Postnatal depression usually develops in the first four to six weeks after childbirth, although in some cases it may not develop for several months.
There are many symptoms of postnatal depression, such as low mood, feeling unable to cope and difficulty sleeping, but many women are not aware they have the condition.
It's common to experience mood changes, irritability and episodes of tearfulness after birth – the so-called baby blues. These normally clear up within a few weeks. But if a woman experiences persistent symptoms, it could well be the result of postnatal depression.
PND Symptoms
Postnatal depression can affect women in different ways. Symptoms can begin soon after the birth and last for months, or in severe cases for more than a year.
Key symptoms are:
- a persistent feeling of sadness and low mood
- loss of interest in the world around you and no longer enjoying things that used to give pleasure
- lack of energy and feeling tired all the time (fatigue)
- disturbed sleep – such as not being able to fall asleep during the night (insomnia) and then being sleepy during the day
- difficulties with concentration and making decisions
- low self-confidence
- poor appetite or an increase in appetite (‘comfort eating’)
- you become very agitated or alternatively you become very apathetic (can’t be bothered)
- feelings of guilt and self-blame
- thinking about suicide and self-harming
What causes PND?
PND can happen whatever your family circumstances, and whether or not the baby is your first. You may have managed happily with your first baby and yet become depressed after your second, or the other way around. There is no one cause for PND, but a number of different possibilities have been put forward to explain why new mothers may become depressed in this way.
The shock of becoming a mother
Women are often unprepared for the physical impact of childbirth, and yet motherhood has further shocks in store. There are new and daunting skills to learn, and this is only the beginning. You are suddenly responsible, 24-hours a day, for a helpless human being whose only communication is crying, which we as adults associate with distress. Some new mothers become very anxious about their babies, feeling overwhelmed by the responsibility of looking after them, and lying awake at night listening for their breathing and fearful of cot death.
As a new mother, you may find you can't go out without the baby, and that you may not even want to. Neither can you leave the baby alone in the house. Suddenly your own freedom to come and go as you please has disappeared. When you do take the baby out, the pram or buggy turns familiar routes into obstacle-courses, and buses and shops are suddenly hard to use. All too often, you may find yourself alone in the house, with no adults to talk to. And you may feel totally exhausted. All this takes getting used to. Becoming a mother involves many losses, not only of freedom, but also of income, of independence, and of your sense of who you are.
Changed relationships
Becoming a mother can be a huge change of role. It alters the relationship between you and your partner. Two adults, who may have had few joint responsibilities previously, are suddenly parents. It will affect your relationship with your own mother, too. You're no longer your mother's little girl but, instead, have turned her into a grandmother. This is a further loss, as well as a gain, which both sides have to adjust to.
You may well have given up a job, if only temporarily, and will find yourself financially dependent on someone else, perhaps for the first time in your adult life.
You may well have given up a job, if only temporarily, and will find yourself financially dependent on someone else, perhaps for the first time in your adult life.
Even when the baby is a second or third one, there are still adjustments to be made, because each new baby changes the family as a whole. In a way, it gives birth to a new family, and all its members have to get used to that.
Help with adjusting
Twenty years ago women often used to spend a week in hospital following the birth of their baby, recovering, and being fed and supported while they learned to feed and care for the infant; nowadays they often go home on the day of the birth, with little or no professional support. One study of experiences of new mothers suggested that lack of support was a key cause of PND. Home births may mean that more support is available, both from the midwife who attends the birth, and from family and friends.
Lack of support
It's easy to ask too much of mothers and motherhood. On the one hand, society idealises motherhood, requiring mothers to be open-armed, ever-giving sources of food and love. On the other, they are expected to achieve this impossible perfection by magic. Mothering is thought of as instinctive, not something that needs to be learned.
In the past, women learnt about motherhood in the large families that used to be common. When they became mothers, in turn, they could expect to call upon the help of their female relatives, young and old. Nowadays, many new mothers have to cope on their own, with, or without the help of their partner, and often neither of them has any previous experience. Not having these skills can feel like a crippling personal failure.
In the past, women learnt about motherhood in the large families that used to be common. When they became mothers, in turn, they could expect to call upon the help of their female relatives, young and old. Nowadays, many new mothers have to cope on their own, with, or without the help of their partner, and often neither of them has any previous experience. Not having these skills can feel like a crippling personal failure.
Other stresses to cope with
If you are under additional strain for any reason, you are more likely to become depressed. The cause could be an illness or death in the family, or because you are moving house or changing your job. Or it could be the result of longer-term difficulties, such as being unemployed, on a low-income or in poor housing.
You may be going through other life experiences which make it harder for you to cope with giving birth. Women who are giving birth in an unfamiliar environment, such as recent immigrants, refugees or asylum seekers, are likely to be more vulnerable to PND. Giving birth in a high tech hospital environment, surrounded by strangers rather than at home with family, brings many extra stresses, and women may feel unable to follow comforting rituals or practices which are an important part of their culture.
Evidence suggests that a new mother is more likely to become depressed if she has no-one to confide in, has no job outside the home and has three or more children under 14 years old living with her. These are all factors that involve some kind of loss and low self-esteem.
You may be going through other life experiences which make it harder for you to cope with giving birth. Women who are giving birth in an unfamiliar environment, such as recent immigrants, refugees or asylum seekers, are likely to be more vulnerable to PND. Giving birth in a high tech hospital environment, surrounded by strangers rather than at home with family, brings many extra stresses, and women may feel unable to follow comforting rituals or practices which are an important part of their culture.
Evidence suggests that a new mother is more likely to become depressed if she has no-one to confide in, has no job outside the home and has three or more children under 14 years old living with her. These are all factors that involve some kind of loss and low self-esteem.
Difficult labour
If you are unfortunate and have a difficult labour with a long and painful delivery, an unplanned caesarean section or emergency treatment, you may be suffering from a form of post-traumatic stress disorder rather than postnatal depression. The impact of this has been under-estimated, as people may feel that the baby is adequate compensation for the trauma and the new mother will soon forget the ordeal in the joy of motherhood; but traumatic childbirth may impair your relationships both with your baby, and your partner. You may feel acute disappointment that childbirth was not the wonderful experience you were hoping for, and feel angry with the obstetricians and midwives if you felt that the delivery was mismanaged. Many mothers avoid further pregnancy after a negative birth experience. Women who suffer traumatic childbirth should be treated for trauma and helped to put the experience behind them, to minimise the risk of developing long-term depression.
Changes to your body
You may also feel upset at the appearance of your body after childbirth. You may have unrealistic expectations about how soon your body may return to its normal size and shape after giving birth, and be upset by stretch marks or scars. Usually weight is lost gradually over a period of months rather than weeks, and scars will fade with time.
Hormonal upheaval
The hormones oestrogen and progesterone affect our emotions. Levels of progesterone are very high during pregnancy and some doctors believe that PND can be caused by the sudden drop in progesterone after the birth. But when women were given progesterone to try and prevent depression it had the reverse effect and the depression got worse, whereas treatment with an oestradiol patch is found to be helpful.
Diet
There is some evidence to show that a lack of certain nutrients during pregnancy can lead to depression; these include omega 3 oils (found in oily fish, seeds and nuts), magnesium (leafy green vegetables and seeds) and zinc (seeds and nuts). Poorly controlled blood sugar levels – caused by irregular eating or omitting the right types of food – can also have the same effect.
Childhood experiences
Your own childhood experiences can have a huge influence on the present. Sometimes, long-buried hurts can be forced to the surface by the shock of giving birth. In particular, if you were separated from your own mother for any length of time before the age of 10 or 11, you could be more vulnerable to postnatal depression. The separation could be because of illness, death or war. Or it could have been through being sent away to relatives (for the birth of a sibling, perhaps) or to boarding school. Some of these events might have been seen as unremarkable at the time, but they may still have been traumatic for you as a child. When these old sorrows emerge, in the form of depression, it can be frightening and bewildering. It's also potentially healing. With the right kind of support, you may be able to let go and move on.
Perinatal depression
The term 'perinatal' means around the time of birth – both before and after. Although depression is thought to be most commonly experienced by new mothers soon after the birth, some women experience depression during pregnancy, and research has suggested symptom scores for depression are higher during pregnancy than after the birth. One study has suggested that depression may in fact be more common before the birth than afterwards.
What can I do to help myself get better?
PND usually gets better in time, although it may take up to a year. Love, support and nurture from family, friends and community can be vital in helping you to cope.
Prescription medicine
A GP can prescribe various different kinds of medication to help, and it's important to discuss this fully, before taking any, and to keep monitoring progress. It is very important to remember that medication may enter breast milk, and if you are breastfeeding you will need to bear this in mind when deciding whether or not to take it. Some drugs have known effects on infants, while others appear to be quite safe, so it is important to discuss this with your doctor.
Manufacturers advise that the following antidepressants should be avoided while breastfeeding: doxepin; phenelzine, isocarboxazid, moclobemide; citalopram, escitalopram, fluoxetine, fluvoxamine, sertraline; duloxetine, venlafaxine; flupentixol, mirtazapine, reboxetine, and agomelatine.
Lithium, benzodiazepine tranquillisers and sleeping pills, zolpidem, zopiclone, and bupropion should also be avoided if you are breastfeeding.
Lithium, benzodiazepine tranquillisers and sleeping pills, zolpidem, zopiclone, and bupropion should also be avoided if you are breastfeeding.
All other drugs should be used with caution; talk to your doctor or a pharmacist if you need more advice about a particular drug.
If you do decide to try medication, it may be necessary to try different drugs to achieve the best results. All antidepressants take time to work. They also all have possible side effects, and when you stop taking them you should withdraw slowly, to avoid possible withdrawal effects which can be unpleasant. If you do take them, they can be very effective, and you should be prepared to take them for at least six months.
If you do decide to try medication, it may be necessary to try different drugs to achieve the best results. All antidepressants take time to work. They also all have possible side effects, and when you stop taking them you should withdraw slowly, to avoid possible withdrawal effects which can be unpleasant. If you do take them, they can be very effective, and you should be prepared to take them for at least six months.
Talking treatments, such as counselling and psychotherapy, offer you the opportunity to look at the underlying factors that have contributed to the PND, as well as helping you to change the way you feel. Many GPs have a counsellor or psychotherapist attached to the practice. They can also refer patients to a psychiatrist or psychologist on the NHS. Various organisations offer talking treatments, and some of them operate a low-fee scheme for those who can't afford to pay. Cognitive behaviour therapy is increasingly popular as a short-term treatment, providing you with practical strategies for dealing with problems
Although postnatal depression is mainly a problem for mothers, with causes that are at least partly physiological, in recent years it has increasingly been recognised that new fathers also become depressed. It has been suggested that as many as 1 in 25 new fathers are affected. The causes include the pressures of fatherhood, increased responsibility, the expense of having children and the change in life-style that it brings, the changed relationship with their partners, as well as lack of sleep and increased workload at home. Research has shown that in families where fathers were depressed soon after the birth, the children were at increased risk of emotional and behavioural problems, and boys were more affected than girls.
Depression in fathers is frequently associated with postnatal depression in mothers, and as with mothers, the father's depression may begin during the pregnancy, when relationships are already changing and they may feel left out while their partner is receiving increased attention as a pregnant woman. Studies have found that both midwives and health visitors may see fathers as problematic and potentially violent, and may marginalise them while working with the family. This may be exacerbated by the fact that men often express depression as hostility, and frequently lack close relationships with people they can confide in. Few services exist for men, although awareness and understanding of this problem is improving slowly.
Spotting the signs in others
Many mothers do not recognise they have postnatal depression, and do not talk to family and friends about their true feelings.
It's therefore important for partners, family members and friends to recognise signs of postnatal depression at an early stage. Warning signs include:
- they frequently cry for no obvious reason
- they have difficulties bonding with their baby
- they seem to be neglecting themselves – for example, not washing or changing clothes
- they seem to have lost all sense of time – often unaware if ten minutes or two hours have past
- they lose all sense of humour and cannot see the funny side of anything
- they worry something is wrong with their baby, regardless of reassurance
If you think someone you know has postnatal depression, encourage them to open up and talk about their feelings to you, a friend, GP, or health visitor.
Postnatal depression needs to be properly treated and isn't something you can just snap out of.
http://www.nhs.uk/conditions/Postnataldepression/Pages/Introduction.aspx
http://www.patient.co.uk/health/Depression-(Post-Natal).htm
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