About 1 in 10 mothers develop postnatal depression. Support and understanding from family, friends and sometimes from a professional such as a health visitor can help you to recover. Other treatment options include psychological treatments such as cognitive behavioural therapy or antidepressant medicines.
What is meant by postnatal depression?
Having a baby is a very emotional experience. You may feel tearful and your mood may feel low. There are three causes of low mood after childbirth:
- Baby blues. It is very common and almost considered normal to have these. Symptoms include being weepy, irritability, anxiety and feeling low. Baby blues usually start around the 3rd day but usually go by the 10th day after childbirth. They do not usually need any medical treatment. Baby blues are not discussed further in this leaflet.
- Postnatal depression (PND). This occurs in about 1 in 10 mothers. It usually develops within the first four weeks after childbirth. However, it can start several months following childbirth. Symptoms, including low mood, last for much longer than with baby blues. Treatment is advised. Most of this leaflet is about this common form of depression.
- Postnatal (puerperal) psychosis. This is an uncommon but severe form of mental illness. It may involve a low mood but there are a number of other features. It develops in about 1 in 1,000 mothers. It is discussed briefly at the end of this leaflet.
The baby's father may also develop depression in the weeks after a baby is born.
What are the symptoms of postnatal depression?
The symptoms are similar to those that occur with depression at any other time. They usually include one or more of the following. In PND, symptoms are usually there on most days, for most of the time, for two weeks or more.
- Low mood. Tends to be worse first thing in the morning, but not always.
- Not really enjoying anything. Lack of interest in yourself and your baby.
- Lack of motivation to do anything.
- Often feeling tearful.
- Feeling irritable a lot of the time.
- Feelings of guilt, rejection, or not being good enough.
- Poor concentration (like forgetting or losing things) or being unable to make a decision about things.
- Feeling unable to cope with anything.
You may also have thoughts about harming your baby. It is not uncommon for women with PND to have these thoughts. If things are very bad you may have ideas of harming or killing yourself. This only happens in very rare cases. If you have such thoughts, you must ask for help.
In addition, you may also have less energy, disturbed sleep, poor appetite and a reduced sex drive. However, these are common and normal for a while after childbirth and on their own do not necessarily mean that you are depressed.
Why should you do anything about postnatal depression?
If you do nothing about the PND (or do not even know that you are depressed), you are likely to get better anyway in 3-6 months. Some people take longer. There are a number of reasons to ask for help:
- To help yourself recover quickly. You need not feel like this. It is not a sign of weakness to admit that you are depressed.
- To help your partner or family. If you are depressed, it can cause problems in your relationships, your job and life in general.
- To help your child (or children). If you are depressed, your relationship with your baby may not be as good as it could be. You may not give as much attention to your baby as you would like to. As a result, your baby's development may not be as quick as it should be. There is evidence to suggest that developmental problems that occur in the baby because of a mother's depression may persist into adolescence.
Many women are able to hide their PND. They care for their baby perfectly well and appear fine to those around them. However, they suffer the condition as an internal misery. Do seek help if you are like this.
What causes postnatal depression?
The exact cause is not clear. It does not seem to be due to hormone changes after you give birth. Any mother could develop PND, but women are more prone to develop it just after childbirth. The main cause seems to be stressful events after childbirth such as feelings of isolation, worry and responsibility about the new baby, etc.
You may also be at greater risk of developing PND if:
- You have had mental health problems in the past (including depression, previous postnatal depression, bipolar disorder or schizophrenia).
- You have had previous treatment by a psychiatrist or mental health team.
- You have had depression during your pregnancy.
- Your family tends to suffer from PND.
- You have had marital or relationship problems.
- You have no close friends or family around you.
- You have money troubles.
- You have had physical health problems during pregnancy or following the birth, or if the birth was very difficult.
- Your partner is depressed.
- You have had a major life event recently (such as somebody in your family dying, or moving house).
- You did not plan to become pregnant in the first place.
- You were trying for a long time before you became pregnant.
However, in many cases, there is no apparent cause.
How is postnatal depression diagnosed?
A doctor, midwife or health visitor will usually check for depression in all women who have recently given birth. They may ask the following two questions when they see you (this may be during one of your postnatal checks or visits):
- During the past month, have you often been bothered by feeling down, depressed, or hopeless?
- During the past month, have you often been bothered by having little interest or pleasure in doing things?
The answers to these questions may suggest you are feeling down. They may also ask you two questions to get an idea of your anxiety levels:
- During the past month have you been feeling nervous, anxious, or on edge?
- During the past month have you not been able to stop or control worrying?
The answers to these questions give an idea about whether more questions should be asked. These would help find out more about your mood and establish whether you may be depressed or not.
It is very important that you are truthful about how you are feeling. You should not think that having PND makes you a bad parent or will mean that your baby is taken away from you. This is extremely rare. Every aim when treating PND is to keep you with your baby wherever possible so that the bond between you can develop.
If the healthcare professional that you see suspects that you may have PND, they will usually refer you to your GP so that the diagnosis can be confirmed. The diagnosis of PND is usually made by your doctor based on what you, and those who know you, tell him or her. Tests are not usually needed. However, sometimes your doctor may do a blood test to make sure there is not a physical reason for the symptoms, such as an underactive thyroid gland or anaemia.
You may not recognise that you are depressed. However, your partner or a family member or friend will probably have noticed that you are different, and may not understand why. Sometimes a friend or family member may suggest that you see a doctor because they are worried that you may have PND.
What are the treatments for postnatal depression?
The type of treatment that is best for you can depend on various things, including:
- How severe your depression is and what symptoms you have.
- The impact of your symptoms on your ability to function (to look after yourself and your baby).
- Whether you have had depression or other mental health problems in the past. What has worked best for you before if this is the case.
- The likely waiting time for any of the treatments.
- Your current situation.
- Your own preferences once the options and the pros and cons have been explained fully to you
- In the case of tablets, the possible effects on the baby if you are breast-feeding.
Together you and your doctor should be able to decide which is the right treatment for you. The following are some of the treatments available. More than one treatment may be suggested in some cases.
Support and advice
Understanding and support from family and friends can help you to recover. It is often best to talk to close friends and family to explain how you feel rather than bottling up your feelings. You may also benefit from some help from family and friends in caring for your baby. This may give you some time off to rest and/or to do some things for yourself. Support and help from a health visitor can also help. Do tell your health visitor if you feel depressed as they may be able to talk things through with you.
Independent advice about any social problems may be available and of help (money issues, childcare, loneliness, relationships, etc). Ask your health visitor about what is available in your area. Also, ask about which support or self-help groups are available. You may be surprised at how many women feel the same way as you. Self-help groups are good at providing encouragement and support, as well as giving advice on how best to cope.
Antidepressant medication is often prescribed for PND, especially if the depression is moderate or severe. Symptoms such as low mood, poor sleep, poor concentration, irritability, etc, are often eased with an antidepressant. This may then allow you to function more normally, and increase your ability to cope better with your new baby.
Antidepressants do not usually work straightaway. It takes 2-4 weeks before their effect builds up fully. A common problem is that some people stop the medication after a week or so as they feel that it is doing no good. You need to give it time. Also, if it is helping, follow the course that a doctor recommends. A normal course of antidepressants lasts up to six months or more after symptoms have eased. Some people stop treatment too early and the depression can quickly return.
There are several types of antidepressants, including tricyclic antidepressants (for example, imipramine, lofepramine) and selective serotonin reuptake inhibitors (SSRIs) - for example, fluoxetine, citalopram. They all have pros and cons. For example, they differ in their possible side-effects. (The leaflet that comes in the medicine packet provides a full list of possible side-effects.) If the first one that you try does not suit then another may be found that is fine. Therefore, tell your doctor if you have any problems with an antidepressant. Antidepressants are not tranquillisers and are not thought to be addictive.
About 5-7 in 10 people with moderate or severe depression improve within a few weeks of starting treatment with a prescribed antidepressant. However, up to 3 in 10 people improve with dummy tablets (placebo) as some people would have improved in this time naturally. So, you are roughly twice as likely to improve with antidepressants compared to taking no treatment. But, antidepressants do not work for everybody.
Some antidepressants come out in breast milk. The amounts are very small and are unlikely to cause any harm to the baby. However, if you are breast-feeding, your doctor is likely to choose a medicine that is well established and has a good safety record with breast-feeding mothers rather than a newer medicine with fewer data about confirming safety in babies. Obviously, it is difficult to do studies in breast-feeding mothers. So, often there is not a lot of definite information about tablets in this situation. Your doctor will explain what is known, and what is not.
Another treatment option is to be referred to a psychologist or other professional for a psychological treatment. There are various types, but their availability on the NHS can vary in different parts of the country. Psychological treatments include the following:
- Cognitive behavioural therapy (CBT). This is a combination of cognitive therapy and behavioural therapy. Briefly, cognitive therapy is based on the idea that certain ways of thinking can trigger, or fuel, certain mental health problems such as depression. The therapist helps you to understand your thought patterns. In particular, to identify any harmful, unhelpful and false ideas or thoughts which you have that can make you depressed. The aim is then to change your ways of thinking to avoid these ideas. The aim is also to help your thought patterns be more realistic and helpful. Therapy is usually done in weekly sessions over several months. You are likely to be given homework between sessions. Behavioural therapy aims to change any behaviours which are harmful or not helpful. In short, CBT helps people to achieve changes in the way that they think, feel and behave. See separate leaflet called Cognitive Behavioural Therapy (CBT).
- Guided self-help. This is based on the same ideas as CBT. You would be given some reading or video or computer-based information. You would then go through this, reading, watching or listening to it at your own pace. You would be able to talk to a therapist regularly, either face-to-face, or on the phone, who would help you work through it.
- Interpersonal therapy. This type of psychological therapy can help you to identify any problems in your relationships with family, friends, partners and other people, and see how these may relate to your depression and other problems.
- Other types of therapy, including problem-solving therapy and psychodynamic psychotherapy, may also be used to treat PND.
For moderate depression, the number of people who improve with CBT is about the same as with antidepressants. Psychological treatments may not be so good for some people with severe depression. This is because you need some motivation to do these treatments and people with severe depression often find motivation difficult.
Another thing to bear in mind is that psychological treatments are sometimes not practical for women with PND, due to the time commitments required. There may also be a waiting list. However, women with PND should start treatment within a month of referral at most. This is the guidance from the National Institute for Health and Care Excellence (NICE).
Some research suggests that a combination of an antidepressant plus a psychological treatment such as CBT may be better than either treatment alone.
St John's wort (hypericum)
This is a herbal antidepressant that you can buy from pharmacies, without a prescription. It recently became a popular over-the-counter treatment for depression. You should not use St John's wort during pregnancy and when breast-feeding. It interacts with certain other types of medication and can have side-effects. The amount of active medicine has been found to vary from brand to brand. For these reasons, national guidelines do not recommend St John's wort for the treatment of depression, including PND.
Specialist and hospital-based treatments
If your depression is severe, or does not get better with treatment, your doctor may suggest that they refer you to a specialist mental health team. They may be able to suggest other treatments such as specialist medication. Occasionally, admission to hospital may be needed. Ideally this would be to a mother and baby unit so that your baby can stay with you.
Some dos and don'ts about depression
- Don't bottle things up or go it alone. Try to tell people who are close to you how you feel. It is not weak to cry or admit that you are struggling.
- Don't despair. Most people with depression recover. It is important to remember this.
- Do try to distract yourself by doing other things. Try doing things that do not need much concentration but can be distracting such as watching TV. Radio or TV is useful late at night if sleeping is a problem.
- Do eat regularly, even if you do not feel like eating.
- Don't drink too much alcohol. Drinking alcohol is tempting to some people with depression, as the immediate effect may seem to relieve the symptoms. However, drinking heavily is likely to make your situation worse in the long run.
- Don't make any major decisions whilst you are depressed. If possible, delay any major decisions about relationships, jobs, or money until you are well again.
- Do tell your doctor if you feel that you are getting worse, particularly if suicidal thoughts are troubling you.
Will it happen again?
If you have an episode of PND you have a greater than average chance of it happening again if you have another baby. About 3 in 10 mothers who have PND have another episode of depression if they have another baby. However, you and your doctor are more likely to be aware of the possibility in future pregnancies. This means that you are more likely to be diagnosed and treated promptly should it come back.
What is postnatal psychosis?
Postnatal (puerperal) psychosis is an uncommon but severe form of mental illness that can occur after childbirth. There may be symptoms of severe depression; there are also other serious symptoms such as false beliefs (delusions), hallucinations (such as hearing voices), odd behaviours, and irrational thoughts. Affected mothers may not recognise that they are ill. Postnatal psychosis usually occurs within the first month of giving birth. Women generally need to be admitted to hospital with their baby for treatment.
If you are a relative or friend of a mother who appears to be acting strangely then do alert a doctor or health visitor. There is a risk of harm to both mother and baby in this uncommon, but serious, mental illness. But please note that the vast majority of women with PND do not develop this severe disorder.
Further reading & references
- Antenatal and postnatal mental health: clinical management and service guidance; NICE Clinical Guideline (December 2014)
- Management of perinatal mood disorders; Scottish Intercollegiate Guidelines Network - SIGN (March 2012)
- Depression in adults: recognition and management; NICE Clinical Guideline (April 2016)
- Dennis CL; Preventing and treating postnatal depression. BMJ. 2009 Jan 15;338:a2975. doi: 10.1136/bmj.a2975.
- Depression - antenatal and postnatal; NICE CKS, September 2015 (UK access only)
- Prenoveau JM, Craske MG, West V, et al; Maternal postnatal depression and anxiety and their association with child emotional negativity and behavior problems at two years. Dev Psychol. 2017 Jan;53(1):50-62. doi: 10.1037/dev0000221.
- Milgrom J, Holt CJ, Gemmill AW, et al; Treating postnatal depressive symptoms in primary care: a randomised controlled trial of GP management, with and without adjunctive counselling. BMC Psychiatry. 2011 May 27;11:95. doi: 10.1186/1471-244X-11-95.
- Dennis CL, Dowswell T; Psychosocial and psychological interventions for preventing postpartum depression. Cochrane Database Syst Rev. 2013 Feb 28;(2):CD001134. doi: 10.1002/14651858.CD001134.pub3.
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. Patient Platform Limited has used all reasonable care in compiling the information but makes no warranty as to its accuracy. Consult a doctor or other healthcare professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Laurence Knott
Dr John Cox