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Postnatal depression
OBSTETRICS & GYNAECOLOGY
[ ,,
......
Mini-symposium: Mental disorders in pregnancy
Postnatal depression
C. A. H e n s h a w and J. L. Cox 10-15% of women become depressed within a year of childbirth. M o s t remain undetected
and untreated. Age, parity and social class are not associated with an increased risk but obstetric complications, particularly Caesarean section, may be. There is a striking association with having an unsupportive partner. Aetiological theories stem from biological psychological and social traditions. For some, biological factors may be important, for example thyroid antibody status, but in most women it is probably multifactorial. Screening in the weeks following childbirth using the Edinburgh Postnatal Depression Scale, treating appropriately and offering prophylaxis to women at risk, will reduce the distress to the patient, her partner and family and the impact on infant development. Increasing awareness of depression in fathers and the specific needs of ethnic minorities point the way to future service developments.
Introduction
Definition
Non-psychotic depression follows 10-15% of deliveries. However, it remains largely undetected and untreated. Over the last century, improvements in obstetric care have led to reductions in maternal and neonatal mortality and morbidity without a corresponding decrease in psychiatric morbidity. The two main psychiatric classification systems do not allow the separate recording of postnatal mental illnesses unless they cannot be classified elsewhere, the argument being that these disorders are not sufficiently different from similar illnesses occurring outwith the postnatal period to justify distinct classification. Evidence of adverse consequences for the infant and the growing awareness of the health economics of depression would point to their separate identification being vital in order to promote adequate definition and resourcing of services.
Postnatal depression (PND) is defined as a depression occurring within 1 year of childbirth. It is further classified as a major or minor depression according to the symptomatology.
Symptomatology Pitt, in 1968, described depression following childbirth as 'atypical' in that it was milder and accompanied by anxiety symptoms and reversal of the diurnal variation and late insomnia of 'classical' depressionso 1 However, most are typical depressive illnesses seen in the context of childbirth.2 The central disturbance is one of depressed mood and loss of pleasure (anhedonia) although this may not be immediately obvious. Many women put on the brave face of 'masked depression' through fears of being seen as an inadequate mother or of having her children taken away. Diurnal variation may be present and mood may also vary on a day-today basis. Anxiety frequently co-exists with low mood and
Dr C. A. Henshaw, John L. Cox, Department of Psychiatry, School of Postgraduate Medicine, Keele University, North
StaffordshireHospital Centre, ThorrlburrowDrive, Stokeon Trent ST4 6QB, UK Current Obstetrics and Gynaecology (1995) 5, 70-74
© 1995PearsonProfessionalLtd
70
POSTNATALDEPRESSION 71 may consist of excessive concerns over her own or the baby's health, e.g. excessive checking during the night in case the infant has stopped breathing and frequent consultations. She compares herself unfavourably to other mothers and feels as if she is the only one to feel like this. Guilt leads her to assume that it is all her fault and the common exhortations from others to 'snap out of it' only increase this when she finds she cannot. Physical symptoms of anxiety commonly occur and may include palpitations, tremor, breathlessness, dizziness, sweating and muscular tension. Panic attacks in which sudden onset of intense fear is accompanied by physical symptoms of anxiety may also be present. Sleep disturbance is frequent and may take the form of initial insomnia, waking during the night unnecessarily or waking earlier than usual in the morning. Fatigue and loss of energy are common in non-depressed women as a consequence of caring for an infant so are not particularly useful diagnostic symptoms. Appetite may be affected and may be either increased or decreased leading to changes in weight. This is also difficult to assess in postpartum women who may be losing weight or actively dieting. Anhedonia is usually accompanied by loss of libido. Careful enquiry will differentiate lack of libido from other reasons for reduced sexual activity such as dyspareunia or fatigue. Reduced concentration is common and confusion may present with an inability to remember whether actions have been performed. Severe depressions can lead to retardation in which there is difficulty initiating any action or alternatively restlessness and agitation may be present. Major and minor depression are defined by operational criteria such as Research Diagnostic Criteria (Table t). Enduring depressed mood for at least 2 weeks distinguishes depression from the 'blues', which occur in the first few days after delivery but which are transient and self-limiting.
Epidemiology Many studies have looked at the incidence or prevalence of P N D and produce rates of 9-21% (Table 2). A study in North Staffordshire by Cox, Murray & Chapman revealed that rates of depression
in postnatal women were no different from rates in women with older children. However, the postnatal women had a 3-fold increase in depressive onsets in the first month following delivery suggesting that childbirth is a specific trigger. 3 Age, parity, social class and obstetric factors have been found to be associated with P N D by some researchers but not by others. Social adversity does seem to increase the risk but complications during pregnancy or at delivery are probably not relevant. 4 Women who have an unexpectedly traumatic delivery may be particularly vulnerable and Caesarean section may be a risk factor. 5 There is a striking association between a poor marital relationship and postnatal depression although it is not clear whether this is casual or a consequence. Many partners of postnatally depressed women also have a psychiatric illness, mostly depression. 6 Women with a personal or family history of depression and those who have had a previous P N D are at increased risk.
Detection and screening Fears of being thought a bad mother, or worries that her children may be removed, may prevent a depressed mother from disclosing how she feels. It is therefore vital to assess this directly. Sympathetic inquiry as to how she is feeling will often be sufficient but many women will still be reticent. The Edinburgh Postnatal Depression Scale (EPDS) was developed by Cox, Holden & Sagovsky in 1987. 7 This is a self-rating scale easily completed in around 5 min and has become a widely used screening tool in clinical practice in the U K and internationally. It can be used by non-psychiatric health professionals to screen postnatal women or to confirm clinical suspicions, a It serves as an opening for women to begin to talk about their feelings. The optimum times to screen women are at 6-8 weeks and again at 12--14 and 20-26 weeks to pick up women whose illnesses onset later. A high score (> 12) suggests a depressive illness is likely and that further clinical assessment is required. However, unless clinical judgement indicates otherwise, a repeated EPDS a week later will differentiate sustained depression from more transient problems. The scale is valid and reliable (although not for use
Table 1 -- Research diagnostic criteria: major and minor depression Depressed mood for 2 weeks and evidenceof impaired function or sought help plus: Major depression Minor depression Four of the following: 1. Reduced/increasedappetite or weight loss/gain 2. Sleep disturbance 3. Loss of energy/fatigue 4. Anhedonia/loss of libido 5. Guilt 6. Difficultyconcentrating 7. Suicidal ideation 8. Retardation/agitation
Two of the following: 1-8. As in major depression plus 9. Crying 10. Pessimism 11. Broodingabout unpleasant things 12. Feelinginadequate 13. Feelingresentful/irritable/angry 14. Dependency/clinging 15. Self-pity 16. Somaticcomplaints
72
CURRENTOBSTETRICSAND GYNAECOLOGY Table2 -- Prevalencerates and sampling thaaesin studies of postnatal depression Year
Reference
Sampling t i m e
Country
Prevalence rate %
1968 1980 1982 1984 1984 1984 1988 1991 I993 1993 1994
Pitt Paykel Cox et al Kumar & Robson Watson et al O'Hara Cooper et al Campbell& Cohn Cox et al Pop et al Websteret al
6 weeks 5-8 weeks 3-5 months 3 months 6 weeks 9 weeks 1 year 2 months 6 months 10 weeks 4 weeks
UK UK UK UK UK USA UK USA UK Holland New Zealand
10.8 20 13 14 12 9 15.1 13.4 13.8 14 21.4
in the early puerperium) and can be used in pregnancy. It has been translated into an increasing number of languages but not validated in all. Aetiology Aetiological theories come under three main headings: biological, psychological and social. Biological As a result of its temporal proximity to childbirth and attendant hormonal changes, biological theories of PND have concentrated on the steroid hormones. These hormones are psychoactive and receptors are present in the brain. 9 Oestradiol is implicated in the triggering of puerperal psychosis but the picture in non-psychotic depression is not so clear. There is one controlled study showing that oestradiol improved treatment response in postnatally depressed women. 1° There is a possibility that the hypo-oestrogenic and hypoandrogenic state present in breastfeeding contributes to depressed mood and reduced sexual interest31 Progesterone has received much interest from researchers. Dalton claims that progesterone withdrawal is responsible for depressed mood in the puerperium and advocates a regime of progesterone to prevent it. a2 However, while there appears to be a weak association between progesterone profiles and the blues ~3 the role of falling progesterone in the genesis of depression has not yet been demonstrated. Abnormalities of the hypothalamopituitary axis are present in depression. Cortisol can induce mental symptoms including depression, rises during and falls after childbirth but may not be related to subsequent depression. High cortisol levels in late pregnancy have been found in women who subsequently had blues, 14 and both blues ~5 and early postpartum euphoria ~6 may be risk factors for subsequent depression. Other possible culprits are prolactin and the endogenous opiate beta endorphin, concentrations of which have been correlated with dysphoric symptoms in the puerperium in some studies. It has been suggested that withdrawal of endorphins may contribute to postnatal depression.
Hyperprolactinaemia may cause dysphoric symptoms and there is some evidence of abnormalities in prolactin secretion in unipolar non-puerperal depression and in one study in postnatal women but this theory remains unproven. For a subgroup of women, thyroid abnormalities are undoubtedly of aetiological significance. Harris and co-workers have shown that euthyroid women with thyroid antibodies were more likely to become depressed following childbirth. 17 Harris argues that all postnatal women should be screened for thyroid antibodies. The role of biochemical factors including neurotransmitters such as noradrenaline, serotonin, dopamine and precursors such as tryptophan is established in non-puerperal depression and it is likely that the hormonal changes of parturition can trigger neuroendocrine abnormalities in vulnerable women. However, the significance of many of the studies looking at indices of neurotransmitter function in the puerperium is unclear. One study found that a marker for endogenous depression, the tyramine test, did not indicate vulnerability to postnatal depression. ~8 Biological factors are probably particularly important for wonlen whose onset o f depression is early but different hormonal or biochemical factors may be important for different subgroups of women.
Social Biological factors do not occur in isolation. Consequently psychosocial theories have also been explored. Brown and Harris 19 highlighted vulnerability factors for depression in women: ® Death of her own mother before the age of 11 , 3 children under the age of 5 No outside employment , Lack of a close confiding relationship. These are relevant to postnatal women. In addition the rote of life-events is well recognised in the genesis of depressive illnesses and any postnatal woman experiencing adverse life-events such as bereavement is likely to be at increased risk. z°
POSTNATAL DEPRESSION
Psychological Personality theories have also been proposed. Neuroticism has long been implicated and Boyce et al have shown that postnatal women with a high degree of neuroticism and high interpersonal sensitivity are more vulnerable to depression. Cognitive style has also been implicated, but while clinical experience suggests that many puerperal depressives have dysfunctional cognitive styles or obsessional personality traits, studies are conflicting.21
Consequences The distress endured by the mother and her family is obvious but the consequences of PND are more wide-ranging. It is now undisputed that the development of infants of depressed mothers is compromised. They are more likely to fail on cognitive tasks, have more insecure attachments and increased behaviour problems, e.g. sleep disturbance, temper tantrums, food fads and clinging at 18 months. 22 At 5-year followup, boys were more likely to be disturbed and hyperactive in the classroom while the girls were less distractable, more prosocial and compliant; qualities which may seem desirable but which may not be adaptive. The effects were more marked in children of lower social class. These effects may be mediated by treatment and the outcome of treatment studies is awaited. Preliminary work in Stoke on Trent (unpublished) suggests that the older siblings may not be affected as severely. The health economics of mental illness are of increasing importance and depression is one of the major health costs to the nation. 23 In addition, many households are now reliant on two incomes or the mother may be the only wage earner in a household and a delay in returning to work as a result of depression can have devastating economic effects. The stigma of mental illness remains for all, but for particular ethnic groups puerperal depression may result in divorce or render a woman's children unmarriageable in the future. Such factors prevent women in many ethnic minorities from accessing treatment.
Assessment Once a puerperal depression is suspected, a careful history and mental state examination should be carried out. This includes the onset, duration and features of the illness and the personal and family history of mental illness. Some assessment is required of the level of support available from the partner, other family members or agencies who may be involved. Current and previous drug therapy should be ascertained. It is vital to enquire about suicidal and infanticidal ideas and the presence of psychotic symptoms such as delusions and hallucinations. Any woman with symptoms in these areas needs urgent psychiatric assessment.
73
Other areas which require sensitive enquiry at some point, but probably not at the first interview, are previous or current abuse and marital or sexual difficulties. These may require tackling in their own right during therapy or referral later to other agencies. Healthcare workers need to be aware of their obligations under the Children's Act if a child is thought to be at risk. 24
Treatment Once detected, it is vital, for the reasons outlined above, to actively treat PND. There are a number of treatment possibilities available, and a variety of treatment settings.
Psychological treatments Mild depressions without the so-called 'biological' symptoms of diurnal variation of mood, early morning wakening and anhedonia have been shown to respond to non-directive counselling given by health visitors who can be trained to provide this therapy in the woman's own h o m e y For the more severely affected, cognitive therapy may be useful which is usually undertaken by a clinical psychologist in an outpatient clinic. Drug therapy Mental state examination will reveal the presence of the 'biological' symptoms which predict response to antidepressant drugs. A non-sedative drug should be used. If she is breastfeeding, a tricyclic antidepressant, e.g. lofepramine, is advised as only small amounts are excreted and it does not appear to accumulate in the baby. In a non-lactating mother, a wider choice of drugs, including selective serotonin reuptake inhibitors, is available. Drug treatment can be carried out by the primary care team and should be accompanied by supportive counselling. If this strategy fails, referral to a psychiatrist would be appropriate. It is crucial to continue to monitor for psychotic symptoms, suicidal and infanticidal ideas during treatment. Once recovery has been achieved, antidepressant therapy should be continued at the dose which achieved recovery for a further 6 months before gradual withdrawal.
Hormonal treatments Hormones particularly progesterone are popular but progesterone has not undergone controlled trials to establish its effectiveness. Oestradiol may be effective but will require concomitant progestogen and possibly endometrial biopsies to prevent endometrial carcinoma. When is admission necessary? Admission should be considered for any woman who is suicidal, feels she may harm her baby or has developed psychotic symptoms. Ideally she should be
74
CURRENT OBSTETRICS AND GYNAECOLOGY
a d m i t t e d with her b a b y in a facility enabling the b a b y to be c a r e d for if she is u n a b l e to o r this becomes d a n g e r o u s . E C T is often used in severe p o s t n a t a l depression as the response is m o r e r a p i d t h a n d r u g t h e r a p y a n d allows the m o t h e r to r e t u r n m o r e quickly to her family. D u r i n g a n y t r e a t m e n t p r o g r a m m e , the p a r t n e r a n d o t h e r family m e m b e r s s h o u l d be involved a n d s u p p o r t e d . I f a w o m a n is in psychiatric care, c o n t i n u e d c o n t a c t with the p r i m a r y care t e a m is essential in o r d e r t h a t discharge a r r a n g e m e n t s are watertight. Awareness o f the levels o f m o r b i d i t y in fathers m e a n s t h a t every o p p o r t u n i t y to include t h e m should be t a k e n a l t h o u g h this c a n p r o v e difficult.
Voluntary organisations T h e following o r g a n i s a t i o n s can offer i n v a l u a b l e support: • • • •
N a t i o n a l C h i l d b i r t h Trust Meet a Mum Association (MAMA) N e w Pin T h e A s s o c i a t i o n for P o s t n a t a l M e n t a l Illness
T h e p a r t i c u l a r difficulties faced b y ethnic m i n o r i t i e s need to be a d d r e s s e d a n d m a y require the assistance o f interpreters a n d link w o r k e r s to facilitate reaching w o m e n in these g r o u p s w h o are often p r e v e n t e d f r o m accessing t r e a t m e n t .
Prevention M a n y factors which m a y influence depression are n o t within the physicians direct control, e.g. social adversity, u n e m p l o y m e n t etc. R e d u c t i o n o f the stigma o f m e n t a l illness is likely to be beneficial. E d u c a t i n g children a b o u t p a r e n t i n g m e n t a l illness m a y help, as w o u l d including P N D in the p a c k a g e offered to e x p e c t a n t parents. E d u c a t i o n o f h e a l t h c a r e w o r k e r s b o t h in p r i m a r y care a n d h o s p i t a l should increase the awareness o f P N D . R o u t i n e screening o f all p o s t n a t a l w o m e n a n d training o f specific h e a l t h professionals in c o n t a c t with m o t h e r s is vital. P r o p h y l a x i s s h o u l d be offered to w o m e n w h o are at risk, i.e. those with p r e v i o u s P N D or a p r i m i p a r o u s w o m a n with a h i s t o r y o f depression. M i d w i v e s a n d obstetricians are ideally p l a c e d to detect these w o m e n a n t e n a t a l l y a n d they s h o u l d be offered assessment, s u p p o r t a n d m o n i t o r i n g into the p u e r p e r i u m a n d d r u g t r e a t m e n t if this is indicated. Tricyclic drugs can be given in full t h e r a p e u t i c dose in late p r e g n a n c y a n d s h o u l d be c o n t i n u e d for a few m o n t h s after delivery. A n y risk to the b a b y is confined to a possible w i t h d r a w a l in the first 2 4 - 2 8 h after delivery w h i c h has n o l o n g - t e r m consequences. F i n a l l y , w o m e n suffering a p o s t n a t a I depression s h o u l d receive effective a n d a d e q u a t e t r e a t m e n t to reduce the distress they a n d their families experience a n d to m i t i g a t e the consequences. This care s h o u l d
be given b y a w a r e a n d c o m p e t e n t p r i m a r y h e a l t h c a r e professionals. F a m i l i e s w h o need psychiatric interv e n t i o n should have access to a specialist team.
References 1. Pitt B. Depression following childbirth. Br J Psychiatry 1968; 114:1325 35 2. Whiffen VE. Is postpartum depression a distinct diagnosis? Clin Psychol Rev 1992; 12:485 508 3. Cox JL, Murray D, Chapman G. A controlled study of the onset, duration and prevalence of postnatal depression. Br J Psychiatry 1993; 163: 27-3l 4. Stein A, Cooper PJ, Campbell EA et al. Social adversity and perinatal complications: their relationship to postnatal depression. Br Med J 1989; 298:1073-74 5. Boyce PM, Todd AL. Increased risk of postnatal depression after emergency caesarean section. Med J Austr 1992; 157: 172-4 6. Ballard CG, Davis R, Cullen PC et aI. Prevalence of postnatal psychiatric morbidity in mothers and fathers. Br J Psychiatry 1994; 164:782-8 7. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987; 150:782-6 8. Holden J. Using the Edinburgh Postnatal Depression Scale in clinical practice. In: Cox J, Holden J (Eds). Perinatal psychiatry: use and misuse of the Edinburgh Postnatal Depression Scale. London: Gaskell, 1994; 125-144 9. George A, Sandler M. Endocrine and biochemical studies in puerperal mental disorders. In: Kumar R, Brockington IF (Eds). Motherhood and mental illness, 2: Causes and consequences. London: Wright, I988:78-112 10. Henderson AF, Gregoire AJP, Kumar R et al. Treatment of severe postnatal depression with oestradiol skin patches. Lancet 1991; 338:816-7 11. Aider EM, Cook A, Davidson D et al. Hormones, mood and sexuality in lactating women. Br J Psychiatry 1986; 148:74-9 12. Dalton K. Progesterone prophylaxis used successfully in postnatal depression. Practitioner 1985; 229:507-8 13. Harris B, Lovett L, Newcombe RG et al. Maternity blues and major endocrine changes: Cardiff puerperal mood and hormone study II. Br Med J 1994; 308:949-53 14. Handley SL, Dunn TL, Waldron G e t al. Tryptophan, cortisol and puerperal mood. Br J Psychiatry 1980; 136: 498-508 15. Cox JL, Connor Y, Kendell RE. Prospective study of the psychiatric disorders of childbirth. Br J Psychiatry 1982; 140: 111-7 16. Glover V, Liddle P, Taylor A et al. Mild hypomania (the highs) can be a feature of the first postpartum week: association with later depression. Br J Psychiatry. 1994; 164: 517-21 17. Harris B, Othman S, Davies JA et al. Association between postpartum thyroid dysfunction and thyroid antibodies and depression. BMJ 1992; 305:152-6 18. Hannah P, Cody D, Glover Vet al. The tyramme test is not a marker for postnatal depression: early postpartum euphoria may be. J Psychsom Obstet Gynaecol I993; 295-304 19. Brown GW, Harris T. The social origins of depression. London: Tavistock Press, 1978 20. Paykel ES, Emms EM, Fletcher Jet al. Life events and social support in puerperal depression. Br J Psychiatry i980; 136:339-46 21. Boyce P. Personality dysfunction, marital probIems and postnatal depression. In: Cox J, Holden J (Eds). Perinatal psychiatry: use and misuse of the Edinburgh Postnatal Depression Scale. London: Gaskell, 1994; 82-102 22. Murray L. The impact of postnatal depression on infant development, J Child Psychol Psychiatry 1992; 33:543-61 23. Jonsson B, Rosenbaum J, eds. The health economics of depression. Chichester: Wiley, 1993 24. Department of Health. The Children Act 1989: an introductory guide for the NHS. London: HMSO, 1992 25. Holden JM, Sagovsky R, Cox JL. Counselling in a general practice setting: a controlled study of health visitor intervention in the treatment of postnatal depression. Br Med J 1989; 298:223-6
[ ,,
......
Mini-symposium: Mental disorders in pregnancy
Postnatal depression
C. A. H e n s h a w and J. L. Cox 10-15% of women become depressed within a year of childbirth. M o s t remain undetected
and untreated. Age, parity and social class are not associated with an increased risk but obstetric complications, particularly Caesarean section, may be. There is a striking association with having an unsupportive partner. Aetiological theories stem from biological psychological and social traditions. For some, biological factors may be important, for example thyroid antibody status, but in most women it is probably multifactorial. Screening in the weeks following childbirth using the Edinburgh Postnatal Depression Scale, treating appropriately and offering prophylaxis to women at risk, will reduce the distress to the patient, her partner and family and the impact on infant development. Increasing awareness of depression in fathers and the specific needs of ethnic minorities point the way to future service developments.
Introduction
Definition
Non-psychotic depression follows 10-15% of deliveries. However, it remains largely undetected and untreated. Over the last century, improvements in obstetric care have led to reductions in maternal and neonatal mortality and morbidity without a corresponding decrease in psychiatric morbidity. The two main psychiatric classification systems do not allow the separate recording of postnatal mental illnesses unless they cannot be classified elsewhere, the argument being that these disorders are not sufficiently different from similar illnesses occurring outwith the postnatal period to justify distinct classification. Evidence of adverse consequences for the infant and the growing awareness of the health economics of depression would point to their separate identification being vital in order to promote adequate definition and resourcing of services.
Postnatal depression (PND) is defined as a depression occurring within 1 year of childbirth. It is further classified as a major or minor depression according to the symptomatology.
Symptomatology Pitt, in 1968, described depression following childbirth as 'atypical' in that it was milder and accompanied by anxiety symptoms and reversal of the diurnal variation and late insomnia of 'classical' depressionso 1 However, most are typical depressive illnesses seen in the context of childbirth.2 The central disturbance is one of depressed mood and loss of pleasure (anhedonia) although this may not be immediately obvious. Many women put on the brave face of 'masked depression' through fears of being seen as an inadequate mother or of having her children taken away. Diurnal variation may be present and mood may also vary on a day-today basis. Anxiety frequently co-exists with low mood and
Dr C. A. Henshaw, John L. Cox, Department of Psychiatry, School of Postgraduate Medicine, Keele University, North
StaffordshireHospital Centre, ThorrlburrowDrive, Stokeon Trent ST4 6QB, UK Current Obstetrics and Gynaecology (1995) 5, 70-74
© 1995PearsonProfessionalLtd
70
POSTNATALDEPRESSION 71 may consist of excessive concerns over her own or the baby's health, e.g. excessive checking during the night in case the infant has stopped breathing and frequent consultations. She compares herself unfavourably to other mothers and feels as if she is the only one to feel like this. Guilt leads her to assume that it is all her fault and the common exhortations from others to 'snap out of it' only increase this when she finds she cannot. Physical symptoms of anxiety commonly occur and may include palpitations, tremor, breathlessness, dizziness, sweating and muscular tension. Panic attacks in which sudden onset of intense fear is accompanied by physical symptoms of anxiety may also be present. Sleep disturbance is frequent and may take the form of initial insomnia, waking during the night unnecessarily or waking earlier than usual in the morning. Fatigue and loss of energy are common in non-depressed women as a consequence of caring for an infant so are not particularly useful diagnostic symptoms. Appetite may be affected and may be either increased or decreased leading to changes in weight. This is also difficult to assess in postpartum women who may be losing weight or actively dieting. Anhedonia is usually accompanied by loss of libido. Careful enquiry will differentiate lack of libido from other reasons for reduced sexual activity such as dyspareunia or fatigue. Reduced concentration is common and confusion may present with an inability to remember whether actions have been performed. Severe depressions can lead to retardation in which there is difficulty initiating any action or alternatively restlessness and agitation may be present. Major and minor depression are defined by operational criteria such as Research Diagnostic Criteria (Table t). Enduring depressed mood for at least 2 weeks distinguishes depression from the 'blues', which occur in the first few days after delivery but which are transient and self-limiting.
Epidemiology Many studies have looked at the incidence or prevalence of P N D and produce rates of 9-21% (Table 2). A study in North Staffordshire by Cox, Murray & Chapman revealed that rates of depression
in postnatal women were no different from rates in women with older children. However, the postnatal women had a 3-fold increase in depressive onsets in the first month following delivery suggesting that childbirth is a specific trigger. 3 Age, parity, social class and obstetric factors have been found to be associated with P N D by some researchers but not by others. Social adversity does seem to increase the risk but complications during pregnancy or at delivery are probably not relevant. 4 Women who have an unexpectedly traumatic delivery may be particularly vulnerable and Caesarean section may be a risk factor. 5 There is a striking association between a poor marital relationship and postnatal depression although it is not clear whether this is casual or a consequence. Many partners of postnatally depressed women also have a psychiatric illness, mostly depression. 6 Women with a personal or family history of depression and those who have had a previous P N D are at increased risk.
Detection and screening Fears of being thought a bad mother, or worries that her children may be removed, may prevent a depressed mother from disclosing how she feels. It is therefore vital to assess this directly. Sympathetic inquiry as to how she is feeling will often be sufficient but many women will still be reticent. The Edinburgh Postnatal Depression Scale (EPDS) was developed by Cox, Holden & Sagovsky in 1987. 7 This is a self-rating scale easily completed in around 5 min and has become a widely used screening tool in clinical practice in the U K and internationally. It can be used by non-psychiatric health professionals to screen postnatal women or to confirm clinical suspicions, a It serves as an opening for women to begin to talk about their feelings. The optimum times to screen women are at 6-8 weeks and again at 12--14 and 20-26 weeks to pick up women whose illnesses onset later. A high score (> 12) suggests a depressive illness is likely and that further clinical assessment is required. However, unless clinical judgement indicates otherwise, a repeated EPDS a week later will differentiate sustained depression from more transient problems. The scale is valid and reliable (although not for use
Table 1 -- Research diagnostic criteria: major and minor depression Depressed mood for 2 weeks and evidenceof impaired function or sought help plus: Major depression Minor depression Four of the following: 1. Reduced/increasedappetite or weight loss/gain 2. Sleep disturbance 3. Loss of energy/fatigue 4. Anhedonia/loss of libido 5. Guilt 6. Difficultyconcentrating 7. Suicidal ideation 8. Retardation/agitation
Two of the following: 1-8. As in major depression plus 9. Crying 10. Pessimism 11. Broodingabout unpleasant things 12. Feelinginadequate 13. Feelingresentful/irritable/angry 14. Dependency/clinging 15. Self-pity 16. Somaticcomplaints
72
CURRENTOBSTETRICSAND GYNAECOLOGY Table2 -- Prevalencerates and sampling thaaesin studies of postnatal depression Year
Reference
Sampling t i m e
Country
Prevalence rate %
1968 1980 1982 1984 1984 1984 1988 1991 I993 1993 1994
Pitt Paykel Cox et al Kumar & Robson Watson et al O'Hara Cooper et al Campbell& Cohn Cox et al Pop et al Websteret al
6 weeks 5-8 weeks 3-5 months 3 months 6 weeks 9 weeks 1 year 2 months 6 months 10 weeks 4 weeks
UK UK UK UK UK USA UK USA UK Holland New Zealand
10.8 20 13 14 12 9 15.1 13.4 13.8 14 21.4
in the early puerperium) and can be used in pregnancy. It has been translated into an increasing number of languages but not validated in all. Aetiology Aetiological theories come under three main headings: biological, psychological and social. Biological As a result of its temporal proximity to childbirth and attendant hormonal changes, biological theories of PND have concentrated on the steroid hormones. These hormones are psychoactive and receptors are present in the brain. 9 Oestradiol is implicated in the triggering of puerperal psychosis but the picture in non-psychotic depression is not so clear. There is one controlled study showing that oestradiol improved treatment response in postnatally depressed women. 1° There is a possibility that the hypo-oestrogenic and hypoandrogenic state present in breastfeeding contributes to depressed mood and reduced sexual interest31 Progesterone has received much interest from researchers. Dalton claims that progesterone withdrawal is responsible for depressed mood in the puerperium and advocates a regime of progesterone to prevent it. a2 However, while there appears to be a weak association between progesterone profiles and the blues ~3 the role of falling progesterone in the genesis of depression has not yet been demonstrated. Abnormalities of the hypothalamopituitary axis are present in depression. Cortisol can induce mental symptoms including depression, rises during and falls after childbirth but may not be related to subsequent depression. High cortisol levels in late pregnancy have been found in women who subsequently had blues, 14 and both blues ~5 and early postpartum euphoria ~6 may be risk factors for subsequent depression. Other possible culprits are prolactin and the endogenous opiate beta endorphin, concentrations of which have been correlated with dysphoric symptoms in the puerperium in some studies. It has been suggested that withdrawal of endorphins may contribute to postnatal depression.
Hyperprolactinaemia may cause dysphoric symptoms and there is some evidence of abnormalities in prolactin secretion in unipolar non-puerperal depression and in one study in postnatal women but this theory remains unproven. For a subgroup of women, thyroid abnormalities are undoubtedly of aetiological significance. Harris and co-workers have shown that euthyroid women with thyroid antibodies were more likely to become depressed following childbirth. 17 Harris argues that all postnatal women should be screened for thyroid antibodies. The role of biochemical factors including neurotransmitters such as noradrenaline, serotonin, dopamine and precursors such as tryptophan is established in non-puerperal depression and it is likely that the hormonal changes of parturition can trigger neuroendocrine abnormalities in vulnerable women. However, the significance of many of the studies looking at indices of neurotransmitter function in the puerperium is unclear. One study found that a marker for endogenous depression, the tyramine test, did not indicate vulnerability to postnatal depression. ~8 Biological factors are probably particularly important for wonlen whose onset o f depression is early but different hormonal or biochemical factors may be important for different subgroups of women.
Social Biological factors do not occur in isolation. Consequently psychosocial theories have also been explored. Brown and Harris 19 highlighted vulnerability factors for depression in women: ® Death of her own mother before the age of 11 , 3 children under the age of 5 No outside employment , Lack of a close confiding relationship. These are relevant to postnatal women. In addition the rote of life-events is well recognised in the genesis of depressive illnesses and any postnatal woman experiencing adverse life-events such as bereavement is likely to be at increased risk. z°
POSTNATAL DEPRESSION
Psychological Personality theories have also been proposed. Neuroticism has long been implicated and Boyce et al have shown that postnatal women with a high degree of neuroticism and high interpersonal sensitivity are more vulnerable to depression. Cognitive style has also been implicated, but while clinical experience suggests that many puerperal depressives have dysfunctional cognitive styles or obsessional personality traits, studies are conflicting.21
Consequences The distress endured by the mother and her family is obvious but the consequences of PND are more wide-ranging. It is now undisputed that the development of infants of depressed mothers is compromised. They are more likely to fail on cognitive tasks, have more insecure attachments and increased behaviour problems, e.g. sleep disturbance, temper tantrums, food fads and clinging at 18 months. 22 At 5-year followup, boys were more likely to be disturbed and hyperactive in the classroom while the girls were less distractable, more prosocial and compliant; qualities which may seem desirable but which may not be adaptive. The effects were more marked in children of lower social class. These effects may be mediated by treatment and the outcome of treatment studies is awaited. Preliminary work in Stoke on Trent (unpublished) suggests that the older siblings may not be affected as severely. The health economics of mental illness are of increasing importance and depression is one of the major health costs to the nation. 23 In addition, many households are now reliant on two incomes or the mother may be the only wage earner in a household and a delay in returning to work as a result of depression can have devastating economic effects. The stigma of mental illness remains for all, but for particular ethnic groups puerperal depression may result in divorce or render a woman's children unmarriageable in the future. Such factors prevent women in many ethnic minorities from accessing treatment.
Assessment Once a puerperal depression is suspected, a careful history and mental state examination should be carried out. This includes the onset, duration and features of the illness and the personal and family history of mental illness. Some assessment is required of the level of support available from the partner, other family members or agencies who may be involved. Current and previous drug therapy should be ascertained. It is vital to enquire about suicidal and infanticidal ideas and the presence of psychotic symptoms such as delusions and hallucinations. Any woman with symptoms in these areas needs urgent psychiatric assessment.
73
Other areas which require sensitive enquiry at some point, but probably not at the first interview, are previous or current abuse and marital or sexual difficulties. These may require tackling in their own right during therapy or referral later to other agencies. Healthcare workers need to be aware of their obligations under the Children's Act if a child is thought to be at risk. 24
Treatment Once detected, it is vital, for the reasons outlined above, to actively treat PND. There are a number of treatment possibilities available, and a variety of treatment settings.
Psychological treatments Mild depressions without the so-called 'biological' symptoms of diurnal variation of mood, early morning wakening and anhedonia have been shown to respond to non-directive counselling given by health visitors who can be trained to provide this therapy in the woman's own h o m e y For the more severely affected, cognitive therapy may be useful which is usually undertaken by a clinical psychologist in an outpatient clinic. Drug therapy Mental state examination will reveal the presence of the 'biological' symptoms which predict response to antidepressant drugs. A non-sedative drug should be used. If she is breastfeeding, a tricyclic antidepressant, e.g. lofepramine, is advised as only small amounts are excreted and it does not appear to accumulate in the baby. In a non-lactating mother, a wider choice of drugs, including selective serotonin reuptake inhibitors, is available. Drug treatment can be carried out by the primary care team and should be accompanied by supportive counselling. If this strategy fails, referral to a psychiatrist would be appropriate. It is crucial to continue to monitor for psychotic symptoms, suicidal and infanticidal ideas during treatment. Once recovery has been achieved, antidepressant therapy should be continued at the dose which achieved recovery for a further 6 months before gradual withdrawal.
Hormonal treatments Hormones particularly progesterone are popular but progesterone has not undergone controlled trials to establish its effectiveness. Oestradiol may be effective but will require concomitant progestogen and possibly endometrial biopsies to prevent endometrial carcinoma. When is admission necessary? Admission should be considered for any woman who is suicidal, feels she may harm her baby or has developed psychotic symptoms. Ideally she should be
74
CURRENT OBSTETRICS AND GYNAECOLOGY
a d m i t t e d with her b a b y in a facility enabling the b a b y to be c a r e d for if she is u n a b l e to o r this becomes d a n g e r o u s . E C T is often used in severe p o s t n a t a l depression as the response is m o r e r a p i d t h a n d r u g t h e r a p y a n d allows the m o t h e r to r e t u r n m o r e quickly to her family. D u r i n g a n y t r e a t m e n t p r o g r a m m e , the p a r t n e r a n d o t h e r family m e m b e r s s h o u l d be involved a n d s u p p o r t e d . I f a w o m a n is in psychiatric care, c o n t i n u e d c o n t a c t with the p r i m a r y care t e a m is essential in o r d e r t h a t discharge a r r a n g e m e n t s are watertight. Awareness o f the levels o f m o r b i d i t y in fathers m e a n s t h a t every o p p o r t u n i t y to include t h e m should be t a k e n a l t h o u g h this c a n p r o v e difficult.
Voluntary organisations T h e following o r g a n i s a t i o n s can offer i n v a l u a b l e support: • • • •
N a t i o n a l C h i l d b i r t h Trust Meet a Mum Association (MAMA) N e w Pin T h e A s s o c i a t i o n for P o s t n a t a l M e n t a l Illness
T h e p a r t i c u l a r difficulties faced b y ethnic m i n o r i t i e s need to be a d d r e s s e d a n d m a y require the assistance o f interpreters a n d link w o r k e r s to facilitate reaching w o m e n in these g r o u p s w h o are often p r e v e n t e d f r o m accessing t r e a t m e n t .
Prevention M a n y factors which m a y influence depression are n o t within the physicians direct control, e.g. social adversity, u n e m p l o y m e n t etc. R e d u c t i o n o f the stigma o f m e n t a l illness is likely to be beneficial. E d u c a t i n g children a b o u t p a r e n t i n g m e n t a l illness m a y help, as w o u l d including P N D in the p a c k a g e offered to e x p e c t a n t parents. E d u c a t i o n o f h e a l t h c a r e w o r k e r s b o t h in p r i m a r y care a n d h o s p i t a l should increase the awareness o f P N D . R o u t i n e screening o f all p o s t n a t a l w o m e n a n d training o f specific h e a l t h professionals in c o n t a c t with m o t h e r s is vital. P r o p h y l a x i s s h o u l d be offered to w o m e n w h o are at risk, i.e. those with p r e v i o u s P N D or a p r i m i p a r o u s w o m a n with a h i s t o r y o f depression. M i d w i v e s a n d obstetricians are ideally p l a c e d to detect these w o m e n a n t e n a t a l l y a n d they s h o u l d be offered assessment, s u p p o r t a n d m o n i t o r i n g into the p u e r p e r i u m a n d d r u g t r e a t m e n t if this is indicated. Tricyclic drugs can be given in full t h e r a p e u t i c dose in late p r e g n a n c y a n d s h o u l d be c o n t i n u e d for a few m o n t h s after delivery. A n y risk to the b a b y is confined to a possible w i t h d r a w a l in the first 2 4 - 2 8 h after delivery w h i c h has n o l o n g - t e r m consequences. F i n a l l y , w o m e n suffering a p o s t n a t a I depression s h o u l d receive effective a n d a d e q u a t e t r e a t m e n t to reduce the distress they a n d their families experience a n d to m i t i g a t e the consequences. This care s h o u l d
be given b y a w a r e a n d c o m p e t e n t p r i m a r y h e a l t h c a r e professionals. F a m i l i e s w h o need psychiatric interv e n t i o n should have access to a specialist team.
References 1. Pitt B. Depression following childbirth. Br J Psychiatry 1968; 114:1325 35 2. Whiffen VE. Is postpartum depression a distinct diagnosis? Clin Psychol Rev 1992; 12:485 508 3. Cox JL, Murray D, Chapman G. A controlled study of the onset, duration and prevalence of postnatal depression. Br J Psychiatry 1993; 163: 27-3l 4. Stein A, Cooper PJ, Campbell EA et al. Social adversity and perinatal complications: their relationship to postnatal depression. Br Med J 1989; 298:1073-74 5. Boyce PM, Todd AL. Increased risk of postnatal depression after emergency caesarean section. Med J Austr 1992; 157: 172-4 6. Ballard CG, Davis R, Cullen PC et aI. Prevalence of postnatal psychiatric morbidity in mothers and fathers. Br J Psychiatry 1994; 164:782-8 7. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987; 150:782-6 8. Holden J. Using the Edinburgh Postnatal Depression Scale in clinical practice. In: Cox J, Holden J (Eds). Perinatal psychiatry: use and misuse of the Edinburgh Postnatal Depression Scale. London: Gaskell, 1994; 125-144 9. George A, Sandler M. Endocrine and biochemical studies in puerperal mental disorders. In: Kumar R, Brockington IF (Eds). Motherhood and mental illness, 2: Causes and consequences. London: Wright, I988:78-112 10. Henderson AF, Gregoire AJP, Kumar R et al. Treatment of severe postnatal depression with oestradiol skin patches. Lancet 1991; 338:816-7 11. Aider EM, Cook A, Davidson D et al. Hormones, mood and sexuality in lactating women. Br J Psychiatry 1986; 148:74-9 12. Dalton K. Progesterone prophylaxis used successfully in postnatal depression. Practitioner 1985; 229:507-8 13. Harris B, Lovett L, Newcombe RG et al. Maternity blues and major endocrine changes: Cardiff puerperal mood and hormone study II. Br Med J 1994; 308:949-53 14. Handley SL, Dunn TL, Waldron G e t al. Tryptophan, cortisol and puerperal mood. Br J Psychiatry 1980; 136: 498-508 15. Cox JL, Connor Y, Kendell RE. Prospective study of the psychiatric disorders of childbirth. Br J Psychiatry 1982; 140: 111-7 16. Glover V, Liddle P, Taylor A et al. Mild hypomania (the highs) can be a feature of the first postpartum week: association with later depression. Br J Psychiatry. 1994; 164: 517-21 17. Harris B, Othman S, Davies JA et al. Association between postpartum thyroid dysfunction and thyroid antibodies and depression. BMJ 1992; 305:152-6 18. Hannah P, Cody D, Glover Vet al. The tyramme test is not a marker for postnatal depression: early postpartum euphoria may be. J Psychsom Obstet Gynaecol I993; 295-304 19. Brown GW, Harris T. The social origins of depression. London: Tavistock Press, 1978 20. Paykel ES, Emms EM, Fletcher Jet al. Life events and social support in puerperal depression. Br J Psychiatry i980; 136:339-46 21. Boyce P. Personality dysfunction, marital probIems and postnatal depression. In: Cox J, Holden J (Eds). Perinatal psychiatry: use and misuse of the Edinburgh Postnatal Depression Scale. London: Gaskell, 1994; 82-102 22. Murray L. The impact of postnatal depression on infant development, J Child Psychol Psychiatry 1992; 33:543-61 23. Jonsson B, Rosenbaum J, eds. The health economics of depression. Chichester: Wiley, 1993 24. Department of Health. The Children Act 1989: an introductory guide for the NHS. London: HMSO, 1992 25. Holden JM, Sagovsky R, Cox JL. Counselling in a general practice setting: a controlled study of health visitor intervention in the treatment of postnatal depression. Br Med J 1989; 298:223-6