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Mood Problems during and after pregnancy

Depression is a common condition affecting one in four women and one in six men at some time in their life. While we all feel 'down' or 'blue' sometimes, a person with depression experiences these feelings for longer periods of time (a few weeks or more).

Feelings of sadness are accompanied by other symptoms such as a loss of interest and pleasure in activities, loss of energy, changes in appetite or weight and sleeping difficulties. Unfortunately, many people suffering from depression are not diagnosed and therefore do not receive the help they need.  Depression can occur at any stage of a person's life, from childhood to old age.

While having a baby is usually a happy occasion, a significant number of women will be affected by depression either during pregnancy or after their baby is born.  Women who are affected by depression during pregnancy or following childbirth may have had previous episodes of depression or it may be the first time they have experienced depression.

Antenatal Depression
Despite its prevalence, depression during pregnancy (referred to as antenatal depression) is often overlooked because some of the symptoms (ie. fatigue, sleep disturbance, appetite changes) are difficult to distinguish from normal changes associated with pregnancy. Women who experience depression during pregnancy do not necessarily go on to have depression after they give birth, although they are at higher risk.

Between 10-15% of pregnant women experience episodes of mood swings that last more than two weeks at a time and interfere with normal day to day functioning.  These can be a reaction to the pregnancy itself, for example if the baby is unplanned or unwanted, or due to health issues the mother has such as persistent nausea, or due to other major life stresses such as serious relationship problems. 

For some women who become depressed during pregnancy there will be more of a genetic or biochemical basis for their symptoms.  Depressive symptoms in pregnancy can also be due to a continuation or relapse of a pre-pregnancy condition especially if prescribed medication has been stopped just prior to the pregnancy. 

Around 40% of women who experience symptoms of depression during pregnancy will go on to experience postnatal depression if they do not receive treatment. 

Postnatal Depression (PND)
Depression following childbirth (referred to as postnatal depression (PND) is generally defined as depression that occurs in the year after childbirth. While symptoms can occur at any time during this first year they usually present within the first three months after delivery.

PND is often confused with the 'baby blues' (see section on Other mental and emotional conditions) however, it is quite different and can be distinguished in a number of ways.

The first difference is the length of time for which the symptoms persist. While the 'baby blues' is a transient state with symptoms disappearing within a few days, a woman suffering from PND will experience the symptoms consistently for a period of two weeks or more.  Secondly, there is the severity of the symptoms. In PND the symptoms are disabling, affecting everyday functioning such as eating, sleeping and thinking.

Symptoms
The symptoms experienced by women with depression during pregnancy or following childbirth will differ greatly. Some women may not actually feel 'down' but, rather, display a number of other symptoms which may include some of the following:

Physical
? Sleep disturbances (Most women with a young baby fall asleep as soon as they are able to. Women with PND can lie awake for hours feeling anxious while their baby sleeps, or wake early in the morning. Others want to sleep all the time and have trouble getting up in the morning.)
? Changes in appetite and weight (Some women may feel totally uninterested in food and say, “I force myself to eat because I am breastfeeding, but I don’t taste anything”. Some overeat in an attempt to control their anxiety, others feel sick at the thought of food.)
? Lack of energy and motivation
? Loss of sexual interest and libido
? Feeling of exhaustion or low energy
? Headaches

Psychological
? Feelings of inability to cope (Daily chores, caring for the baby or self care may seem insurmountable to women with PND. 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.)
? Feelings of anger, guilt, resentment, shame (Feelings of guilt is common for most mothers but more so for the mother with PND. Her thoughts and feelings constantly reinforce in her own mind that she is inadequate and 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.)
? Irritability (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.”)
? 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 PND 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.)
? Mental confusion, lack of concentration, poor memory (A woman may forget what she wanted to say mid-sentence. She may not be able to concentrate on simple tasks or 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 or find solutions - like reaching out to services that will help her.
? Anxiety (She may feel a ‘knot in the tummy’ most of the time and panic without cause. 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 deny being depressed.)
? Feelings of inadequacy, worthlessness, emptiness, failure as a mother
? Persistent low mood
? Social withdrawal
? Sadness, tearfulness and crying without apparent reason
? Irrational fears and obsessive negative thoughts
? Feeling of apathy and low energy
? Not feeling how they expected to towards the baby
? Thoughts of suicide


Other mental and emotional conditions associated with pregnancy and childbirth

Postnatal blues ('baby blues')
The postnatal blues (also referred to as the 'baby blues') is a brief period of emotional distress which can occur between the third and 10th day following delivery (7). The condition is very common, occurring in up to 80% of all women who give birth.  The 'baby blues' is characterised by tearfulness, irritability, mood changes, anxiety, fatigue and feelings of sadness and loneliness.

This emotional disturbance is thought to be caused by a number of factors including the enormity of the experience of giving birth and taking home a new baby, sudden changes in hormone levels following childbirth, unexpected discomfort (breast engorgement, soreness from delivery), anxiety about the transition from hospital to home and breast feeding, and sleep deprivation.  The 'baby blues' is a transient state with symptoms disappearing within a few days. No specific treatment is required if there is recognition, understanding, empathy and support from family, friends and medical staff. However, if the symptoms persist for longer than two weeks a woman should consult a health care professional.

Postnatal psychosis
Postnatal psychosis (also called puerperal psychosis) is a rare and severe postnatal condition. Only 1-3 of every 1000 mothers will be affected by this illness following birth (8). A woman suffering from postnatal psychosis may place herself, her baby and her other children in danger because she is unable to make safe decisions. Thus it is a medical emergency requiring immediate attention, including assessment by a psychiatrist and, most often, hospitalisation.

A person with psychosis is unable to distinguish between what is real and what is imaginary. Symptoms of postnatal psychosis usually occur suddenly and dramatically within the first three weeks following delivery. Symptoms can include:
? disturbances in mood (from very high to very low mood)
? disturbances in thought processes (confusion, illogical conversations, bizarre thoughts and delusions)
? disturbances in perception (hearing, seeing or smelling things that do not exist)
? disturbances in sleep
? disturbances in behaviour (behaving in an odd or uncharacteristic manner)

Post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) is an anxiety disorder that develops in response to exposure to a traumatic event. Women who perceive their birth experience as traumatic can develop PTSD in the same way as people involved in a car accident or violent crime. While some of the symptoms of PTSD following childbirth are similar to depression (sleep disturbances, social withdrawal), others are quite distinct and include:
? repetitive, intrusive thoughts about the event
? flashbacks and nightmares
? avoidance of situations associated with the traumatic event
? emotional withdrawal

Other anxiety disorders
Anxiety disorders like generalised anxiety disorder, panic disorder or obsessive compulsive disorder can develop during pregnancy or after childbirth.  Generalised anxiety disorder is characterised by excessive anxiety and worry about a number of events or activities. In panic disorder people have recurrent and unexpected panic attacks and worry about when the next panic attack will occur. People with obsessive compulsive disorder (OCD) experience obsessions (recurrent, persistent thoughts, impulses or images) and compulsions (urge to perform certain mental or physical behaviours).  It is common for people with anxiety disorders to also have other mental and emotional health problems, such as depression.


Risk factors for depression during pregnancy and following childbirth.
There is no single cause of depression during pregnancy or after childbirth. It appears that a range of factors may contribute to its development, including:

Psychological
? previous history of depression
? family history of mood disorders, including depression
? low self esteem
? depression during pregnancy
? severe 'baby blues'
? negative thinking patterns (eg. disqualifying the positives, catastrophising)

Socio-cultural
? poor relationship with partner or no partner
? perceived lack of support (from partner, family and friends)
? stressful life events (relationship breakdown, loss of employment/unemployment, moving, financial difficulties, bereavement)
? negative birth experience, complications in labour or delivery
? unplanned pregnancy
? ill health of baby
? 'difficult' baby (problems with sleeping, feeding, settling)

Other factors
hormonal changes
? having a baby early or late in life
? poor relationship with parents (including a negative experience of being parented)
? recent death of a parent
? unresolved grief for a previous pregnancy/baby (miscarriage, stillbirth or cot death)
? early discharge from hospital without adequate postnatal support
? loss of a previous pregnancy
? use of assisted reproductive technologies (ie. IVF) to conceive
? premature birth
? history of sexual abuse
? physical health problems (eg. pain, tiredness, sexual difficulties, urinary incontinence)

It is important to note that the causes of depression differ greatly amongst women. Each woman has individual life experiences and her own ways of coping with stress and life events.

Expectations of motherhood
Women may delay seeking help for depression during pregnancy and following childbirth because of the 'motherhood myth'. The 'motherhood myth' consists of a number of beliefs about what pregnancy and being a mother is like and how they are represented in society.

Common myths include:
? Pregnancy is a wonderful and enjoyable experience - the idea that all women love being pregnant and embrace every change it brings.
? Pregnant women glow - the notion that during pregnancy women look and feel great.
? Motherhood is natural and intuitive - this belief suggests that women have some kind of innate knowledge about how to care for a baby. This mothering 'instinct' miraculously appears soon after the birth of the baby.
? Motherhood is the fulfillment of womanhood - the belief that having a baby is the most important achievement that a woman can have. Having a child will leave her with feelings of complete fulfillment and contentment.
? Motherhood is the central role for a woman - when a woman has a baby, it is often expected that this role will take primary importance over all other aspects of her life (career, sexual relationships, social contacts, personal time).
? Supermum - increasingly, there are representations of women in society who 'do it all', maintain a career, raise children and manage the household. There is the expectation that performing all these tasks is achievable with good organisational skills.
? Babies are always delightful - the images we see of babies are often idealised. Babies are generally only depicted as being clean, smiling and sleeping and feeding normally.

The reality
? Some women find the changes pregnancy brings difficult to adjust to and are actually relieved when it is all over.
? Morning sickness, back aches and the fatigue commonly associated with being pregnant often leave women feeling anything but 'glowing'.
? Negotiating maternity leave, discrimination towards pregnant women in the work force and financial worries associated with being off work can make pregnancy a stressful time.
? Mothering is not instinctive and is instead a demanding job that requires the learning of new skills.
? Mothering does not come 'naturally' to women simply because they are women and the mother-baby bond does not always take place immediately.
? The responsibility of caring for someone who is fragile, helpless and totally dependent can be overwhelming for some women.
? Women do not always feel that their life is complete after having a child. If a woman had many other interests prior to having a baby, she may initially find motherhood monotonous or stifling.
? The lack of adult company and feeling of isolation can also be distressing to women who are at home with a baby.
? Professional women who give up work during their pregnancy and after having a baby may miss the mental challenges that their careers provided.
? Women employed in occupations where they had a significant amount of control may find the lack of control associated with a new baby difficult to come to terms with.
? Juggling motherhood with a career is not easy and requires more than just good planning.
? Not all mothers have a partner present to offer them ongoing support.
? While babies are delightful they also cry, vomit, poo and can keep you awake at night.

It appears that if women have realistic expectations of what motherhood involves as well as information on pregnancy, labour, delivery and parenting, their risk of depression is reduced.


Impact on relationships
Depression during pregnancy and following childbirth not only affects the woman but can also be extremely disruptive to relationships with her partner, the baby, other children, family members and friends.  These people may be unaware that women can experience depression during these times and, therefore, not recognise the symptoms. Unfortunately, this lack of awareness can result in people giving unhelpful and unsympathetic advice such as "Pull yourself together", "You'll feel different when the baby arrives" or "It's just baby blues".

Partner
It is common for a woman's partner to feel confused and helpless about her condition. The partner is often also influenced by myths surrounding motherhood and cannot understand why their partner is not happy now that she is pregnant/has a baby. They may not understand her mood changes and depressed state.  Men that are used to their partner doing the majority of the domestic chores may become annoyed over the state of the house or the lack of regular evening meals. Others may feel resentment towards their partner and the baby for the changes that have occurred in the relationship.

It is very common for a woman with depression to experience a lack of sexual interest and even feel irritated or repulsed by her partner's sexual advances. The woman's partner may feel rejected and think that she is no longer sexually attracted to them.

Some partners may react to the difficulties at home by withdrawing, staying at work later or by spending more time with their friends. Others may feel guilty that they are not at home more, but are unable to take time off from work.  Partners of women with depression may also develop depression, either simultaneously, or after their partner has recovered.

Baby
The relationship between mother and baby is an extremely close one. A mother's everyday emotional and behavioural changes and interactions with her partner (if she is in a relationship) can have an effect on the baby. The baby may respond to feelings of depression, anxiety or anger by becoming anxious, irritable or by developing feeding or sleeping problems.

Women with depression are often concerned that they have not 'been there' for their baby. While untreated depression can have an impact on the baby's emotional, cognitive and behavioural development, if depression is detected and addressed early the effects should only be temporary.

Other family members
The arrival of a new member to the family can be a difficult time for other children who may feel they are not receiving as much attention. Their mother being constantly fatigued, depressed or emotionally distant can heighten their concerns of being 'left out'.  Relatives can sometimes place added pressures on the woman by trivialising her feelings or telling her she just has to "snap out of it". This type of advice simply reinforces the woman's feelings of inadequacy or of being a bad mother.

Friends
Female friends who experienced no problems during or following their pregnancy may find it difficult to relate to the woman's feelings. They might also offer advice that, although well-meaning, is not helpful in the woman's circumstances. Friends may also not know how to respond to someone whose behaviour and personality are so different from what they are used to.  Improving family and friends' understanding of depression plays an important part in a woman's recovery. If they are better informed about depression they will be able to understand the woman's experiences and feelings and provide her with the necessary support she requires.


Overcoming depression
The first step towards recovery is recognising that depression is an illness for which treatment is available. It is extremely important for women to receive treatment early as the longer the condition is left untreated, the longer the recovery time. Women do recover but recovery is a gradual process.  The types of treatment needed will vary according to a woman's individual circumstances and the severity of her depression.
 
Women who believe they may be suffering from depression should initially contact a health professional (general practitioner, child health nurse, midwife). Some women may be reluctant to make this first step, fearing that they will not be understood. Other women may not be aware that they have depression. In these cases, it is important that the woman's partner, family or friends encourage and assist her in finding the appropriate help.

A health professional can assess the woman's condition and, if necessary, see that she is referred to other relevant health professionals or services. It is important that the woman feels supported by the health professional/s and confident in their ability to diagnose and/or treat depression. A woman may find it reassuring to see a health professional with an interest and experience in treating depression during pregnancy or following childbirth*. Other health professionals that may be involved in treating depression include a psychiatrist or psychologist.

A psychiatrist is a medical doctor who has undertaken higher training in the field of psychiatry. Psychiatrists treat a variety of mental and emotional problems, including depression. They can offer a variety of treatments of a psychological or medical nature including prescribing medications where necessary.

A psychologist has completed a degree in the field of psychology as well as a number of years under the professional supervision of another registered psychologist. A psychologist cannot prescribe medications.

Intervention options
'Talking' therapies
Counselling involves non-judgemental listening and providing the person with assistance in working through their problems. Counselling may be suitable for women with mild depression.  Psychotherapy is the collective name given to a large number of psychological therapies. The therapies may focus on a person's past experiences, current situation or behaviour and patterns of thought. Psychotherapy allows the woman (and/or her partner) to express symptoms, feelings and experiences to the therapist in a supportive, non-judgmental environment. The therapist listens to what is said and then uses the information to offer reassurance, problem-solving techniques or practical strategies.

Medication
There are several reasons for recommending the use of medication, the most important being the severity and duration of the illness. Women are often reluctant to take medication but they should be aware it can play an important role in recovery. If a woman has severe depression medication can assist in making her well enough to attend counselling or psychotherapy.

Medication should always be used in conjunction with 'talking therapies'.  While women are generally told to be cautious about taking medications when they are pregnant or breastfeeding, sometimes it is necessary to take them during these times. The use of medications in such situations must be decided by weighing up the risks and benefits to both mother and baby. If medications are prescribed they should be given in the lowest possible dose and be closely monitored.

The decision to start a medication is made by the general practitioner, obstetrician or psychiatrist in consultation with the patient. The most commonly prescribed medications for depression are antidepressants.  There are several different types of antidepressants. Selective serotonin reuptake inhibitors (SSRIs), are most commonly prescribed because they have fewer side effects than the older types. Antidepressants typically take two to three weeks to start having a therapeutic effect (sometimes even longer).

Although most women will respond to the first antidepressant chosen by their doctor, others may need to try a second or even third antidepressant to find the one most effective for them. Antidepressants are non-addictive and do not change a woman's personality in any way.  Side effects differ for each type of antidepressant and for individuals. It is important that a woman discusses with their doctor what to expect regarding side effects and what to do if they occur. The majority of side effects tend to settle within the first couple of weeks after a woman adjusts to the medication. Antidepressant medication needs to be reviewed regularly by the prescribing doctor.

Hospitalisation
In some cases, it may be recommended that a woman be hospitalised for a period of time. Although this may be a frightening prospect for many women, it is sometimes a necessary step to recovery. Hospitalisation allows for intensive treatment as well as the careful monitoring of any medications. Women may participate in one-to-one counselling/ psychotherapy, group work, and life skills training while also getting adequate rest. 
For women suffering from depression following childbirth, some hospitals provide mother-baby units where a woman can be admitted along with her baby. Mother-baby units allow the woman to receive treatment for her illness, while retaining the bonding process between mother and infant. While mothers are encouraged to care for their babies, staff are present to provide encouragement and support if it is required. The number of mother-baby units is, however, limited with the vast majority being in the private sector.

Diet and exercise and alternative therapies
Adequate nutrition is an important step in the recovery process. Women should aim to limit their use of stimulants like alcohol, tea and coffee, and include more fresh foods in their diet. Participating in regular exercise has been shown to improve one's mood and sense of well-being.

There are several complementary therapies used in the treatment of depression. It is important that anyone using these therapies informs their doctor as they can have side effects and interact with other treatments.  St. John's wort (a herbal remedy) has been found to be effective in treating mild to moderately severe depression. St. John's wort can interact with a large number of medications including warfarin, anticonvulsants, oral contraceptives and antidepressants. For this reason, it is vital that people do not self medicate with St. John's wort and always tell their doctor they are taking it.

Support from other women
Talking to other women about their experiences can help relieve a woman's feelings of isolation and/or inadequacy. Some women may find joining a mother's group or playgroup or chatting online helpful.  Other women may wish to join a support group specifically for depression during pregnancy and following childbirth. These groups can also be a source of support for partners and other family members who are trying to understand their loved one's illness. Women should look for support groups run either by women who have recovered from depression and have facilitation skills or by a health professional with expertise in depression and experience in running groups.
 
What a woman can do to help herself
? get plenty of sleep
? minimise workload through sharing it with others or ignoring anything unnecessary
? accept help when others offer it
? talk about experiences and feelings to family and friends
? eat a well balanced diet
? exercise regularly
? do something special for herself (have an aromatic bath, read a favourite book, buy fresh flowers)
? get out of the house regularly
? maintain social contacts
? be open to treatments suggested by health professionals (counselling/psychotherapy, medication, hospitalisation, ECT)
? establish connections with other women (mother's group, playgroups, online groups and support groups).

Although it may not always be easy to put these suggestions into practice, incorporating just a few can be very beneficial.

What a partner can do
? Listen to what the woman is saying, without trying to solve the problem/s.
? Be understanding (even if the house is a wreck and there is nothing to have for dinner).
? Minimise visitors - although maintaining contact with people is very important, entertaining visitors can be very tiring. It is best not to host any large get- togethers and to keep visitors' calls brief. If certain people are known to be unsympathetic to the woman's condition it may better if they are not invited.
? Attend appointments with health professionals - this can provide the partner with a better understanding of what depression is and make the woman feel that she is being supported in the treatment process.
? Express love and affection in non-sexual ways, such as hugs and cuddles.
? Organise time together as a couple, where the focus is on the relationship rather than on the baby.
? Take time out to relax and spend time doing enjoyable things.
? Consult a health professional for their own emotional and mental health needs if it gets 'too much'.

What family and friends can do
? There are a number of practical strategies that family and friends can adopt to support the woman through her illness and help in her recovery. These include:
? Listening - encourage the woman to talk about her emotions without feeling guilty or selfish. Being able to share such feelings with someone is very reassuring and can help relieve stress and anxiety.
? Practical assistance - offer to do the weekly shopping or bill paying. Prepare meals or volunteer to pick up takeaway. Organise for paid help to do housework or a laundry service to wash the nappies.
? Child-care - offer to baby-sit to allow the woman and her partner some time together. Providing them with the time to go for a walk, drive in the country or night at the movies can be very beneficial.


The lack of awareness surrounding depression during pregnancy or following childbirth means the symptoms may go unrecognised for a period of time. It is important for women, partners and families to be aware of the various symptoms so that if the woman does develop depression she can receive treatment at an early stage.

Additionally, there are a number of strategies that can be put in place before the birth of the baby that may help minimise the risk of depression developing. These include:
? Have realistic expectations of what motherhood will be like and what can be achieved with a new baby in the house.
? Avoid major upheavals, such as moving house just before or after the birth of the baby.
? Establish a comfortable relationship with at least one health professional before the birth of the baby; if a woman can contact someone she feels she can trust and confide in, she will find it much easier to express any difficulties that she is having.
? Establish contacts with other mothers-to-be or new mothers; sharing experiences can often be reassuring and relieve feelings of isolation.
? Teach partner how to do numerous domestic chores, if they do not already know (how to use the washing machine, ironing, cooking simple meals).
? Suggest to friends and family that instead of sending flowers and baby gifts following the birth they contribute to the hire of a nappy laundering service or cleaning lady for a period of time.
? Investigate child care options.

With adequate understanding and treatment of depression during pregnancy or following childbirth, women can recover and once again enjoy life with their baby, family and friends.

 

Narelle Dickinson

Health Psychologist

 

Thanks and acknowledgements to :
• Queensland Association of Mental Health.
• Post and Antenatal Disorders Association Inc

 
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