Postnatal Depression

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Postnatal Depression – A guide for mothers and their families

  1. Introduction
  2. Normal Emotional Changes After Childbirth: The First days
  3. Depression: What Does It Mean?
  4. Postnatal Depression – General Info
  5. What is Puerperal Psychosis?
  6. Is There Such A Thing As Antenatal Depression?
  7. Advice For Families
  8. A Final Word

 

Introduction
Having a baby is a major event in any woman’s life and this is particularly so in the case of a first baby. Motherhood is an exciting and wonderful experience. Baby books and magazines expound at length about the joys of parenthood. This booklet is designed to explain both the normal and abnormal emotional responses which may follow on the birth of a new baby. Emotional distress following delivery ranges from the very common, mild and short lived “baby blues”, through postnatal depression, to the more serious but rare condition, Puerperal Psychosis. Although there is emphasis on postnatal depression in this booklet, happily the vast majority of women, 85% of them, succeed in getting through pregnancy, childbirth and the year that follows, without any major psychological difficulties.
Remember, if you have postnatal depression, do not despair, it is treatable and you will make a full recovery.

Normal Emotional Changes After Childbirth:
The First Five Days
The “Pinks”

For the first three days or so after giving birth most women, although tired,experience a “high”, that is they feel happy, excited, thrilled with the baby
and themselves, and they may experience difficulties sleeping. This period
is sometimes referred to as the “Pinks”. A minority of women experience a
feeling of anticlimax after the birth and some even dislike their new baby
initially, which can be very distressing. Generally all these feelings pass in
a matter of days.

The “Baby Blues”
Sometime around the third day or so, the happy period ends abruptly and, for 60% of women or more, the “Baby Blues” are experienced. The “Blues” are characterised by emotional mood swings which oscillate from feeling sad to happy and back again. Most women at this time find they cry very easily for the least thing and can feel very irritable. The “Baby Blues” are generally attributable to marked hormonal changes which are occurring around this time. Hormones such as progesterone and oestrogen, which were at very high levels during pregnancy, suddenly drop and similarly a steroid hormone called prolactin is on the increase. At around this time “the milk comes in”. The breasts tend to be full and painful and there may be anxieties about establishing feeding. Overall, the “Baby Blues” is an unpleasant experience and mothers frequently find themselves worrying over little things and questioning their ability as a mother around this time. Happily the “Blues” do not last. Most women experience them for just 1 or 2 days. Even when more severe, the “Blues” resolve within 10 days of delivery. As such it can be regarded as a normal reaction and does not require any treatment. However, it is important for family and friends alike to recognise these symptoms when they occur and offer reassurance and
support to the mother.

First Few Weeks

During the six to eight weeks after childbirth new mothers return to normal, both physically and emotionally. Full emotional recovery, however,may not occur until the baby and mother are sleeping through the night, thus allowing for some kind of routine. As such, mothers who breastfeed may take longer to recover emotionally than mothers who do not. It is a general characteristic of this period that mothers tend to be very easily upset and are over-sensitive. New mothers in particular can be over-anxious with regard to the baby’s health and their own wellbeing. Some women experience very transient feelings of sadness or guilt during this time, others experience a sense of unreality and strangeness, sometimes even wondering if the new baby is even theirs. Above all, in the early weeks, it is very common to feel overwhelming exhaustion and many of the symptoms described probably arise out of fatigue. A new mother can feel very possessive about her baby and dislike anyone else handling it, even her own partner or other. Difficulties in concentration are common around this time and because of this, forgetfulness is also a striking feature. Once a normal night’s sleep pattern returns, all of these symptoms fade. Childbirth, therefore, gives rise to a multiplicity of emotions. For a first time mother in particular, there is the fear of the unknown and the sudden realisation of the great responsibility which is now hers. Having a baby in the house gives rise to a dramatic change in the structure of one’s life, marriage and relationships generally. No matter how eagerly the baby was anticipated, after its arrival there can be transient feelings of sadness or loss for the way things were before the baby came. This is part and parcel of the emotional adjustment to the new situation. Given the vast range of normal reactions which can be experienced after the baby is born, it is easy to see how vulnerable a woman is at this time to any additional stresses and strains that might arise. Likewise if life was not entirely harmonis before the baby’s arrival, a woman’s ability to cope afterwards may be in serious trouble.

Depression: What Does it Mean?
“I feel depressed” is an expression we all use from time to time. Generally we mean by it that we feel fed up for whatever reason; we are at odds with the world around us. Generally this kind of depression passes off quickly after a cup of tea or a chat with a friend, and we regard this as normal depression.
When the depressed feeling is more prolonged or more severe than a person can cope with, it is regarded as an abnormal or clinical depression. Before dealing with postnatal depression let us look at three different types of depression.

Reactive Depression
All of us at some stage in our lives will experience this kind of depression. It is in a sense a prolonged period of unhappiness, which generally follows on the loss of something dear to us such as the death of a close relative or friend or loss of an alternative kind, such as a job through unemployment or retirement. This sort of depression is associated not only with feelings of sadness or loss, but also effects our ability to cope. We may lose our appetite, experience sleep disturbance and have loss of interest in things generally. This form of depression can take weeks or months to resolve. Mothers whose babies are stillborn or die shortly after birth, suffer from this type of depression which is a grief reaction. Indeed many women who have had a miscarriage also go through a similar reaction afterwards.

Personality Based Depressive Reactions
Some people, because of personalities are more prone to depressive bouts than others. Men and women who are anxious by nature and worry a lot, experience more than their share of depressed feelings because of this. They tend to cross bridges before they come to them. Likewise people who are overly conscious and perfectionistic by nature set high standards for themselves and others which sometimes are unattainable, giving rise to disappointment and a down feeling. These lows are a psychological reaction within a certain type of person.

Biological Depression
This refers to depression that cannot be totally explained by an upsetting event or a person’s upbringing or personality; it is an internal, chemically determined, depression. It often occurs out of the blue and is usually a more severe type of depression.

There are two forms of this condition: unipolar or endogenous meaning internal depression and bipolar disorder or manic-depression. Treatment is generally along the lines of medication. This form of depression can recur from time to time. There is often a family history of similar type of depressive illness.

Postnatal Depression – General Info
There are in fact two types of “postnatal depression”. The first type is called postnatal depression and it refers to a less severe form of depression. The second type is more often referred to as puerperal psychosis and it is a major form of depression which is biological in nature. Both of these types of depression are quite different in their cause and, therefore, treatment will be described separately. Remember that 85% of women do not suffer from any form of depression after giving birth. Approximately 15% of women, however, will suffer from a depression postnatally.

Postnatal Depression – Symptoms
Postnatal depression has only been described in detail and studied in the last twenty years. The symptoms generally start some weeks after the baby is born. Women affected commonly describe feelings of tiredness, irritability and anxiety. Definite feelings of sadness and unhappiness as
such, are less common. As a result, many women suffer from the condition without recognising it for what it is and so, do not seek help. They assume that what they are experiencing is due to being tired from coping with the new baby and perhaps other children, or having interrupted sleep due to the baby crying.

Common symptoms in postnatal depression are:

  •  Feeling tired and finding everything an effort.
  •  Worrying excessively over the baby, e.g. constantly checking on the baby.
  •  Finding it hard to cope with even minor day-to-day mishaps.
  •  Finding it hard to concentrate and, as a result, being more forgetful.
  •  Feeling tense and nervous much of the time. Feeling panicky for no good reason.
  •  Feelings of sadness and a tendency to cry easily. Feelings of inadequacy,feeling “no good”.
  •  Not wanting to be alone.
  •  No interest in sex.

To find out more about postnatal depression it was necessary to study large groups of women over the twelve months after giving birth. The results of these studies have shown that postnatal depression is not uncommon. In fact, approximately 15% of women are affected. The condition generally starts within six weeks of giving birth and lasts in or around three months.
This is the natural history of the condition without any treatment or intervention. Postnatal depression almost invariably has disappeared of its own accord by the time the baby is a year old or, usually, much earlier.

Who Gets Postnatal Depression?
Postnatal depression can happen to anyone. Women who are most at risk of developing it are women who have a poor relationship with their partners. By poor relationship is meant lack of support, be it practical or emotional, or overt disharmony. We know that the best way to cope with a new stress is to be able to share any worries or anxieties we have about it with someone else who will support us. Lack of a supporting relationship deprives us of a buffer when faced with difficulties. Also at risk are women who have had psychological problems in the past of one kind or another. As such, women who have vulnerable personalities are at risk of postnatal depression because they are likely to have difficulty adjusting to the demands of a new baby. So, generally the cause of postnatal depression would appear to be psychological. We know it is definitely unrelated to such factors as complications at birth or hormonal changes afterwards. However, recent studies of postnatal depression suggest that socio-economic diffculties are also a risk factor. Women who have pre-existing financial difficulties andwho are unemployed are more likely to become depressed after the baby arrives.

Treatment of Postnatal Depression
Research studies are currently trying to evaluate the most efficient way of helping women with postnatal depression and how best to prevent it in the first place. Postnatal depression can be successfully treated by both individual counselling – someone who can provide a sympathetic ear and practical advice to the new mother – and by group psychotherapy. Regular group support sessions appear to be successful in both treating and in preventing postnatal depression by providing information, practical advice and emotional support. Medication has little role to play in postnatal depression although some medication in the short term may be helpful to alleviate certain symptoms such as inability to go to sleep.

Although postnatal depression can be classified as a mild condition, undoubtedly it is the cause of much distress and misery. The effect of an anxious, irritable, tired mother on a young baby and the rest of the family has yet to be elucidated. It is important that women and their families are aware of the symptoms and seek help early rather than allow it to drag on for months.

Coping with Postnatal Depression
We cope best in any new situation by being well prepared in advance, having had the chance to weigh up the pros and cons and being able to anticipate what to expect. A new baby in the household creates demands which are there twenty-four hours a day, seven days a week. A new baby is very tiring. To cope it is very important to ensure sufficient rest. Ideally, a partner should look after the baby on alternate nights to allow a good night’s sleep at least every second night. If a baby sleeps by day the mother should rest during these periods rather than take the opportunity of trying to catch up on household chores, thus tiring herself out still further. It is important to accept practical help from others, rather than trying to be “Superwomen”. Having regular breaks from the baby helps. Even having twenty minutes to herself every day helps the coping mechanisms. Allowing someone else “babysit” to allow for a trip to the hairdressers or perhaps an evening out also helps. If a mother is worried or anxious aboutthe baby or herself, it is very important that she confides in her partner or family about these worries and if necessary, seeks expert advice from a health care professional rather than allow worries to get “bottled up”.

DOs and DON’Ts of Coping

Do

  • Get adequate rest
  • Eat a balanced diet
  • Talk over any worries or anxieties with someone close to you
  • Accept practical help from others
  • Involve your partner in looking after baby
  • Get some fresh air and exercise every day if you can
  • Take a break at least once a week such as a trip to the hairdresser or visit to friends
  • Avoid any extra pressures
  • Avoid people or situations which upset you

Don’t

  • Bottle things up
  • Get over-tired
  • Try to do everything
  • Refuse help
  • Isolate yourself from others
  • Feel you have to be the perfect mother
  • Avoid getting help if you are feeling down

Remember, postnatal depression does not last forever. It lasts weeks rather than months, and complete recovery is the rule.

What is Puerperal Psychosis?
The term puerperal psychosis generally refers to a severe form of depression or elation occurring in the first few weeks after the baby is born. The term “puerperal” refers to the six week period immediately following childbirth.

A psychosis is any form of severe mental illness in which the sufferer loses contact with reality. There are different kinds of psychoses, but puerperal psychosis generally refers to a mood disorder. It must be said that puerperal psychosis is a relatively rare disorder affecting at most 1 woman in every 500 who give birth. It is a biological or chemical form of mood disorder like depressive illness or manic-depression. In fact a woman with a history of manic-depression runs a 20% chance of having puerperal psychosis after having a baby. There is a family history of severe depression in up to 65% of women who develop a puerperal psychosis, suggesting a very strong genetic basis for the disorder. Being a first time mother also increases the risk of puerperal psychosis. Over half all women who become ill in this way do so after having their first baby. If a mother does not have a partner at the time of the birth, or has a Caesarean section or a stillbirth, she has a slightly increased risk of having this condition. This type of illness frequently results in hospitalisation. This is because a mother who is severely depressed or elated may not be able to take care of her baby or herself. A very depressed mother can have strong suicidal ideas or less frequently, infanticidal ones. Hospitalisation in these instances becomes essential.

Treatment
Treatment of puerperal psychosis is usually with medication, most commonly with antidepressants or anti-elatants. Both work to restore normal mood again. Sometimes a mood stabilising drug such as lithium is also required. Drug treatment is generally continued over a six to twelve month period after the initial upset. In the past electro-convulsive therapy (E.C.T.) was frequently used to treat puerperal psychosis. Nowadays with more effective drugs, this is less common. E.C.T. is now only used in more severe forms of puerperal psychosis with, for example, marked suicidal ideas – when in this situation it can be life-saving. In a small percentage of women who fail to respond to drug treatment, E.C.T. can be an extremely effective treatment.
Most psychiatric hospitals, at present, do not have Mother & Baby Units, thus inevitably leading to a period of separation of the baby from its mother if hospitalisation is required. Provided the baby is well cared for in its mother’s absence, there is no evidence that this causes any long term adverse effects on the baby. We know from the past when there was no effective treatment for this condition that the illness lasted on average six months. Now with the use of drug treatment, the average duration of illness is a few weeks. The outcome is invariably excellent. Every woman
suffering from puerperal psychosis recovers completely.

Risk of Recurrence
There is a risk of recurrence of puerperal psychosis. Should a woman become pregnant again, she has a one-in-five chance of getting severely depressed again after birth. The risk of a recurrence of elation following a
subsequent baby is slightly higher. Although these odds are significant, it must be remembered that there is at least a 70% chance of all being well after the subsequent baby.

Is There Such a Thing as Antenatal Depression?
Yes, there is. We tend to associate pregnancy with both physical and emotional wellbeing, but the evidence is that in the first three months of pregnancy, at least up to 10% of women become depressed. This is particularly so if they are currently having marital difficulties or having doubts about having a baby. Women who have had abortions in the past sometimes go through a depressive patch when they become pregnant again. Most of these depressive symptoms clear as the pregnancy progresses. There is no direct association between antenatal and postnatal depression, although marital disharmony is common to both.

Advice for Families

  • Try to be patient.
  • Try to understand.
  • Find out all you can about postnatal depression.
  • Remember, postnatal depression will pass.
  • Be as helpful as you can both in practical ways and in givingemotional support.
  • Remember, it is helpful for a mother to talk about her worries and fears.
  • Allow her time to talk. Postnatal depression is a treatable conditionencourage her to seek help and follow advice.
  •  Give reassurance. Depression is a frightening experience for anyone. It helps to be reminded that all will be soon well again.

A Final Word
Remember, if you have recently had a baby and you are not “yourself ” and you think you may be suffering from some form of depression or mood disorder, report your symptoms to your family doctor, public health nurse or gynaecologist. Don’t put up with feeling off-form; seek advice and help.

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