Postnatal depression

There are three types of depression which can occur after childbirth.

Postnatal or maternity blues are very common and involve a brief period of the mother feeling down and tearful in the week after her baby is born. This feeling passes after a few days.

Postnatal depression, a much more serious condition, is also common. The woman becomes seriously depressed in the first months following the baby's birth.

Postnatal psychosis (sometimes called post partum psychosis) is rare and involves symptoms of psychosis (being out of touch with reality) associated with changes in mood - either a depressed or an extremely high mood. It usually begins in the first two weeks after the child is born.

This article focuses on postnatal depression, that is, any lasting depression associated with childbirth. This may happen to women who have never been mentally unwell before, while others will have had depression in the past. Regardless of what has happened before, the symptoms and treatment are similar. The major difference is there is a concern for the care of the baby, as well as the mother.

There is no medical test which can diagnose depression (or psychosis). A diagnosis is made when the woman has some or all of the typical symptoms outlined below. For this reason it is very important for a health professional to get a full understanding of the difficulties the woman has had, from herself and her family or whanau or others who know her well, if there is any indication of depression.

If you are developing postnatal depression or postnatal psychosis it is most important to seek help as early as possible. These can be effectively treated, and you are likely to recover. The earlier effective treatment is started, the better the chances of recovery.

Risk factors in postnatal depression

Ten to 15 per cent of women will develop postnatal depression in the months after the birth of a baby. It may also start during pregnancy, and, if untreated, continue and perhaps get worse after the baby is born.

There are a number of risk factors which increase the chances of developing postnatal depression.

Risk factors before pregnancy and birth

• Past history of depression or other mental health problem.
• Relationship difficulties, especially with the father of the baby or with own mother.
• Having little social support.
• Onset of depression during pregnancy.
• Life stresses or difficulties such as money or housing problems.

Risk factors related to the birth

• Birth complications, such as caesarean delivery.
• The birth did not live up to expectations (eg. birth in hospital or with intervention when the woman wanted a home or natural birth).
• Birth of a brain-damaged or ill baby.

Risk factors after birth

• Persisting postnatal blues.
• Not wanting to hold the baby or feeling detached, having negative thoughts about the baby.
• The mother experiences sleep problems.
• The baby is fussy, has problems feeding, or has colic or reflux.

It is important to identify which of these risks are present through pregnancy, birth and afterwards, as the woman and those involved in her support and care can work to resolve any factors which may be reversible. They can also be alert for signs of any developing depression.

This is particularly important as the weeks and months following the birth are a critical time for mother and baby to establish a good bonding relationship. A long period of depression can interfere with this important process.

Symptoms of postnatal depression

The signs or symptoms of postnatal depression are the same as for depression which can occur at other times. These may vary between women, and over time in any one woman. Not everyone with depression will complain of sadness or a persistent low mood. They may have other signs of depression such as sleep problems. Others will complain of vague physical symptoms.

 The symptoms of depression are often divided into three categories - mood, physical, and cognitive (related to thoughts and beliefs) symptoms. Some women will also have anxiety symptoms. For a diagnosis of depression to be made, mood symptoms and some or all of the other signs must have been present for at least two weeks.

Mood symptoms of postnatal depression

• Persistent low, sad or depressed mood. This can be described in varying ways by people, especially if they are from non-European cultures. The woman may describe feeling sad, empty, having no feelings, or may complain of pain which is hard to locate. She may cry for no apparent reason. Some women may feel sad or low in mood all of the time, others have periods where their mood is more normal but the periods of feeling good do not last more than a day or two.
• Loss of interest and pleasure in usual activities. This is a reduced ability to enjoy things which you would usually find pleasurable, and can be quite distressing. It includes loss of interest in sex, although this often lessens for a period after childbirth as a result of hormonal changes.
• Irritable mood. This may be the main mood change for some. If it continues, it can make dealing with the frustrations of caring for a baby very difficult, and may also be very damaging to other relationships.

Physical symptoms of postnatal depression

• Change in sleeping patterns. The most common change is reduced sleep, with difficulty getting to sleep, disturbed sleep, and/or waking early and being unable to return to sleep. For a few women, sleep is increased. Most people with depression wake feeling unrefreshed from their sleep. While it is usual for mothers to have their sleep interrupted by a waking baby, women with postnatal depression often find they cannot sleep even when the baby is settled. For example, they may lie awake worrying about the next feed or the next day.
• Change in appetite, often not feeling like eating and, as a result, losing weight. Some women will have increased appetite, often without taking any pleasure in eating. This is often seen in those who also sleep more.
• Decreased energy, tiredness and fatigue may be so severe that even the smallest task seems too difficult to complete, causing great difficulty in caring for the baby. Women with postnatal depression need a lot of assistance with caring for the baby and any other children.
• Physical slowing or agitation often comes with severe depression. The person may sit in one place for periods and move, respond and talk very slowly; or they may be unable to sit still, pace and wring their hands. The same person may experience alternating slowing and agitation.

Cognitive symptoms of postnatal depression

• Thoughts of worthlessness or guilt involve loss of self-confidence, and excessive guilt about past minor wrongs. As a result of feeling bad about themselves, women may withdraw from doing things and from contact with others. They may also feel they are a bad mother.
• Thoughts of hopelessness and death and feeling there is no hope in life. The woman may wish she were dead or have thoughts of suicide. While many women with postnatal depression have thoughts of harming themselves (and sometimes their baby), often it is not that they want to die or hurt the baby, but rather they want the situation to change.
• Difficulty thinking clearly. Women may have difficulty in concentrating. They may not feel able to read the paper or watch television. They may also have great difficulty making even simple everyday decisions.
• Anxiety symptoms of various kinds are also very common as part of depression (80 to 90 per cent of people with depression) but as the depression resolves, these symptoms stop. They may include:
• Excessive worry or fear, with associated physical symptoms such as muscle tension, pounding heart or dry mouth. The focus of worry will often be the baby.
• Panic attacks, with sudden episodes of extreme anxiety and panic and physical symptoms of fear. Again, the focus is often to do with the baby,
• Phobias. Specific fears about situations, fear of open spaces, confined spaces, heights, objects, animals or creatures such as spiders.
• Excessive concern about physical health. The woman may worry she is physically ill in some way, or that her baby is ill or has something terribly wrong with him/her.

How long will postnatal depression last?

The course of postnatal depression is variable. Without treatment, an episode may last six months or more. With treatment, 70 to 80 per cent of women will recover much sooner. In the majority of women, there is complete recovery.

Twenty to 30 per cent of women will improve but still have some symptoms of depression persisting for months or even years later. For a minority (five to ten per cent) there is no improvement and the woman remains unwell for two or more years.

Early access to treatment increases the chance of full recovery. Over time, some women have a single episode and remain well following the birth of future children. However, some will have postnatal depression following any future births, particularly if the risk factors persist. Others will go on to have other episodes of depression outside of the specific post-childbirth period.

Risks associated with postnatal depression

As well as the risk factors for developing postnatal depression outlined above, a woman with postnatal depression is also at risk of other difficulties.

• Problems in the developing mother-baby relationship. This relationship is critical to the future mental health of mother and baby. There is evidence, that where the early mother-baby relationship is disturbed, the baby has an increased risk of later physical or emotional abuse by the mother. This is why early diagnosis and effective treatment, support of the mother, and support of the developing mother-baby relationship are very important. Separation of mother and baby for any length of time should be avoided unless there is no other option.
• Delays in accessing care may increase the severity of postnatal depression, cause poorer response to treatment and result in possible chronic unwellness and subsequent disability.
• Persistent depression may be a greater risk if there are continuing problems between the woman and her partner or there are family or whanau problems. These are reversible risk factors and are important to address.
• The more episodes a woman has, the higher her chances of further episodes, according to some evidence. Having a good relationship with health professionals, continuing treatment where this is advised, education about postnatal depression for the woman and her family or whanau, and clear plans for staying well are increasingly recognised as critical. Maintaining wellness and early treatment of symptoms of depression through future pregnancies is especially important.
• Alcohol and/or drug abuse are a common complication of depression, particularly where it is severe and persistent. Early recognition and treatment of co-existing alcohol and drug problems are critical to promote recovery.
• Suicide risk in women with postnatal depression is significant. This risk is highest during the episode of depression, although the time of greatest risk may be during the initial period of beginning to recover from the worst symptoms. It is important that any expressed suicidal thoughts or urges are taken very seriously and the woman receives expert care.
• Violent behaviour in women with postnatal depression is rare. A very small number of women with severe depression may be at risk of harming their children. This may be a result of severe feelings of hopelessness and despondency, and a belief the world is a bad place from which their loved ones must be spared. More commonly, there may be increased risk of child abuse if irritability is a symptom. Again, prompt treatment and good care can prevent the postnatal depression from reaching a point where tragedy occurs.

Myths about postnatal depression

NOT TRUE Postnatal or any depression is a sign of a weak character.
Postnatal depression can strike any woman after the birth of a baby. While some particular personality types may be more likely to develop depression, the vast majority of women who develop the condition have been previously healthy and led normal lives.
NOT TRUE Women with postnatal depression can 'snap out of it' or just choose to 'pull their socks up'.
One of the most disabling symptoms of depression is that it saps the will and makes doing anything an enormous effort. Depression is an extremely unpleasant experience, and most women with this condition would (and do) do anything to get well.

Causes of postnatal depression

As with all mental health conditions, the exact cause of postnatal depression remains unknown. All the clearly identified risks can be contributing factors to it.

For all women, childbirth is rated high on the scale of life stress, with many adjustments to be made and many stressful situations, including the birth itself. For women who are vulnerable to depression, (and who may have had a previous episode) there is an increased risk due to factors such as significant loss of, or disturbed sleep.

Women with postnatal depression and their families and whanau may believe they developed it because of the stress of giving birth and being a new parent. Other people with postnatal distress may agree with the view that their mental illness is biological in origin and due to the huge hormonal changes that happen during and after birth. A lot of people with postnatal distress believe it is a combination of these things.

Sometimes people think their mental illness is a punishment for their moral or spiritual failure. It's important to remember it is not your fault you have a mental illness.

See also: Postnatal psychosis; Postnatal depression - living with; postnatal depression - treatment

Support groups

See the support organisations (which include helplines) under Further information and support below.

Original material provided by the Mental Health Foundation of New Zealand, 2002. Edited by everybody, June 2005.