Need to know - postnatal depression
Primary care mental health researcher Professor Deborah Sharp answers GP Dr Mandy Fry’s questions on depression scales, choosing an antidepressant and whether men get PND
Primary care mental health researcher Professor Deborah Sharp answers GP Dr Mandy Fry's questions on depression scales, choosing an antidepressant and whether men get PND
1. Our health visitors seem to use the Edinburgh scale for assessing postnatal depression. How does this differ from the scales we normally use – such as the PHQ9 or HADS?
It can be downloaded from the column on the right.
The EPDS began life as a 13-item scale containing relevant questions from other instruments such as the HAD scale and the Beck depression inventory. Field testing revealed it to have satisfactory properties but three questions appeared redundant and so the 10-item version became standard.
It's a screening instrument, identifying women who are more likely to be depressed. In order to confirm a diagnosis of depression, some form of clinical assessment is required. It's been shown to be better than PHQ9 in postnatal depression (PND).
2. How can you try to prevent a recurrence of PND in subsequent pregnancies? Is there any evidence base for the use of hormones?
A hormonal aetiology for PND seems to be the most plausible. The most likely candidates would be oestrogen or progesterone – and several studies have looked at their therapeutic effectiveness assuming a deficit in one or the other.
But these have reported very few positive findings and hormonal treatment is not recommended for either PND treatment or prevention.
The most important action to prevent a recurrence is to take a good psychiatric history at the beginning of subsequent pregnancies.
Past psychiatric disorder, especially depression and most especially PND, is a predictor for a further episode.
Identifying depression at this stage enables treatment options to be discussed early on in the hope that symptoms resolve before the birth. Close monitoring is essential and women need to be empowered to report a deterioration of mood to their GP or midwife.
Psychological therapies might be more acceptable to women during pregnancy but GPs should not shy away from the use of antidepressants where they are indicated clinically. Sharing care with a perinatal psychiatrist may be warranted.
3. If PND requires the use of medication, which is the safest and most effective if the mother intends to breast-feed?
PND is no different an illness from depression at any other time in a woman's life. It's the timing that makes it different, as well as the impact on not only the mother but also the infant and its development, the partner, family, friends and colleagues.
As with other forms of depression, the trend is towards the use of SSRIs.
There is very little research evidence on the comparative effectiveness of the different antidepressants postnatally, so choice of drug will be governed by GP and patient choice to a large extent – depending on previous experience and response where relevant. Where a woman wishes to continue breast-feeding, the current advice is to avoid fluoxetine and citalopram – where evidence of transmission to infant is known – and to favour sertraline and paroxetine.
4. Does postnatal depression ever become a puerperal psychosis or are these completely different disease entities? How common is puerperal psychosis?
PND and puerperal psychosis are completely different entities.
PND is very common, affecting between 8% and 13% of women in the first few months after the birth. It tends to start after the first month – commonly between six and 12 weeks postnatal – often with an insidious onset and the diagnosis is commonly missed. The symptoms are frequently somatic – headache, backache, vaginal discharge associated with fatigue, irritability and loss of concentration – and are often considered a normal consequence of a recent birth. It's the constellation of these symptoms and the lack of enjoyment of the baby – sometimes even hostility – that should make us think of PND.
Puerperal psychosis is a completely different disorder. It is very rare, affecting only about one in 500 women, usually presents in the first month after the birth and is virtually impossible to miss as the presentation can be explosive with very florid symptoms. The mother becomes very distracted, behaving in an irrational, agitated fashion, expressing incongruent thoughts about herself and the baby, sometimes with auditory hallucinations. She may not sleep, care for the baby or herself, and in extreme cases may become violent towards herself and others – including the baby, who may be at risk.
Just occasionally the baby blues, a very common disorder characterised by tearfulness and a feeling of being unable to cope, may be severe or prolonged and herald a puerperal psychosis. The involvement of specialist mental health services is mandatory, preferably via a mother and baby unit.
5. In which women with PND would you consider measuring hormone levels, such as TFTs?
The underlying aetiology of PND is still debated. Studies of oestrogen or progesterone as therapeutic agents were singularly unhelpful in demonstrating an association between systematic changes in hormone levels after birth with mood change. Thyroid gland dysfunction in the aetiology of PND was put forward some years ago after studies found a higher incidence of thyroid antibodies in women with depressed mood postpartum. But further research found this association to be spurious and thyroxine treatment trials have been negative.
Outside the perinatal period there is an association between thyroid disease and depression. So testing for thyroid function is recommended in women who either have a family history of thyroid disease, whose depression is refractory to treatment or who may present with some of the usual signs or symptoms of reduced thyroid function.
6. Anecdotally it seems PND is more common in women who have had negative birth experiences. Is this a true association?
Actually there is not very good evidence for a causal relationship between a negative birth experience and PND, although it would provide an opportunity for offering early intervention or primary prevention.
In particular, research has looked at specific physical trauma such as a difficult forceps delivery, third-degree tears, an unplanned caesarean section or negative psychological experiences, which could all come under the umbrella of unfulfilled expectations of the birth itself.
This being so, there is still probably a case to be made for women to be provided with more information about the multitude of problems that can suddenly appear in what has otherwise been a perfectly normal and happy pregnancy and early labour. It is important that the caring professional team communicate effectively with both parents about any unforeseen problems, and a joint decision-making approach to their resolution is recommended.
Always bear in mind that drug or substance misuse may be present and that victims of domestic violence may present with psychological symptoms postnatally.
7. One of my patients recently told me that she had read a magazine article about men getting PND. Is this true?
This is probably easier to answer now than ever. As mentioned above, PND in women is probably no different from depression at other times in their lives and so there's no reason why men shouldn't suffer from a depressive illness after the birth of a child.
About 10% of fathers suffer from psychiatric morbidity in the postnatal period. Depression among fathers is associated with having depressed partners, having an unsupportive relationship and being unemployed.
It can be helpful to consider PND as a type of adjustment disorder. There is some research suggesting the depression suffered by fathers in the postnatal period might be a type of post-traumatic stress – especially if they have witnessed their wife suffering a very traumatic labour or delivery.
There is some evidence that the EPDS has reasonable validity and reliability in men. It is important to recognise that the onset of a depressive illness in a father at this time can be a major blow for the family, mainly in terms of the impact on the infant, especially if the mother is also unwell.
8. Health visitors seem to screen for PND at about six to eight weeks postpartum. Why is this? Does it help to make sure that you only identify those with true postnatal depression rather than ‘baby blues'? How might you identify women who are really struggling earlier?
Historically the postnatal check was done by GPs at about 6 weeks and the first baby immunisation at about 8 weeks. This led to these two landmark visits being used to screen for emotional disorder.
The HV will often have visited before 6 weeks and have a good idea as to how the mother is coping and feeling. If the baby blues has been a problem early on this should have disappeared by 6 to 8 weeks and thus a high score on the EPDS is more likely to mean that the disorder is significant.
Women with the blues tend to be emotionally very labile and tearful. But the onset of a more pervasive depressive illness tends to present with a flat affect, loss of interest, profound fatigue and various somatic symptoms.
It is common for a HV seeing a mother at 6 weeks to offer an EPDS to be filled in and if the score is high – 13 or more - to arrange a home visit to make a more detailed clinical assessment. At this point if the HV believes the woman is suffering from postnatal depression, they often recommend an appointment with the GP. Or, they may offer non-directive counselling also known as listening visits, over a period of four to eight weeks, before suggesting seeing the GP.
9. Postnatal depression can be a really isolating experience. What resources can you suggest that we could signpost to women and their partners so that they feel less alone?
Going to antenatal classes can help develop friendships with other couples going through the same life event. Enduring friendships are often made this way, especially through the National Childbirth Trust classes. For many women leaving work, to stay at home with a baby can be a very solitary experience and peer group support either informal or more formal through organisations such as Mothers for Mothers can be helpful. The Association for Postnatal Illness offers telephone support for women with postnatal depression and many larger towns have informal drop in groups, postnatal exercise classes, and voluntary sector counselling. Fathers are less well catered for in this respect. They are more reluctant to share their worries with friends and colleagues, tending to go to the gym or down the pub or simply absent themselves from home when they feel they can't cope. Women need to recognise that their partners might also need help and the GP is often the most acceptable face for support.
Professor Deborah Sharp is head of the academic unit of primary care at the University of Bristol
Competing interests: none declared
Dr Mandy Fry responds to the answers to her questions
• I will continue to use the EPDS as a screening tool for PND.
• I will consider the use of sertraline or paroxetine in preference to other SSRIs in breast-feeding women for whom medication is indicated.
• I will consider checking thyroid function in women who have a family history of thyroid disorders. This is particularly important if their depression seems refractory to treatment.
• I will consider using the EPDS as a screening tool for depression in men in the postnatal period.
• I'll bear in mind that this might be especially useful in those who have a history of psychiatric disorder, whose partner is depressed or who have witnessed a traumatic birth experience.
• I'll keep in mind that psychological disturbance postnatally might be a marker for domestic violence, and try to make sure women feel able to talk about their experiences.
Dr Mandy Fry is a GP in Cirencester, Gloucestershire, and senior primary care lecturer at Oxford Brookes University
Edinburgh Postnatal Depression ScalePostnatal depression