A 42-year-old woman comes to see her GP with concerns that her youngest child, a three-month-old girl, is not thriving. This is the third such appointment since her baby’s six-week check and previous contacts have found a healthy, settled baby with consistently appropriate weight gain.
In addition to questions about the baby, this time the GP extends the enquiries to what is happening at home and how the rest of the family is adapting to an additional member. Further sensitive questioning of how the woman is ‘finding motherhood this time round’ reveals she is ‘really sad all the time’.
She becomes tearful on direct questioning but denies thoughts of self-harm or suicide. She admits to being scared that others will see her as ‘a failure and a rubbish mum’. She has not told anyone else how she is feeling, even her husband. She describes deep guilt that she is not enjoying being a mum this time and is anxious about the long-term effects on her baby.
Her GP suggests a diagnosis of postnatal depression and asks if she has ever had mental health problems before, and if so what helped her get well. Then they discuss the treatment options available.
Mental health problems are the most common medical complication of having a baby, with up to one in five women affected.1 However, women are not often given information antenatally about conditions such as postnatal depression and so any such illness can be a great shock and source of long-lasting disappointment and guilt.
Where women present for the first time with symptoms of depression within 12 months of having a baby, a diagnosis of postnatal depression (PND) would be accurate. If women become ill after this time, the illness is less clearly related to having a baby and so should be considered and treated as a general case of depression.
PND is thought to affect 10-15% of women and usually starts within the first two months of giving birth. It may be misdiagnosed as ‘the baby blues’, which is a temporary state of tearful emotional lability, caused by physiological hormone fluctuations and affecting up to half of all women from day three post-birth, and resolving by day 10.2
Risk factors for PND
- Personal history of mental health problems, whether perinatal or at other times in the patient’s life.
- Personal history of childhood abuse including sexual, physical and severe bullying.
- Substance misuse including alcohol.
- Relationship in which domestic violence occurs.
- Social adversity including unstable economic, immigration or housing status.
PND may present in a similar way to depression at any other time – low mood, tearfulness, fatigue, poor sleep and lack of enjoyment of usual activities. In addition, women may complain about feeling ‘overwhelmed’ by the responsibilities of motherhood or they might present with repeated concerns about the baby’s health. Less commonly, there may be dissociation from the baby, thoughts of violent self-harm or a rapid worsening of symptoms, which are red flags for severe mental illness.3
The clinical vignette on page 42 illustrates several of the factors that may inhibit disclosure of symptoms by the woman and diagnosis from the GP, which mean many cases of perinatal mental illness go undetected. Open questioning is preferred rather than the Edinburgh Postnatal Depression Scale, which is no longer recommended.2 Thoughts of self-harm and suicidal ideation must be asked about, as suicide sadly remains one of the leading causes of death for women in the first year postnatally.3 Although GPs may have less contact with women during the perinatal time due to restructuring of maternity services, you should consider it your role to ask about mental health and not assume someone else has.
Acknowledgement of her symptoms, validation of the diagnosis and explanation that there is evidence-based treatment to help can be hugely helpful to women at diagnosis. In addition, emphasising that early intervention reduces the negative impact on her child can be reassuring. The treatment options include some that are familiar when treating women with depression at other times of their life, and also some that are specific to this time.
If a woman is not responding to some of the low-level interventions, or if symptoms are progressing, it would be reasonable to offer a referral to IAPT, which should be highlighted as a priority case. This allows women to receive treatment promptly, which minimises the adverse effects on them and their child. Severe cases of PND are unusual and warrant psychiatric input as well as co-ordinated GP and health visitor care. It is sometimes necessary for women to be admitted to hospital, ideally to a mother and baby unit but there is significant variation across the UK.
Facilitated self help
- Signposting to mother and baby groups.
- Postnatal exercise classes.
- Self-directed reading.
- Online parenting support.
- Health visitor-directed low-level interventions.
- Self-directed online CBT.
- Rapid referral to IAPT within two weeks to be starting therapy within four weeks.
- If not breastfeeding, the choice is similar to general pharmacological treatment of depression.
- If a woman is breastfeeding, SSRIs such as sertraline and paroxetine are usually preferred.
- May need to involve specialist psychiatric colleagues to allow women to make an informed choice.
- Online resources available.
Prescribing decisions must be made on an individual basis and take account of several factors including:
- Breastfeeding preference.
- Severity of symptoms.
- Past response to medication.
- Past side-effect profile.
- Lowest possible dose for shortest time.
- Above all, patient preference.
The RCGP Perinatal Mental Health Toolkit has some useful resources with up-to-date, accurate information about the evidence base to support women in making an informed choice about medication during the perinatal time.5
Although having an episode of PND may increase a woman’s chance of such illness in the future, this is not inevitable, with only three in 10 experiencing a relapse in subsequent pregnancies. Early recognition of symptoms with prompt diagnosis means that the woman should be on the road to recovery more quickly, minimising the negative impact a recurrence of PND may bring.
Dr Carrie Ladd is a GP in Oxfordshire and RCGP clinical champion in perinatal mental health, leading the Spotlight Project in Wessex, supported by the Wessex Clinical Network
Conflicts declared: none