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Postnatal depression: recognising the signs of "baby blues"

Jane Hanley
PhD RGN RMN DipHV DipCounselling FETC
Lecturer in Primary Care and Public Health
Swansea

Every mother is probably familiar with "the baby blues" and has either experienced it, knows someone who has had it or has heard of it. Once a little known phenomenon it has now become part of our everyday language. It has been described as a "fleeting phenomenon", occurring a few days after the birth.
Childbirth is an intensely emotional event and many mothers may experience postnatal blues as they become overwhelmed by feelings of sensitivity and anxiety, which they are unable to control. However, mothers may be assured that the blues is self-limiting and usually subside within a few days.(1)
However, in one-third of cases, the symptoms of the blues become progressively worse and may develop into postnatal depression. This may occur when the mother is unsupported or the seriousness of her condition has not been recognised

What is postnatal depression?
Many commentators suggest that it is difficult to differentiate the variety of signs and symptoms of postnatal depression from the signs of a classical depression.(2) However, very few women of childbearing age present such feelings of unhappiness outside of their childbirth experience.(3) The insidiousness with which symptoms appear and progress mimics the onset of any depression. However, unlike the traumatic events that trigger depression, this is a "joyous" event that predisposes the mother towards postnatal depression. The birth of a baby is a cause for celebration, and should have the opposite effect. Thus the main difference between classical depression and postnatal depression is the addition of a child and all the responsibilities that this incurs.

Signs and symptoms of postnatal depression
The symptoms of sleep deprivation, anorexia, isolation, fatigue, despair and poor concentration are a set of characteristics that make up the pathological syndrome of depression.
Mothers frequently complain of fatigue, sleep deprivation and constant tiredness caused by the 24-hour demands of the infant. Often appetite is impaired and the lack of a substantial diet can add to the feelings of listlessness and fatigue. Problems with sleep and diet are not the main contenders for precipitating postnatal depression but are contributory factors.
The mother may have overoptimistic expectations of both herself and motherhood. Self-blame is evident and when this permeates into her relationship with others it can have a devastating effect on both the mother and her family. There is a danger she may become preoccupied with thoughts of self-reproach, incompetence and often fears of inadequacy and failure to cope, which may have a detrimental effect on her baby's development and general health. If the mother cannot release herself from this state then the only recourse is to plummet ever downwards until either she is rescued, or becomes so overwhelmed by her feelings of unhappiness that she decides her own fate and extricates herself from it, permanently.
The Confidential Enquiry Into Maternal Deaths found that since 1996, psychiatric disorders have been the leading cause for maternal death in the UK, with over half of these due to suicide.(4)

Risk factors
The risk of suffering a serious mental illness is greater following childbirth than at any other time in a woman's life and may have greater adverse consequences for all concerned than at any other time. It is a well established fact that one in 10 mothers who have recently had a baby may have postnatal depression. 
There is increasing evidence to suggest that detection is just as important in the antenatal period. The most important risk factors identified by studies are depressed mood or anxiety during pregnancy, poor levels of social support and/or emotional support, traumatic life events and a previous history of depression. In a study it was found that lone parents have higher rates of depression than couples. One study found that mothers who have suffered from postnatal depression have a one in five chance of a further episode with the second and subsequent pregnancies.(5,6)

Predictors of postnatal depression
Lane et al found that the best predictor of postnatal depression is a mother's mood state three days following delivery.(7) There is evidence to suggest that women who had had an emergency caesarean section were six times more likely to develop postnatal depression at three months postpartum, compared with women who had delivered their babies either spontaneously or by forceps delivery. Some mothers who were expecting twins experienced poorer physical and psychological wellbeing than those expecting a single child.

Consequences for child and partner
Maternal mental health problems may have long-term consequences on the cognitive development of children.(8) Some children suffer from behavioural problems.(9) Mothers who have suffered from chronic postnatal depression have been shown to have a detrimental effect on their children's physical, emotional and psychological wellbeing.
Occasionally the mother loses her libido and partners may see this as a threat to their relationship. They may exacerbate the situation by blaming the mother's overindulgence of their infant's needs over their own. Partners might feel that they are increasingly burdened, not only with their own feelings, but also those of the mother. The impact on their social economic situation may also be significant.(10)

Detection and management
There are ways of detecting postnatal depression in the early stages, by sensitive and careful monitoring.  The most widely recognised means of detecting postnatal depression is the application of a screening test, known as the Edinburgh postnatal depression scale (EPDS).(11) This is a 10-item self-report questionnaire in which a mother is asked to rate how she has felt in the last seven days. Is she as happy as she always was; is she able to laugh; has she still retained her sense of humour? Other questions denote her anxiety state; - does she blame herself when things go wrong or can she cope as well now as she did before the birth of her child? The responses can range from a positive to a negative answer and the mother completes the form by ticking the appropriate box. Negative answers score higher, the higher the score, the more prone to depression the mother may be. Possible scores range from 0 to 30. Mothers who score 12 or above require a further assessment.1 The cut-off for probable depression has been suggested at 12/13, and possible depression at 9/10. This tool has been widely adopted, but recent studies have suggested it has its limitations and should be used in conjunction with sound professional judgement and a clinical interview.(12)

Referral pathways
The majority of common mental health problems are treated in primary care and mothers diagnosed with postnatal depression are no exception. In practice it is the health visitor who usually introduces the EPDS to the mother and will discuss the mother's responses in the form. This focuses on the mother's emotional and social circumstances as well as her medical signs and symptoms. The most appropriate form of management is then highlighted and the mother's preferences taken into consideration. It must be remembered that, as in all patient care, it is important to involve members of the primary care team to help with decision-making and this includes the GP, midwife and/or social services as well as practice nurses.
In an ideal world every mother would be aware of the signs of postnatal depression and have the opportunity to discuss her feelings, but this is not always feasible and mothers at risk may remain undetected. This is where the perceptiveness of the primary care team, and practice nurses in particular, are invaluable. Apart from the accepted symptoms of depression, the mother may present with constant somatic symptoms such as headaches, stomach pains without adequate physical cause. She may have excessive concern about her infant's health and be preoccupied with minor feeding difficulties. The infant may be failing to thrive, may cry excessively, or the mother may confide that the GP and health visitor are critical of her parenting ability and she is worried that the child will be taken into care.(1) One or all of the following signs could alert the nurse that a mother has a potential depressive state and needs referral to the GP and health visitor.
The current organisation of perinatal mental health services is inconsistent across England and Wales, and recommendations are often fragmented.  However, it is hoped that the implementation of the NICE Guidelines in 2007 will rectify this and allow for a more national, coordinated approach.(13)

Treatment
Until women's mental health is taken into the mainstream of care the management of the condition will depend on the commitment and enthusiasm of the primary care team. There are several options to help mothers. The most effective is talking, where the communication skills of the nurse are vital, not only to detect emotional distress, but to understand what it means to the mother and how it may be resolved. These are commonly known as "listening visits" - where the health practitioner does just that - listens to the mother and focuses on her needs and not just those of her infant. At least six sessions may be required if the depression is mild to moderate. Social support as well as emotional support may be relevant in this period.(14)
In more severe cases, when the condition is at its most fierce, the effect of mood becomes flat and as a result impairs cognitive behaviour. The mother usually requires medication, which may take the form of selective serotonin reuptake inhibitors (SSRIs), a class of antidepressant, in conjunction with counselling or psychological support, usually provided by a trained cognitive behavioural therapist. 
The antidepression medication usually takes approximately four to six weeks to be effective and sometimes it is another six to eight weeks before the mother feels completely well. As the condition affects individuals differently, some women may progress more slowly than others.
In the more severe cases the treatment may include inpatient treatment in a psychiatric unit or, if available, a mother and baby unit under the care of a specialised perinatal mental health team, where medication may be combined with specialised treatments and electroconvulsive therapy if necessary.
Left undiagnosed or poorly treated, the condition can perpetuate for several months. One-third of women will still be depressed one year later, but very few suffer for a second year. However, if a mother is made aware of the potential risk to her mental health she can take precautions to minimise the threat.
The increased awareness of postnatal depression causes something of a conundrum as some mothers may fear being stigmatised and may attempt to camouflage the signs. It is important that health practitioners keep an eye out for the classical signs and symptoms. They may not be immediately obvious and there is a danger they may be dismissed as normal, but it is the culmination of events that, as in any condition, creates the picture of a mother who needs help and support.   

Conclusion
In clinical terms, postnatal depression may appear to be of relatively minor importance compared with more florid illnesses. Yet the impairment of personal and family life may be severe and long-lasting, so this debilitating condition merits serious attention.

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