Postnatal depression: what is it?
The arrival of a new baby is usually a happy event, but it can also be a stressful time during which many adjustments have to be made. Many women are not aware that mood changes are common after childbirth and vary from mild to severe. In fact, in the year after childbirth a woman is more likely to need psychiatric help than at any time in her life.
There are three recognised mood disorders in the postpartum period.
At one end of the spectrum is ‘baby blues’, affecting about 80 per cent of new mothers. It usually occurs between the third and tenth day after birth. Symptoms include tearfulness, anxiety, mood fluctuations and irritability. The ‘blues’ are transient and will pass with understanding and support.
At the other end of the spectrum is puerperal or postnatal psychosis. This affects one in 500 mothers, usually in the first 3 to 4 weeks after delivery. Postnatal psychosis is a serious condition. The mother herself may be unaware she is ill, as her grasp on reality is affected. Symptoms include severe mood disturbance (either marked elation or depression or fluctuations from one to the other), disturbance in thought processes, bizarre thoughts, insomnia, and inappropriate responses to the baby. There is risk to the life of both mother and baby if the problem is not recognised and treated. Postnatal psychosis requires a hospital stay. With appropriate treatment, women suffering from postnatal psychosis fully recover.
Between the ‘blues’ and psychosis lies postnatal depression. One in 7 women are diagnosed with postnatal depression each year in Australia (Deloitte 2012). The total number may be higher as many more struggle without seeking a diagnosis or support. Many women do not know that postnatal depression can occur after delivery and typically blame themselves, their partners or their baby for the way they feel. Some try hard to ‘snap out of it’ without understanding that women with postnatal depression have little control over the way they are feeling. It is very important for women and their partners to learn to recognise the signs and symptoms of postnatal depression so that they can ask for help as early as possible.
- Occurs in all cultures and all socio-economic classes, and can happen to child-bearing women of all ages.
- Is not a modern condition. Each generation calls it something different. What we call postnatal depression today may have been called a ‘nervous breakdown’ 50 years ago.
- Appears with mild, moderate, or severe symptoms. It can begin during pregnancy (antenatal depression), suddenly after birth, or gradually in the weeks or months following delivery. Symptoms can emerge at any time during the first year after birth, but most cases have their onset within the first 4 months.
- Can happen after miscarriage, stillbirth, normal delivery, or Caesarean delivery. Pregnancy is the common factor.
- Happens mostly after the first baby, but can occur after any other pregnancy.
- Can recur with a subsequent pregnancy. If a woman becomes pregnant again before recovering from postnatal depression, the condition will continue through the pregnancy and may worsen. It is wise to wait at least a year after discontinuing medication before falling pregnant again.
Bio-psycho-social postnatal depression and recovery
Postnatal depression should be viewed as a bio-psycho-social condition that has an impact on the woman’s biological, psychological (spiritual) and social (cultural) wellbeing. Factors that contribute to postnatal depression come from all these areas and result in a variety of symptoms. A different combination of factors is responsible for each woman’s unique experience of postnatal depression. Strategies for managing postnatal depression towards recovery must address all bio-psycho-social aspects of the woman’s life. This usually requires a combination of interventions.
Postnatal depression exists within families and communities, not with the woman alone. Assessment and intervention need to consider the significant other people in her life.
Contributing factors for postnatal depression
- Genetic predisposition to depression.
- Sudden changes in pregnancy hormones following delivery.
- Nutritional deficiencies and sleep deprivation.
- Difficult pregnancy or childbirth experiences.
- History of pre-menstrual tension.
- Previous experience of postnatal depression, or family/personal history of mental health conditions.
- Infertility and use of IVF for conception.
- Difficult or traumatic birth (unexpected interventions, e.g. emergency Caesarean).
- Traumatic or abusive childhood (particularly sexual abuse).
- Unrealistic expectations of motherhood and of herself.
- Certain personality types (perfectionist or controlling).
- Limited social and emotional skills (difficulties in effectively communicating).
- Problematic or unresolved relationship issues with own mother.
- Past unresolved issues of grief and loss such as previous miscarriage.
- Lack of family and community support.
- Difficult relationship with partner — removed emotionally, works long hours or travels.
- Intrusive or difficult family relationships.
- Social isolation and lack of transport.
- Financial hardship.
- Lack of close friends, particularly families with children.
- Being of a younger or older age.
- Stressful life events such as a death in the family or job loss.
Women experiencing some of these things should be encouraged to talk with their doctor and family. It is important that the individual meaning and response to these factors are discussed and assessed.
Symptoms can begin anywhere from 24 hours to several months after delivery. Women are more likely to seek help early when onset is abrupt and symptoms severe. When the symptoms are harder to separate from the normal changes after having a baby, women can delay seeking help and postnatal depression can linger into the second year.
The following descriptions of postnatal depression symptoms come from women who have spoken to PANDA or attended postnatal depression groups, and can also apply to a man's experience of postnatal depression.
Sleep disturbance unrelated to baby’s sleep needs
Most women with a young baby fall asleep as soon as they are able to. Women with postnatal depression can lie awake for hours feeling anxious while the baby sleeps, or wake early in the morning. Others want to sleep all the time and have trouble getting up.
Women may feel totally uninterested in food and say, ‘I force myself to eat, but I don't taste anything.’ Some overeat in an attempt to control their anxiety. Others feel sick at the thought of food.
A woman may feel sad and cry without apparent reason. Tears come easily day and night. Others say, ‘I want to cry but can't. I am crying on the inside.’
Unable to cope
Daily chores, caring for the baby or self-care may seem insurmountable. Small demands she previously coped with may completely overwhelm her. She may feel like running away, overwhelmingly exhausted and very heavy, physically and emotionally, or wish it would all go away.
She may snap at her partner or other children without cause. Partners often say, ‘I can't do anything right. If I fold nappies she complains I do it the wrong way. If I don't help, I'm being unsupportive.’
She may feel a ‘knot in the tummy’ most of the time and panic without cause. Some experience heart palpitations so severe they fear they are having a heart attack. She may be anxious about her own or her baby's health even after being reassured that nothing is wrong. Many women describe anxiety as their most obvious symptom and reject the term postnatal depression. They deny being depressed. The term ‘postnatal anxiety’ might more accurately describe the way some women feel.
Negative obsessive thoughts
There can be little peace in the thought processes of women with postnatal depression. Small worries can consume thought processes, interfering with her ability to listen, concentrate or remember. She may experience unrealistic fears, afraid to let her partner go to work in case he has a car accident or fear something bad could happen to her baby. No amount of reassurance or distraction can hold her thinking at bay.
Fear of being alone
Many women go out a lot or need their partner (or someone) at home with them at all times because they are afraid of being alone at home. The fear of something going wrong with the baby or her own perceived inability to cope with the baby on her own is overwhelming. Some feel incredibly lonely and go out to feel connected with other people - This takes an enormous amount of effort. Others feel they cannot be with other people and withdraw from family and friends, not answering the door or telephone.
Memory difficulties and loss of concentration
A woman may forget what she wanted to say mid-sentence. She may not be able to concentrate on simple tasks or to take in new information. Organising herself and her family can become too difficult. Sometimes she doesn’t know where to start or may start everything at once. She may be unable to think creatively about her problems and find solutions - like reaching out to services that will help her.
Feeling guilty and inadequate
Feeling guilty can be a common feeling for all mothers but more so for the mother with postnatal depression. Her thoughts and feelings constantly reinforce in her own mind that she is inadequate or a bad mother. She may be unable to take encouragement from the good things she has done or to feel affirmed by her relationship with her baby. Reassurance will not dissuade her thinking and can discourage her from talking about how inadequate and guilty she feels.
Loss of confidence and self-esteem
A woman who enjoyed her job may panic at the thought of returning to it, no longer sure she is able to do it. A woman who enjoyed having family and friends over may panic at the thought of visitors. She may feel unable to prepare a meal which she enjoyed doing before the baby was born. Most women with postnatal depression have very low self esteem regardless of how well they seem. Some describe their experience as a loss of sense of who they are, a loss of sense of self.
Postnatal depression is difficult to identify
Society makes it difficult for a woman to acknowledge that she may be experiencing postnatal depression. She is constantly confronted by messages about joy and bliss but not about the challenges that come with motherhood. The media tends to reinforce the unrealistic expectations of motherhood, for example promoting celebrities who appear to be coping exceptionally well.
Added to this is the stigma of depression, with postnatal depression often being portrayed in a negative and sensational way. Women will put on a brave face and go to extraordinary lengths to hide how they feel. A woman who is not coping can feel very alone and can find it very hard to come to terms with her feelings.
Effects of postnatal depression
If postnatal depression is not identified or treated, the toll it takes on the woman, her baby, partner, family and extended relationships increases. It does not usually resolve itself fully without treatment, and she may experience future episodes of depression and mental illness.
Many women with postnatal depression are very close to their babies despite how they feel. For others, if postnatal depression is ongoing they may struggle to connect with their baby. This can have an impact on the wellbeing of the baby. With early identification and intervention most women fully recover from postnatal depression and there are no long-term effects.
All women with postnatal depression need emotional support from family and friends. Some women find psychological treatments helpful especially if they have experienced traumatic events in their childhood or more recently.
Antidepressant medication is a successful part of treatment for many women, especially in combination with counselling. There are many misconceptions about antidepressants, and women who could benefit from them refuse them because they are afraid the medication is harmful. Antidepressants are not addictive and some can be safely taken while breastfeeding and pregnant.
It can be helpful to seek objective advice from a pharmacist or Drug Information Line.
This type of medication does not ‘change your personality’, it corrects the chemical imbalances in the brain that are thought to be responsible for symptoms of depression and anxiety.
It is important to understand that women cannot ‘snap out of’ depression any more than they could ‘snap out of’ diabetes.
Living with someone suffering postnatal depression is difficult. Partners also need a lot of support as they often feel confused, lost and helpless. It is important that partners be included by the health professionals treating women with postnatal depression. Partners are much more supportive if they understand what the problem is and what they can do to help.
Where to go for help
If a woman does not feel the way she expected to feel after having a baby it is very important that she talk to PANDA, her doctor or maternal and child health nurse. It could simply be that she is having trouble adjusting to the changes in lifestyle or the increased demand that occurs when a baby is born. If she is suffering postnatal depression, it is important that she receives appropriate help as soon as possible. Postnatal depression is not something to be ashamed of. It should be seen as one of the many complications of pregnancy and delivery. With appropriate help, women with postnatal depression do recover.