child from having a depressed mother, may be the arguments commissioners will best understand.

References

  1. O'Hara MW, Swain AM. Rates and risk of postnatal depression: a meta-analysis. Int Rev Psychiatry 1996;8:37-54.
  2. Family and Parenting Institute (FPI). Health visitors - an endangered species. London: FPI; 2007.
  3. Netmums. A Mum's Life. Available from: www.netmums.com/campaigns/A_Mum_s_Life.656/
  4. Centre for Longitudinal Studies (CLS). Millennium Cohort Study. London: CLS; 2004.
  5. Evans J, Heron J, Francomb H, Oke S, Golding J. Cohort study of depressed mood during pregnancy and after childbirth. BMJ 2001;323;
  6. 257-60.
  7. Avan B, Richter LM, Ramchandani PG, Norris SA, Stein A. Maternal postnatal depression and children's growth and behaviour during the early years of life: exploring the interaction between physical and mental health. Arch Dis Child 2010;95(9):
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  9. Hay DF, Pawlby S, Angold A, Harold GT, Sharp D. Pathways to violence in the children of mothers who were depressed postpartum. Dev Psychol 2003;39(6):1083-94.
  10. Halligan SL, Murray L, Martins C, Cooper PJ. Maternal depression and psychiatric outcomes in adolescent offspring: a 13-year longitudinal study. J Affect Disord 2007;97(1-3):145-54.
  11. Morrell CJ, Slade P, Warner R et al. Clinical effectiveness of health visitor training in psychologically informed approaches for depression in postnatal women: a pragmatic cluster randomised trial in primary care. BMJ 2009;338:a3045.
  12.  Bauer A, Knapp M, McDaid D. Health visiting and reducing postnatal depression. In: Knapp M, McDaid D, Parsonage M (eds). Mental health promotion and prevention: the economic case. Personal Social Services Research Unit; 2010.
  13. NICE. Antenatal and postnatal mental health: clinical management and service guidance. London: NICE; 2007.
  14.  DH. Healthy Child Programme from 5 to 19 years old. London: DH; 2009.
  15.  Coyle B, Adams C. The EPDS: Guidelines for its use as part of a maternal mood assessment. Community Practitioner 2002;75(10):394-5.
  16.  Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987;150:782-6.
  17.  DH. Healthy Lives, Healthy People. DH: London; 2010.