Perinatal mental illness is the term which encompasses all mental health problems which occur as a result of pregnancy and continuing up until a year after the birth. Antenatal and Postnatal Depression are terms to describe a form of depression which may occur during pregnancy and after childbirth. It is not unusual for a woman to experience the ‘baby blues’ after giving birth, but if it lasts for longer than a few days, there is a possibility that she is experiencing postnatal depression. Perinatal depression affects between 10-15% of all parents who have a baby and therefore, it is essential that all healthcare professionals and expecting parents can recognise the signs and symptoms. Antenatal and postnatal depression are categorised by persistent low mood, fatigue, helplessness, isolation, lack of motivation, difficulty bonding with your baby and intrusive thoughts (perhaps the want to harm yourself or your baby.) 1 in 7 women die from suicide and this could be prevented with a high standard of perinatal mental health care.
Who is at risk of antenatal/postnatal depression?
It is possible that any childbearing woman could develop perinatal depression, whether that be before or after the birth of their child. It is also becoming increasingly more common for fathers to develop the illness. There are, however, a few risk factors that could make someone more likely to develop the illness:
- Suffered perinatal mental illness previously
- Suffered/are suffering mental health problems
- Stopped/changed medication in due to pregnancy e.g. antidepressant
- Have a family history of mental health problems
- If a woman’s mother or sister have suffered from perinatal depression
- Experienced a stressful life event recently e.g. bereavement/relationship breakdown
- Feeling negative about the pregnancy, for example, if they didn’t plan to have a baby
- Having a lack of support
What causes perinatal depression?
It can be difficult to pinpoint the cause of depressive illnesses. During childbearing, women experience a lot of normal physical and psychological changes in their body’s. These are hormonal and physiological, as well as mentally having to adapt to the fact that in the coming months, they will have a person who is reliant upon them. Pregnancy is physically and mentally exhausting and can cause a lot of stress for many women. The changes that occur to the body can cause physical symptoms which can cause distress to some women and fear that something is ‘wrong’ with them.
Situational factors may also have an impact on a woman’s chances of developing perinatal mental illness. If a woman is experiencing financial difficulties or of a low social economic status, she may worry about not being able to provide for her family, leading to a state of depression. Immigrant women may also be vulnerable, due to language barriers and reduced social support. During childbirth, women may not feel like they have a choice in what is going on, complications may arise or they may experience birth trauma. Postnatally, infant feeding can be a precursor for postnatal depression. Many women have a desire to breastfeed and due to lack of support or a painful experience, they may not be able to fulfil their desire. This can cause a lot of guilt as women feel they are not providing their baby with the optimum nourishment.
What treatment is available?
Treatment for perinatal depression is similar to what would be on offer for any other depressive illness. These include:
- Cognitive Behavioural Therapy (CBT) to develop coping mechanisms and ‘rewire your brain’
- Counselling enables the sufferer to discuss how they are feeling – this could be especially useful if birth trauma had occurred
- Medication can be used under specialist guidance. Some anti-depressant medications are not recommended during pregnancy or when breastfeeding due to the adverse effects they could have on the baby, including withdrawal, stillbirth and miscarriage, however, there are some which are more appropriate to use. The Drugs in Breastmilk helpline is a useful resource for advice regarding which anti-depressants are safe to take when breastfeeding. Tricyclic antidepressants carry less risks in the early months of pregnancy compared to SSRI’s.
- Lifestyle – although lifestyle changes may not ‘cure’ a mental illness, eating healthily, exercising regularly and getting enough sleep can have an impact on the way you are feeling. It can be difficult to do these things whilst pregnant or with a new baby, but these factors can have a psychological impact.
The role of a midwife
It is essential that all midwives and healthcare professionals have an awareness of mental health problems as a whole, so they can give appropriate advice to women regarding the signs and symptoms to look out for. Midwives must know the appropriate procedures to follow if they suspect that a woman in their care may be suffering a mental health problem. At her booking appointment, the midwife will ask a few questions regarding the woman’s mental health, used as a screening tool. If it is bought to a midwife’s attention during booking that a woman is already suffering mental health problems or has experienced perinatal mental illness in previous pregnancies, they will be automatically referred to a community mental health team. The Royal College of Midwives advises that every maternity unit has a named mental health midwife who is specifically trained in this area.
It is important that midwives explain to all women that pregnancy and becoming a parent can be a very challenging time both physically and mentally, therefore, it is normal to feel exhausted, stressed and emotional. However, it is not normal for these to be experienced constantly, over a long period of time. Women are unlikely to tell their midwife exactly how they are feeling, unless they have built up a trusting relationship with them, which is why continuity of care is so important in a midwifery setting. This also allows the midwife to observe any changes to a woman’s mood over time.
Mental health is incredibly stigmatised and so many women fear that social services may become involved if they state that they are not coping. Midwives should reassure the woman that this is not the case unless it is evident that there is a child protection issue. However, if the midwife can see that the woman is not coping well e.g. suicidal, self- harming, not looking after herself or baby, the relevant teams should be advised and additional appointments (antenatal and postnatal) should be made with the midwife to check wellbeing.
Antenatally, the NICE guidelines state that a nulliparous woman should have 10 appointments and a multiparous appointment. However, if the woman has a pre-existing mental illness or has developed antenatal depression, contact time should be increased, depending on the individual’s circumstances and wellbeing. Postnatally, guidelines state that if all is well with the mother and baby, midwives should discharge at 10 days postpartum and hand over to the health visitor. At this point, many women would not have developed postnatal depression. By day 3/4, a woman may experience the ‘baby blues’ which she should be reassured is completely normal; it is common in 50-70% of new mothers. It should be explained that if this does not subside after 2 weeks, there is a possibility that she may be experiencing postnatal depression and the steps she can take to seek support. At every postnatal appointment, the midwife should ask how the mother is feeling emotionally and observe her behaviour. If she has any concerns over her mental health, additional visits are advisable. Refer to the NICE antenatal and postnatal mental health pathway for further guidance.
Lastly, it is crucial that midwives ensure that women feel comfortable, act in an approachable manner and remain non-judgemental if a woman is experiencing perinatal depression. Language is incredibly important; if a woman is suffering, they are unlikely to feel much of a bond with their baby and therefore, comments such as ‘your baby needs you,’ said innocently without thinking, could cause distress and guilt. Midwives must remain kind and considerate with all women, but especially those who could be vulnerable to these types of passing comments.
What other support can be given to women?
The PANDAS Foundation (Pre And postNatal Depression Advice and Support) offer a variety of support services to women and their families who are suffering from all perinatal mental illnesses. These include: a helpline, open 7 days a week, 9am-8pm; email support, a closed facebook group, social media pages and local support groups. All details can be found on the PANDAS website along with a variety of useful information on perinatal mental illness.
Our services are provided by volunteers, the majority have lived experience of perinatal mental illness. They can provide practical advice and a listening ear for those in need, as well as advice to healthcare professionals on the most appropriate ways to support those in their care. We offer an advocacy service for those who do not feel they can effectively communicate with their primary care givers, run by a trained safeguarding officer.
- NHS England (2016) Health and high quality care for all, now and for future generations. Available at: https://www.england.nhs.uk/mentalhealth/perinatal/ (Accessed: 21 November 2016).
- Royal College of Psychiatrists, Green, L. and Thachil, A. (2012) Mental health in pregnancy. Available at: http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/mentalhealthinpregnancy.aspx (Accessed: 21 November 2016).
- Mothers and babies: Reducing Risk through Audits and Confidential Enquiries across the UK (2015). Saving Lives, Improving Mothers’ Care. Oxford: MBRRACE-UK.
- Mayo Foundation for Medical Education and Research (2015) Postpartum Depression Risk Factors. Available at: http://www.mayoclinic.org/diseases-conditions/postpartum-depression/basics/risk-factors/con-20029130 (Accessed: 21 November 2016).
- Fitelson, E., Kim, S., Baker, A.S. and Leight, K. (2010) ‘Treatment of postpartum depression: Clinical, psychological and pharmacological options’, International Journal of Women’s Health, 3, pp. 1–14.
- MIND (2013) Anti-depressants. Available at: http://www.mind.org.uk/information-support/drugs-and-treatments/antidepressants/antidepressants-in-pregnancy/#.WDNCq-aLTIV (Accessed: 21 November 2016).
- Royal College of Midwives (2013). Specialist Mental Health Midwives: What they do and why they matter. Available at: https://www.rcm.org.uk/sites/default/files/MMHA%20SMHMs%20Nov%2013.pdf (Accessed 21st November 2016)
- National Institute for Health and Care Excellence (NICE), 2008. Antenatal Care for Uncomplicated Pregnancies. London: NICE.
- Andrews-Fike, C. (1999) ‘A review of postpartum depression’, The primary care companion to the journal of clinical psychiatry, 1(1), pp. 9–14.
- National Institute for Health and Care Excellence (NICE), 2014. Antenatal and Postnatal Mental Health. London: NICE.
- Robertson, E., Grace, S., Wallington, T. and Stewart, D. (2004) ‘Antenatal risk factors for postpartum depression: a synthesis of recent literature’, General Hospital Psychiatry, 26(4), pp. 289–295.
In partnership with The PANDAS Foundation. To find out more visit their website which contains a wealth of information for patients, carers and professionals.