Treatment of postnatal depression

Summary of treatment options
Treatment of postnatal depression involves the availability of a number of important components, each of which can be tailored to the needs of the individual, the stage and the type of the condition. The main components are:

Psychosocial treatments

Psychosocial treatments are non-medical treatments which address the woman's thinking, behaviour, relationships and environment, including her culture. Counselling is as effective as antidepressants for milder forms of depression. Counselling may include some techniques used in psychological therapies, but is mainly based on supportive listening, practical problem-solving and information giving.

Psychoeducation

Psychoeducation is a process whereby the person and her family or whanau have the opportunity to learn about depression, and about how to work together to communicate effectively and deal with stress. This is particularly used in moderate or severe depression or psychosis where it has been shown to contribute to improved outcome.

Psychological therapies

Psychological therapies (often referred to as therapy or psychotherapy) involve a trained professional who uses clinically researched techniques, usually talking therapies, to assess and help people understand what has happened to them and to make positive changes in their lives.

They may involve the use of specific therapies such as cognitive behavioural therapy (CBT), which largely focuses on overcoming unhelpful beliefs, or interpersonal therapy (IPT) which focuses on exploring relationships.

Both of these have been shown to be slightly more effective in treating mild to moderate depression than antidepressants. Used with medication there is often an improved effect.

All types of therapy/counselling should be provided to people and their families and whanau in a manner which is respectful of them and with which they feel comfortable and free to ask questions. It should be consistent with and incorporate their cultural beliefs and practices.

Medication

The mainstay of this aspect of treatment is antidepressants for depression. Other medicines may be used according to individual need and symptoms. Finding the right medication can be a matter of trial and error - there is no way to predict which medication will be effective and tolerated (have fewer troublesome side effects) by any one person.

If you are prescribed medication you are entitled to know the names of the medicines; what symptoms they are supposed to treat; how long it will be before they take effect; how long you will have to take them for and what their side effects (short and long-term) are. You should receive clear instructions about how you should take them and what precautions are necessary.

Complementary therapies

Complementary therapies which enhance the woman's life may be used in addition to psychosocial treatments and prescription medicines.

Psychosocial treatments

Counselling
Supportive counselling is a treatment for milder forms of postnatal depression, where it is as effective as antidepressant medication. Over about six sessions the woman is taught how to use her own skills and resources to cope with worries and problems.

Such counselling can include a problem-solving technique which has the following steps:

• identifying and clarifying the problem
• setting clear achievable goals
• brainstorming solutions
• selecting the preferred option
• evaluating progress in putting the chosen option into action.

Psychoeducation

In psychoeducation a health professional works with women who have postnatal depression, and with their families and whanau, to provide information about the condition, its treatment, and how to support recovery. Central to this approach is that family or whanau, along with the woman herself, are critical members of the treatment team. Together they identify ways of dealing with symptoms, difficult to understand behaviour, and stress.

The early signs which indicate a possible relapse are identified and a plan of early response is developed. There is also attention to the kinds of support that everyone needs, and how to get this support.

Psychological therapies

Psychological therapies have been found to be effective in the treatment of postnatal depression.

Often they will be recommended in addition to medication, or as an alternative to medication in the case of less severe depression or where a woman does not choose medication. Therapy may be one-to-one; it may include partners or families and whanau for some sessions; or it may be group therapy with other women who have postnatal depression.

The focus of psychotherapy or counselling in the treatment of postnatal depression is on education and support for the woman to understand what is happening to her, to learn coping strategies, and to pursue a path of recovery. Through these processes women can regain the confidence and belief in themselves that is critical to recovery. Specific therapeutic approaches can then be used within this supportive setting.

Two such approaches, cognitive-behavioural therapy (CBT) and interpersonal psychotherapy (IPT) have been clinically researched and found to be effective in the treatment of postnatal depression.

Cognitive-behavioural therapy (CBT)
The basic theory of cognitive behavioural therapy is that our thoughts and beliefs influence our feelings and behaviour. The focus of treatment is on identifying specific negative thoughts and actions, and developing ways to change these.

The cognitive part of the therapy helps the woman to identify, examine and challenge these thoughts. She may, for example, say that she is always sad. With encouragement from the therapist she may come to see that it is only certain situations which make her sad. At other times she still experiences some pleasure.

The therapist may then encourage behavioural strategies to help lift her mood, such as going for a short walk or doing some small thing which she may once have enjoyed. These activities are often given in the form of homework tasks. CBT also incorporates other techniques useful in helping depression, such as teaching relaxation, stress management and problem-solving skills (as outlined in the Counselling section above).

CBT alone is effective in all but severe depression, but people with severe depression may also benefit from this treatment as they recover. Unlike antidepressants which are only effective as long as they are taken, the benefits of CBT may protect against future episodes of depression. Treatment is usually time limited and may include eight to 12 sessions over three to six months.

Interpersonal therapy (IPT)
This therapy is based on the theory that depression may be triggered by difficulties in the person's relationships with others. These difficulties are often increased when a person is depressed, so IPT aims to identify the interpersonal difficulties very clearly. With postnatal depression, changes in roles and relationships such as giving up work and becoming a mother, or feeling socially isolated, may have triggered the depression.

The therapist spends time working with the woman to develop ways to overcome her difficulties, and to find ways of relating to others which work better for her. As with general counselling, she may be taught specific techniques such as effective communication skills, assertiveness, and problem-solving.

ITP is a time limited, focused treatment which may include up to 16 sessions.

Treatment for postnatal depression may be available free of charge at a community mental health service either on a one-to-one or, in some areas, a group basis. At a number of community service agencies, charges are based on your ability to pay. Private therapists' fees may range from $60 to $200 per session but many also have a sliding scale of fees.

Medication

While it is the best and safest option during pregnancy not to take medication, the risks relating to becoming mentally unwell for both the mother and her baby need to be weighed against the risks of treatment with medication.

Research regarding which medications are safe in pregnancy or while breastfeeding, and which are useful for treating postnatal depression, is ongoing. It is, therefore, most important that women prescribed medications at these times check with their doctor about the latest information on which medications are considered safe and effective.

All psychiatric medicines pass into breast milk. With some medications, bottle-feeding is the only choice; for others, breastfeeding can be considered as long as there is close observation for side effects in the baby.

Antidepressants
There are three different groups of antidepressants which may be used to treat postnatal depression:

• Selective Serotonin Re-uptake Inhibitors (SSRIs)
• Reversible Inhibitors of Monoamine Oxidase A (RIMAs)
• Tricyclic Antidepressants (Tricyclics/TCAs).

SSRIs and RIMAs
Selective Serotonin Re-uptake Inhibitors (SSRIs), and Reversible Inhibitors of Monoamine Oxidase A (RIMAs), are newer types of antidepressants that have less troublesome side effects but are equal in effectiveness to the older tricyclic antidepressants. SSRIs can be started at an effective dose from day one. The effective dose of RIMA is usually reached over a week or more.

Taking any antidepressant during pregnancy requires careful consideration of possible risks and benefits. Bottle-feeding is advised, but breastfeeding can occur as long as the baby is monitored for side effects.

Common side effects of SSRIs:

• Nausea. Sometimes this can be reduced by taking the medication with food.
• Headache. Sometimes this is an initial effect which wears off.
• Sleep difficulties. SSRIs may aggravate the sleep problems of depression, though as the medicine works sleep will improve.
• Agitation (feeling jittery). While not common, this can be distressing. It tends to reduce with time, but may mean a change of medicine is needed.
• Sexual problems are the most common side effect and affect up to 20 percent of people.
• Weight loss for some people.
• Rash. This is not common, but means the medication should be stopped.

Common side effects of RIMAs:

• Diarrhoea.
• Anxiety or jittery feeling, while not common, this can be distressing. It tends to reduce with time, but may mean a change of medicine is needed.
• Headache.
• Insomnia, especially if the medication is taken at night.

Tricyclic antidepressants (tricyclics/TCAs)
The tricyclic antidepressants have a number of common side effects so should be started at a low dose and slowly increased to a therapeutic dose (around 150mg per day). These side effects differ from person to person and, although they can be quite severe for some people, they usually fade away after two to three weeks. You may need to try different antidepressants before you find one which suits you.

These medicines are considered safe during pregnancy, however, taking any antidepressant during pregnancy requires careful consideration of possible risks and benefits. Bottle-feeding is advised but breastfeeding can occur as long as the baby is monitored for side effects.

This group of antidepressants is dangerous in overdose.

Common side effects of tricyclic antidepressants:

• Drowsiness and loss of energy. This can be useful if sleep is a problem. In this case the medicine is taken at night.
• Dizziness, especially with standing up from lying or sitting.
• Dry mouth. Water and sugar-free gum are good ways to reduce this.
• Constipation. Plenty of liquids, fruit and vegetables can reduce this.
• Blurred vision. This may mean reduction or change of drug.
• Increased sweating. While many people notice this, most are not troubled by it.
• Weight gain. Exercise and a healthy diet are the best ways to minimise this.
• Sexual problems such as impotence, reduced sex drive, or lack of orgasm.
• Serious side effects of tricyclic antidepressants
• Heart problems. This is only in people who already have heart problems. Some of this group of medications are actually safer for people with heart problems.
• Psychosis symptoms, or worsening of symptoms of psychosis. This is rare.
• Overdose. These drugs are very dangerous in overdose, due to their effects on the heart.

Taking antidepressants
Antidepressants are not addictive. Apart from the risk of recurrence of the depression, there are usually no withdrawal effects, although if stopped suddenly there may be mild symptoms such as feeling shaky. Finding the right antidepressant can be a matter of trial and error - there is no way to predict which drug will be effective or tolerated by any one person.

Onset of the full effect of all these antidepressants is delayed by around two weeks after reaching the effective dose. With the tricyclics in particular, there may be reduction in levels of other symptoms, such as anxiety and agitation, within a few days. After recovery from a first episode of depression it is recommended that the person stay on medication for six to 12 months, as there is a high rate of return of symptoms if antidepressants are stopped sooner.

Benzodiazepines (tranquillisers)
Benzodiazepines are sometimes used during the acute phase of depression and psychosis to treat severe agitation and sleep problems. With short-term use there are few side effects - the main one being sedation, which may be useful during the acute phase. This usually wears off. The main problem with benzodiazepines is they are addictive with long term use. For this reason they are generally only prescribed for up to two weeks.

 Women taking benzodiazepines need to be aware they may become too drowsy or relaxed to drive or operate machinery. Those with severe breathing problems need to be careful as benzodiazepines can reduce breathing a little. Stopping them needs to be done gradually.

Sudden stopping may produce withdrawal symptoms such as anxiety, insomnia, headaches and dizziness and, if severe, they may induce epileptic seizures. People with epilepsy must be careful as withdrawal can also make seizures more likely.

Benzodiazepines are safe with almost all other medicines. The effects of alcohol are magnified by them, so this should be avoided.

With the exception of clonazepam, benzodiazepines are not safe during pregnancy and should not be taken by pregnant women. Even clonazepam should be used only for short periods and with careful monitoring. After birth, benzodiazepines pass into breast milk, and affect the baby, so, if they are prescribed, bottle feeding is required.

Medicine interactions

Most psychiatric medicines tend to react with each other when taken in combination. Their sedative effect in particular may make you feel sleepy. Your doctor will, where possible, limit the number of medications prescribed. You should not mix different types of antidepressants unless instructed by your doctor as this could be very dangerous.

The effects of alcohol and many illegal drugs will also be heightened, so they should be avoided. Alcohol and other drugs may aggravate mental health conditions and are not good for the baby.

It is important the doctor knows all the medications (including any herbal medicines) you are taking, as some taken together can be dangerous.

Complementary therapies

The term complementary therapy is generally used to indicate therapies and treatments which differ from conventional Western medicine and which may be used to complement, support or sometimes replace it.  There is an ever-growing awareness that it is vital to treat the whole person and assist them to find ways to address the causes of mental health problems rather than merely alleviating the symptoms. 

This is often referred to as an holistic approach. Complementary therapies often support an holistic approach and are seen as a way to address physical, nutritional, environmental, emotional, social, spiritual and lifestyle needs. 

Many cultures have their own treatment and care practices which many people find helpful and which can often provide additional benefits to health and wellbeing. Rongoa Maori is the indigenous health and healing practice of New Zealand.  Tohunga Puna Ora is a traditional healing practitioner. Traditional healing for many Pacific Islands' people involves massage, herbal remedies and spiritual healers.

In general, meditation, hypnotherapy, yoga, exercise, relaxation, massage, mirimiri and aromatherapy have all been shown to have some effect in alleviating mental distress.Complementary therapies can include using a number of herbal and other medicinal preparations to treat particular conditions. It is recommended that care is taken as prescription medicines, herbal and medicinal preparations can interact with each other.

Women who may be pregnant or breastfeeding are advised to take extra care and to consult a doctor about any supplements, herbal or medicinal preparations they are considering using, to make sure they are safe and that they will not harm their own or their baby's health.

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

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.