Ruth DeSouza » Mental Health »Postnatal depression

Postnatal depression and more

I have been teaching community groups, students and professionals about maternal mental health for over twelve years. Wwomen have a lifetime prevalence of major depression that is almost twice that of men. In terms of labels, I am concerned about the narrow focus on postnatal depression (PND) rather than considering the spectrum of depressive and anxiety disorders that can arise in the peri-natal period (pregnancy and the first year postpartum) and that in addition women can have experiences that go beyond the familiar triad of blues, depression and postnatal psychosis such as: New or recurring episode of mental illness Varying degrees of anxiety (panic, OCD) Post-traumatic stress disorders following traumatic deliveries Bonding disorders Drug and alcohol abuse Women are more likely to develop emotional problems after childbirth than at any other time in their lives especially in the first three months. Women with a pre-existing psychiatric disorder can also face a relapse or recurrence of their condition. Psychiatric illness occurring at this time can have an adverse effect not only on the women herself but on her relationship, family and the future development of her infant. Labels are problematic too as they can be a catch all term for very different experiences. Family support is critical as is support for partners.

Have a look at the new PND brochure Wairua Consulting developed in consultation with consumers and health professionals for the Mental Health Foundation and EGG Maternity.

Criticisms of labelling and the medical model

There is criticism from some feminists about the risk of pathologising women and seing PND as the failure of a woman to cope or as individual pathology. Thorpe suggests that PND is a “reasonable response to an unreasonable social change dictated by a society designed by and for men”, while Oakley argues that PND is a " pseudo-scientific tag for the description and ideological transformation of maternal discontent” Labels such as PND may not provide an appropriate description of what is going on.There is concern that the dominance of DSM-IV in psychiatric settings means that a diagnosis pathologises behaviour (Crowe, 1996; Gallop, 1997) and Brown (1992) insists that context and variables such as race, gender, class and experience of abuse or victimisation be considered. Oakley (1980) suggests that a model of loss is more useful, she suggests that women's value is measured in terms of economic value and contribution. Women become patients, they reduce or cease paid work to take up unpaid work without the status. This is all compounded with a family un-friendly society that makes it difficult to return to work. Other losses include becoming a housewife, being pregnant and becoming a mother.

This page has information and links that will assist women, their partners and professionals, importantly there are lots of peer support groups around, so support isn't far away.

General maternal resources

Antenatal depression

Almost 25% of women with postnatal depression had depression during their pregnancy and some researchers suggest that symptoms of depression are not more common or severe after childbirth than during pregnancy and that more effort needs to be made towards understanding, recognising, and treating antenatal depression (Evans; Heron; Francomb; Oke; Golding, 2001). According to an article in the Harvard Mental Health Letter, 2002 the lack of recognition of antenatal depression could be due to the misconception that pregnancy protects against mood disorders.

The Blues

The mildest form is "the blues", seen in the first week postpartum, lasting between a few hours to a few days and characterised by sadness and tearfulness. It is thought to be physiologically based and is seen in all cultures and soci-economic groups.

Postnatal Depression (PND)

Postnatal depression (PND) is thought to affect between ten and twenty percent of mothers. This has been difficult to ascertain as depressed post partum women may feel that they have to minimise their negative feelings because most cultures depict the birth of a child as a highly positive event. The rates of PND are similar all over the world, but reasons and causes may vary.PND is characterised by a prolonged lowness in mood, a decreased interest in activities, fatigue and disturbances of sleep and appetite. PND is important because of its high incidence and often-long duration. Research has shown that there is a reluctance to seek help for PND as depressed post partum women often feel that they have to minimise their negative feelings or experience shame, fear or embarrassment. When mothers eventually do access health professionals, often-unhelpful responses and inappropriate treatments are advocated).This identification can be even more problematic where linguistic and cultural barriers exist. . PND can be misdiagnosed or undiagnosed and one study found only 2-4% of depressed women were identified as depressed by health professionals. PND also affects families, partners can also be depressed and infants may later suffer from behavioural problems, relationship problems and cognitive deficits. PND needs to be recognised by health professionals so that families can be supported, treated and ill effects prevented.

Causes of Postnatal Depression

There are many theories about why PND occurs. I prefer to have a multi-faceted approach to PND and equally a multi-faceted approach to its treatment.

Psychological

Psychological theories of PND were the earliest and it was proposed that PND was related to the unconscious and the past. Other theories suggested that anxious, obsessional women with "inadequate" personality structures and low self esteem were at risk of developing PND. More recently studies suggest that the woman's self perception of being an ineffective mother is significant and that conflicts with the maternal role, resulting in ambivalence or role rejection lead to PND. A limitation of this view is that it does not acknowledge the stressfulness of childbirth and its impact on women including their ability to adjust and cope with a major life event which also affects their biologic and social status. This view also "blames the victim" by seeing difficulties as intrapersonal and related to the woman's vulnerability or predispositions.

Biophysical

Some researchers suggest a history of depression, postnatal depression, pre-menstrual tension and dysmenorrhoea can predispose a woman to PND. Biophysical theories of PND suggest hormonal changes, genetic predisposition, previous mood disorder or psychotic episodes contribute to the development of PND. The hormone withdrawal hypothesis suggests that in the first few days postpartum, hormones such as oestrogens, progesterone and beta-endorphins that were dramatically, but gradually, elevated during pregnancy drop sharply to prepregnancy levels. This does not explain why all women do not get depressed with the hormonal fluctuations postpartum or why studies show there is no link between PND and a previous psychiatric history. Contradictory studies show that obstetric complications have no relationship with PND and others suggest Obstetric complications protect against PND.

Social

Much of the literature implicates social factors in the development of PND . Negative life events and the development of PND have been linked whilst others dispute the links. Marital difficulties and a lack of social support have been suggested as possible causes. Infant stressors and PND have been found significant. Strong social support has been found to be a significant factor in the recovery from PND.

Situational Stress

Interestingly when I worked in the postnatal arena, I often cared for women and their families who were making masive changes such as moving to a new house, starting a new job, or had recently lost a significant person. These changes often accentuated losses felt in the postpartum period. Often new families have poor emotional, physical, or social support from family or friends.

Loss

PND can also be viewed within a paradigm of loss. Such losses and changes are related to economic value and contribution and include: becoming a patient; Reduction or cessation of paid work to take up unpaid work without the status; a family un-friendly society that makes it difficult to return to work; becoming a housewife; being pregnant and becoming a mother. Then there are the losses at the time of birthing, such as loss of control (appropriation of the process by "experts' and technology); Loss of the child from inside her; Loss of career advancement; Financial costs and the change in relationship with one's partner.

Multiples

Some years ago I was inspired to offer a support group for parents of multiples that were depressed.These parents presented to the maternal mental health service where I worked in a different way and with unique issues. To read the abstract of a presentation Sue Dykes and myself did about the group click here.

PTSD

For some women Post-traumatic stress (PTSD) can occur after childbirth. This label once was used to describe the distress that war veterans were experiencing but the definition has now expanded to include other group other than combatants. Two common features of childbirth that are potentially traumatising are severe pain and loss of control (Reynolds, 1997). Extreme ain during labour has been significantly associated with severe bonding disorders between mothers and infants (Kumar, 1997).

According to the Diagnostic and Statistical Manual of Mental Disorders (1994), PTSD involves:

Exposure to a traumatic event in which the person has responded with intense fear, helplessness, or horror. Reexperiencing of the traumatic event in recurrent, intrusive, and distressing images, thoughts, or perceptions. Persistent avoidance of stimuli associated with the trauma, accompanied by a numbing of general responsiveness which wasn't present before the trauma. Persistent symptoms of increased arousal, such as hypervigilance or exaggerated startle response, which were not present before the trauma. Clinically significant distress or impairment in social, occupational, or other important areas of functioning.

PTSD can co-exist with other psychological difficulties for example depression (Charles, 1997; Silver, Sandberg, Hales, 1990) which can make it difficult to diagnose. In four women diagnosed with PTSD within 48 hours of delivery there was also co-morbid depression (Ballard, Stanley, Brockington, 1995). In addition a pre-exiting psychiatric disorder can be exacerbated by a traumatic event (Silver,et al., 1990).Follow the link to an article by Debra Creedy called Postnatal Depression and Post Traumatic Stress Disorder: What are the links?

Read a summary of a presentation by TABS here: Trauma and Birth Stress.

Nurses, Midwives and Doctors are well placed to prevent this disorder and the long term deleterious effects such as impaired mother/ infant interaction, inability to breastfeed, lack of interest in sex, impaired self worth, remembering nothing of the birth of their child or feeling only fear, pain, anger or sadness (Reynolds, 1997).

Postpartum psychosis

Puerperal psychosis, the most severe form of postnatal distress is rare occurring in 1 in 1000 births, but is highly incapacitating and can include such experiences as hallucinations and mania. Heterogeneous group of disorders. Most puerperal psychotic symptoms occur in the context of mood disorders and are characterised by greater than usual lability. The likelihood of developing postpartum psychosis increases from about 1 in 1,000 to about 1 in 4 if there is a personal and or family history of psychosis, especially bipolar mood disorder.

Infant mental health

Also see the parenting page for other resources. Infant mental health can be defined as the developing capacity of the infant or young child to*:

• Experience, regulate, and express emotions;
• Form close and secure interpersonal relationships;
• Explore the environment and learn - all in the context of family, community and cultural expectations for young children.

* Adapted from a working definition developed by ZERO TO THREE: National Center for Infants, Toddlers and Families - Infant Mental Health Task Force.

Maternal Mental Health Resources and Links

Information for fathers

Parental mental illness

Culture and Maternal Mental Health

Little is known of the experiences of minority women in New Zealand in regard to mothering. However, Mäori women consistently experience disproportionately greater inequalities than non-Mäori women and men and Mäori men. Data for Pacific women is not routinely available and from my experience services and staff are unresourced for supporting refugee and migrant women experiencing multiple transitions. Few researchers in New Zealand have made migrant motherhood an area of investigation. An exception is a study by Lealaiauloto and Bridgman (1997) of new mothers of Pacific Island backgrounds. Forty-eight new mothers, their partners and thirteen health workers were interviewed with a common theme emerging that highlighted the high stress levels experienced by these mothers. Other New Zealand studies have ignored cultural dimensions, under-represented or, worse still, discarded data relating to them. Webster, Thompson, Mitchell and Werry (1994) discarded the Edinburgh Postnatal Depression Scale (EPDS) scores of five women of Asian and Pacific Island ethnicity because their scores could not be validated in a clinical interview due to language difficulties. This exclusion of ethnic minority groups can also seen in a study by Kearns, Neuwelt, Hitchman and Lennan (1997). The researchers explored the social context of well-being for women before and after childbirth, but were only able to procure a sample of four per cent self-identified Maori and Pacific Islanders whilst these groups at the time made up a proportion of 18 per cent in the Auckland area. For this reason I decided that research was needed into the experiences of migrant women and mothering. I chose migrant women from Goa, India for my Masters research (the majority of Indians in New Zealand originate from Gujarat in Western India).

Parenting

Childbirth ranks highly on the scale of life events and is one of the most dramatic developmental stages in a persons life. It is a time of change and disruption that tends to be idealised for both parents but awareness is growing of motherhood in particular being a depressing occupation, however support systems remain minimal as parenting is seen as an individual responsibility rather than a societal one.See also child and adolescent mental health

Midwifery/obstetric links

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Copyright © 2003-2007 Ruth DeSouza. All rights reserved. Contact: ruth[at]wairua.com.