Postnatal depression

Symptoms and causes

What is postnatal depression?

Having a baby is usually thought of as a happy time. However, as a new mother, you may not necessarily feel this straight away.

You may go through a brief period of feeling emotional and tearful – known as the 'baby blues'. It usually starts 3-10 days after giving birth and affects around 85 per cent of new mothers. It is so common that it is considered normal. New fathers may also feel it. And, although having the baby blues may be distressing, it's important to be aware that it doesn't last long – usually only a few days – and is generally quite manageable.

However, around 10-15 per cent of new mothers develop a much deeper and longer-term depression known as postnatal depression (PND). It usually develops within six weeks of giving birth and can come on gradually or all of a sudden. It can range from being relatively mild to very severe.

Common signs of postnatal depression

You may experience one or more of the following symptoms. However, it is unlikely that you will go through all of them.

How you may feel

• sad and low
• tearful for no apparent reason
• worthless
• hopeless about the future
• tired
• unable to cope
• irritable and angry
• guilty
• hostile or indifferent to your husband or partner
• hostile or indifferent to your baby.

You may find that you

• lose concentration
• have disturbed sleep
• find it hard to sleep – even when you have the opportunity
• have a reduced appetite
• lack interest in sex
• have thoughts about death.

As babies need care and attention frequently, including during the night, it is common to feel tired in the months following the birth of a child. And lack of sleep can make you feel both low and irritable. This is normal, and it is important not to confuse this with PND. However, one indication that you are going through PND is if you find it hard to sleep even when you’re tired and have the opportunity to do so.

My postnatal depression snuck up on me as a dark shadow, every morning waking up and noticing a heaviness and blackness to
my mood. The only 'comforts' were private fantasies about ending it all, running away, escaping my responsibilities, tearing myself to shreds to try and grasp why I felt so bleak.If you experience thoughts about death or harming yourself or the baby, this can be very frightening, and may make you feel as if you are going mad or completely out of control. You may be afraid to tell anyone about these feelings. But it's important to realise that having these thoughts doesn't mean that you are actually going to harm yourself or your children. However difficult it is, the more you can bring these feelings out into the open and talk about them, whether to a family member, a friend or a health professional, the less likely you will be to act on them.

Diagnosing postnatal depression

Experience of depression or other mental health problems before your child is born can put you at greater risk of developing PND. Health professionals should therefore ask about your wellbeing and mental health, during your pregnancy. (If you feel depressed while you are pregnant or later, you may also information on Depression helpful.)

Postnatal depression is assessed, often by health visitors, using a questionnaire called the Edinburgh Postnatal Depression Scale. As a new mother, you may be asked to fill this in within the first two months after the birth, to check for early symptoms.

What causes postnatal depression?

There is no known cause for postnatal depression, and sometimes it can start for no obvious reason. However, some researchers have suggested a number of possibilities.

Some think it is likely to be biological; for example, changes in your body, including hormonal changes. However, although some studies show that changes in the level of hormones during pregnancy and after birth can trigger changes in mood, only some women go on to develop PND – so hormones are unlikely to be the single cause.

Others think the cause is linked to past experiences or social circumstances. Many suggest that a combination of different issues cause PND.

Some situations are considered to put you at particular risk of developing PND:

• previous mental health problems
• lack of support
• experience of abuse
• low self-esteem
• poverty and poor living conditions
• major life events.

Previous mental health problems

If you have experienced a mental health problem in the past – including during pregnancy – this may recur after you have given birth. It is also important to be aware that what caused your mental health problem in the past, can also put you at risk of PND.

If you experienced PND after the birth of one child, you are at increased risk of developing PND after the birth of your next child. However, you may have coped well with you first child, and felt depressed after the second, or the other way around.

Lack of support

Several studies suggest that lack of support from a partner or other family members can put you at risk of PND. You are at particular risk if you are a single mother (especially if you’re young), recent immigrant, refugee or asylum seeker.

Depression during pregnancy needs to be publicised more – because I was never ever asked how I was, even when they knew was about to be a single parent and aware that I had no support.

Experience of abuse

If you experienced emotional, physical or sexual abuse while growing up, you may find it hard to relate to others, including your baby. If your own parents did not have good parenting skills, you may find it hard to adapt to your new role as a mother. For example, you may feel unsure how to respond when your baby is crying. You may even fear that you are going to harm your baby somehow, because you are unsure how to take care of them.

Domestic violence, including verbal, emotional and financial abuse, can trigger anxiety, depression and lower your self-esteem. It also puts you at risk of developing PND.

If you experienced abuse as a child or later in life you may also have posttraumatic stress disorder (PTSD), which can further add to your risk for postnatal depression. (For more information, see Post-traumatic stress disorder.)

Low self-esteem

If your self-esteem is low, you may doubt your ability to cope as a new mother. When your baby cries, for example, you may think it is because of something you have done wrong – or because of something you haven’t done. The way you think about yourself can put you at risk of developing PND. (See How to increase your self-esteem for more information.)

Poverty and poor living conditions

It can be difficult for anyone to deal with poverty. If you face life with a new baby while living in poor housing and with little money to spend, this adds stress to your life and puts you at risk of developing PND. You may feel that you are unable to provide your baby with everything that he or she needs, and you may feel that you are failing your baby. Dealing with poverty can be particularly difficult if you are also living alone with little or no support from others.

Major life events

Major life events can include:

• an illness or death in the family
• the break-up of a relationship
• moving house
• losing your job
• having a baby.

Each of these events can add serious stress to your life. If you experience any of these in addition to having a baby, this can increase your risk of getting PND. However, increased risk does not mean that you will definitely develop PND.

Having a baby is a major life event in itself, as it is likely to involve many changes in your life. You may have had to give up your job and lose your financial independence. You may also have had to give up social activities and have limited or no opportunities to meet up with your friends. Being responsible for a baby 24 hours a day means that your day is likely to revolve around your child’s needs rather than yours.

Self help and treatments

What help is available?

I was too scared to tell anyone how I really felt in case they took my baby away.You may fear that your baby will be taken away if you admit to feeling depressed, anxious or having distressing thoughts, for example, about harming yourself or the baby. But fear of asking for help may be part of the problem, and you may need encouragement and support in getting it.

PND is not only a distressing condition, it can also be a disabling one, so the earlier you get help the better. If PND is acknowledged and addressed, it is likely to pass sooner and be less severe than if you get no help. It is then also less likely to affect the relationship between you and your baby.

I thought I was a bad mother, until I told my health visitor how I was feeling. When she named ‘it’ postnatal depression and got me the right support, it felt like someone had opened the door and let a glimmer of sunlight in.There are many health professionals who are familiar with these issues and who can provide you with support in several different ways. These may include your GP, midwife, health visitor, community psychiatric nurse, psychiatrist, psychotherapist or counsellor, or complementary practitioner.

Research suggests that the treatment most new mothers prefer for PND is a combination of practical support and advice, and counselling or psychotherapy. If necessary, you may want antidepressants. In rare cases, you may be offered electroconvulsive therapy (ECT).

Counselling and psychotherapy

Talking treatments, such as counselling and psychotherapy, can offer you the opportunity to look at the underlying reasons that have contributed to the way you feel, as well as helping you to change and manage your feelings.

The NICE (National Institute for Health and Clinical Excellence) guidelines on antenatal and postnatal care say that healthcare professionals should, before and during pregnancy if possible, and after the birth, ask specific questions designed to detect signs of depression, and follow this up as appropriate.

Many GPs have a counsellor or psychotherapist attached to their practice. They can also refer you to a psychiatrist or psychologist on the NHS. Various organisations offer talking treatments, and some of them operate a low-fee scheme for those who can't afford to pay. (For more information, see Talking treatments.) Cognitive behaviour therapy (CBT) is increasingly popular as a short-term treatment, and provides practical ways of dealing with problems (see Cognitive behaviour therapy.)

Talking therapies should be more readily available to you if you are pregnant or breastfeeding because of the increased risk of using medicines at these times.

Prescription medicine

Your GP can prescribe medication to help you. But it's important to discuss potential benefits and side effects fully, before taking any, and to keep monitoring your progress with them.

Medication may enter breast milk, and if you are breastfeeding you will need to bear this in mind when deciding whether or not to take it. Some drugs have known effects on infants, while others appear to be quite safe, so it is important to discuss this with your doctor. If you do decide to try medication, it may be necessary to try different drugs to achieve the best results.

Antidepressants

All antidepressants take time to work. If you do take them, they can be very effective, but you should be prepared to take them for at least six months. They also all have possible side effects, and when you stop taking them you should withdraw slowly, to avoid possible withdrawal effects which can be unpleasant.

Manufacturers advise that the following antidepressants should be avoided while breastfeeding: doxepin; phenelzine, isocarboxazid, moclobemide; citalopram, escitalopram, fluoxetine, fluvoxamine, sertraline; duloxetine, venlafaxine; flupentixol, mirtazapine, reboxetine, and agomelatine. (See Antidepressants for more information.)

Mood stabilisers, such as lithium, should also be avoided while breastfeeding.

Sleeping pills and tranquillisers

If lack of sleep has become a habit you can’t break, your GP may consider prescribing sleeping pills to help you. Any sleeping pills should be taken for brief periods only, and preferably not for several nights in a row, in order to avoid becoming dependent on them.

They should not be taken if you are breastfeeding because they are excreted in breast milk, and are absorbed by the baby.

See Sleeping pills and minor tranquillisers for more information.

Other drugs

You may also be taking other medication for a mental health problem or physical condition. These can sometimes interact with drugs the doctor may wish to prescribe for postnatal depression. All drugs should be used with caution. Talk to your doctor or a pharmacist if you need more advice about a particular drug or combination of drugs. (Also see medication more details on individual drugs for mental health problems.)

Electroconvulsive therapy (ECT)

ECT is a controversial treatment, but some psychiatrists favour it for PND because when it works it can relieve depression quickly. The treatment is done under anaesthetic and involves passing an electrical current through the brain. Many people are nervous of it, and it does not work for everyone. It can also have serious side effects. The NICE guidelines suggest that ECT should only be offered if you experience severe depression and if other treatments have not helped. (see Electroconvulsive therapy.)

Complementary therapies

Some women have found complementary therapies helpful when they experience PND. These are holistic therapies – treating you as a whole person to support your body and mind in healing. They include cranial osteopathy, herbal remedies, homeopathy, massage, reflexology and aromatherapy. Some people find these therapies can help them relax and may reduce symptoms of, for example, depression and anxiety. (See the Complementary and Natural  Healthcare Council)

What can I do to help myself?

Postnatal depression usually gets better in time, although it may take up to a year. Where you feel you can, ask for and accept help from those around you. Love, practical and emotional support from family, friends and community can be vital in helping you to cope.

Meet other parents

Talking to other new mothers and fathers, and finding that other new parents share the anxieties and frustrations you are experiencing, can be very reassuring. It can also give you a chance to share skills and experiences, to realise you are not alone, and above all to get some emotional and practical support. It can help to affirm you in your new role.

You can develop your own network of support; for example, by keeping in touch with people you may have met at your antenatal classes, and going to parent-and-baby groups locally. There are many organisations that can put local mothers in touch with each other, including Netmums and Home-Start. Having a baby can be a wonderful way to make new friends.

I suffered badly from postnatal depression, I felt very lonely and frightened. My health visitor got me into a baby massage class to help me bond with my baby and also meet other mums suffering. It really helped to meet and talk through our experiences. It made me realise I was not alone.

Get help to shop and cook

Difficulty in concentrating and lack of appetite are common symptoms of depression. The first can make it difficult for you to prepare food; the second can make it difficult to eat. Lack of food can make your condition worse. You may also be anaemic, which will make you feel tired and make it harder to relate to your baby. You may also be lacking vitamin B, calcium and magnesium.

Accept offers of help from relatives and friends to help you prepare or buy food. People often like to do something practical to help you and this is one great way.

Get help with feeding your baby

If your baby takes a bottle, you could ask your partner or other family member to take over the night feeds, if only for a night or two. If you are breastfeeding only, you can have the baby’s cot next to your bed, so that you can feed with the minimum of disruption. In time, you and the baby are likely to fall into a more natural rhythm of sleeping and waking, and this will make the night feeds much less stressful and tiring.

Do less housework and rest when possible

It can help if you don’t try to do too much round the house; you and the baby are much more important. If you are having many broken nights, you can try to sleep when the baby does, and, if at all possible, have people to help you out with daily responsibilities, so that you can rest during the day.

The postnatal depression seemed to go on forever, but I did sleep more eventually, and my 'depression' magically lifted. I think a lot of new mums just need more help – and definitely more sleep – than they get!

Exercise

It might seem impossible to find the time, but if you can, physical activity can work as an antidepressant, especially if it's enjoyable. Do anything you find fun, e.g. walking fast with the pram, dancing to the radio at home. Or try to arrange for a time for yourself to go to a class or for a run, while your partner or friend looks after the baby. (Also see Tips: physical activity.)

Learn to relax

• Learning simple breathing or relaxation techniques, such as those you learn in antenatal classes can be helpful. (Also see How to manage stress.)

• Giving yourself a relaxing bath with candles and scented foam while the baby is asleep or is being entertained by someone else, can help recharge your batteries.

• You can try to find something to do, just for the fun of it. It doesn’t matter whether it’s five minutes with your feet up and a glass of orange juice, reading a book or listening to music, as long as it gives you pleasure.

Fathers and PND

What about fathers?

Only mothers can formally be diagnosed with postnatal depression. However, studies suggest that fathers can also experience depression after the birth of a child. Research suggests that between 1 and 4 per cent of men experience depression during the first year after the birth of a child.

Some new fathers appear to be more vulnerable to depression than others. Being young, unemployed and/or poor when the child is born increases the risk of depression after becoming a dad. It may be that young fathers are more at risk because being young might mean that it is less likely that the child was planned. A young dad might therefore not feel ready to take on the new responsibilities that come with fatherhood.

If the new mother is depressed, this might make the role as a father more stressful, which in turn can add to the risk of experiencing depression.

Other possible causes include increased responsibility; the expense of having children and the change in life-style that it brings; the changed relationship with their partner; as well as lack of sleep and the increased workload at home.

Few services exist for men, although awareness and understanding of this problem is improving slowly. (Contact the Fatherhood Institute under for further information.)

PTSD and Puerperal psychosis

What other mental health disorders can affect you after childbirth?

This section focuses on two mental health disorders that are linked directly to childbirth. If you are concerned about childbirth because of a pre-existing mental health problem, Mind Infoline (0300 123 3393) can direct you to the relevant information.

Post-traumatic stress disorder (PTSD)

If you have a difficult labour with a long and painful delivery, an unplanned caesarean section or emergency treatment, you may experience a form of post-traumatic stress rather than postnatal depression. The impacts of these are often under-estimated, as people may feel that the baby is adequate compensation for the trauma, and that, as a new mother, you will soon forget the ordeal in the joy of motherhood.

However, a traumatic childbirth may impair your relationships with both your baby, and your partner. You may feel acute disappointment that childbirth was not the wonderful experience you were hoping for, and feel angry with the medical staff if you felt that the delivery wasn’t handled well. Many mothers even avoid further pregnancy after a negative birth experience like this.

If you have experienced a traumatic delivery, you can ask for help via your GP or health visitor to deal with the trauma. This can make it easier to put the experience behind you and minimise the risk of developing longterm depression. (See Post-traumatic stress disorder)

Puerperal psychosis

This is a serious, but rare, psychiatric illness, occurring in less than one in 1,000 births. It is similar in some ways to bipolar disorder. If you are diagnosed with this disorder, you may experience the following symptoms:

• mania
• severe depression with delusions
• confusion or stupor
• rapid changes in mood between mania and depression
• delusions
• hallucinations.

It usually starts quite suddenly a few weeks after the birth. You may feel very restless, excited or elated and unable to sleep. You may feel confused and disorientated, and find it difficult to relate to your environment, or fail to recognise friends or family members. This can make it difficult for you to bond with your baby.

You may have delusions or hallucinations. You may misinterpret what is happening around you – for example, you may think your baby is being taken away from you, when staff are simply taking it for a sleep or a feed. You may be manic (for example, cleaning the house at three o'clock in the morning) or have wild mood swings from high to low. Your behaviour may become increasingly disturbing to those around you, and you may lose touch with reality. It is likely that you will need help, and medical and social support.

Causes and risk factors

There is some evidence that puerperal psychosis runs in families, and if you have a previous or family history of mental health problems (for example, a diagnosis of bipolar disorder) you are at a higher risk of developing it. However, it often appears with no warning.

It is slightly more common in first rather than later pregnancies, and one experience of puerperal psychosis does not necessarily mean that you are likely to have it again after subsequent pregnancies.

Available treatments

It is important to get appropriate help as quickly as possible, as there is an increased risk that you might not be able to care for your baby without support from others.

Treatment may involve you being in hospital, in a mother and baby unit within a psychiatric ward where this is available, and will usually include antipsychotic drugs such as olanzapine or quetiapine, or antidepressants. As many psychiatric wards or hospitals do not have mother and baby units, you may have to be away from your baby while you are being treated. Clearly this is undesirable, and if you have to be away from your baby, this should be for as short as possible.

Sometimes it may be necessary for you to be treated with certain drugs. All published advice states that antipsychotics should be  avoided while breastfeeding. (See Antipsychotics.)

Doctors may suggest using electroconvulsive therapy (ECT) which  can be effective, and does mean that breastfeeding can continue. If you are offered this treatment, it will be given under general  anaesthetic. Because there is risk of side effects – headaches and short- and long-term memory loss, your treatment should be carefully monitored. If you experience memory loss, the treatment should be stopped. ECT should only be offered if other treatments have not worked. (See Electroconvulsive therapy.)

Most women recover within a few weeks, but it may take a long time to get over it completely.

Family and friends

How can family and friends help?

This section is for friends or family who wish to support someone they know who has postnatal depression.

Studies suggest that new mothers who experience postnatal depression (PND) find support from partners, family and friends helpful.

It may be difficult, upsetting and frustrating to live with someone who has PND, but it's important not to blame them for how they are feeling. Some mothers who experience PND may be reluctant to ask for help out of fear that she might be labelled as mad and that it will result in the baby being taken away from her. It can therefore be helpful if you reassure her that many women experience PND, and that she is not going mad and that she will get better.

If you are prepared to talk about what is going on, this can help make the problem visible – and less threatening – and can be a vital first step towards resolving it.

If you learn about PND you may feel better able to understand what she is going through – and how best to help.

You could also offer to go with her to the GP or hospital. This can make her feel safe, and it will be easier afterwards when there are two of you to remember what was said and what advice was given.

Offer practical support

The best way to find out what she needs is to ask her. However, if she feels very low, she might find it difficult to make suggestions. You could then suggest various things you are willing to do.

Practical support can include:

• doing shopping, cleaning and other jobs that need doing
• cooking and providing healthy food
• looking after the baby (so she can sleep, have a bath, exercise etc)
• spending time with her so she doesn't have to be alone all the time
• helping her get a treat; for example a massage.
• If necessary, you could offer to check out what options for help are
• available in your area. If you need help with this, you can contact Mind Infoline.

Useful contacts

Mind Infoline
tel: 0300 123 3393 (Monday to Friday, 9.00am to 6.00pm)
email: info@mind.org.uk
web: www.mind.org.uk
Details of local Minds and other local services, and Mind's Legal Advice Line.  Language Line is available for talking in a language other than English

The Association for Post Natal Illness
tel: 020 7386 0868
web: apni.org
Provides support to mothers with postnatal depression

Birth trauma association
web: birthtraumaassociation.org.uk
Support for women who have experienced traumatic childbirth. Has a fathers/partners section.

The Breastfeeding Network
supporterline: 0300 100 0210
web: breastfeedingnetwork.org.uk
Support and information, including on drugs and breastfeeding

British Association for Behavioural and Cognitive Psychotherapies (BABCP)
tel: 0161 705 4304
web: babcp.com
Can provide details of accredited therapists

British Association for Counselling and Psychotherapy (BACP)
tel: 01455 883 300
web: itsgoodtotalk.org.uk
For practitioners in your area

Complementary and Natural Healthcare Council
tel: 020 3178 2199
web: cnhc.org.uk
Has a register of government-accredited complementary healthcare practitioners.

Depression in pregnancy
web: depression-in-pregnancy.org.uk
Information for women who experience depression, anxiety or stress during pregnancy.

Fatherhood Institute
web: fatherhoodinstitute.org
The UK’s fatherhood think-tank, providing news, training information, policy updates, research summaries and guides for supporting fathers and their families

Home-Start
freephone: 0800 068 63 68
web: home-start.org.uk
Informal and friendly with local support networks for families with young children

NICE (The National Institute for Health and Clinical Excellence)
web: nice.org.uk
Guidelines on evidence-based treatments

NCT
Helpline: 0300 330 0700
Web: nct.org.uk
NCT is the UK’s largest charity for parents. Its website and helpline offer practical and emotional support in all areas of pregnancy, birth and early parenthood

Netmums
web: netmums.com
Online parenting organisation helping parents share information and advice.

Perinatal Illness UK
web: pni-uk.com
For anyone with any kind of illness or trauma while pregnant, and
during and after childbirth.

Post Natal Depression & Puerperal Psychosis
web: puerperalpsychosis.org.uk
Information and advice.

United Kingdom Council for Psychotherapy (UKCP)
tel. 020 7014 9955
web: psychotherapy.org.uk
Details of local and registered psychotherapists.

Published 2013
To be revised 2015
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