Carol Henshaw1 and James Patterson2
1 Liverpool Women’s NHS Foundation Trust, Crown Street, Liverpool, UK
2 Greenmoss Medical Centre, Scholar Green, Stoke on Trent, UK
This chapter considers what is known about anxiety and depression during pregnancy and in the postpartum period and the effective treatments. We will discuss this in relation to the two cases in Box 5.1.
Postnatal depression is the most common medical complication of childbirth and follows around 13% of deliveries. Higher rates are reported in areas with social adversity and deprivation. There are a number of factors that increase the risk of postnatal depression (see Box 5.2). This leaves women like Hannah – in the second case study in Box 5.1 – vulnerable to depression following delivery as her partner has left, she is feeling isolated from her friends, and her parents are disapproving of her situation. Shabila, in the first case study, feels unsupported by her children and already has some symptoms suggestive of depression, which increase her risk after delivery.
Untreated depression can last for a few weeks to a few months but around 10% of cases will last into the second year after childbirth. Pregnancy has often been thought to be a time of emotional wellbeing but depression is as common during pregnancy as it is after delivery. Up to one-third of postnatal depressive episodes have onset during pregnancy. Three to five percent of women will experience a depression severe enough to require referral to secondary mental health care, and 1 in 500 will suffer a puerperal psychosis. Two-thirds of puerperal psychoses are psychotic depressions and one-third are manic episodes. Manic episodes tend to onset more rapidly than depression but more severe depressive episodes can also develop quickly.
Less attention has been paid to anxiety disorders in the perinatal period, but they are as common as depression and comorbidity with depression is not unusual. Generalised anxiety disorder, panic disorder and phobic disorders occur during pregnancy and postpartum, and some women suffering from depression will experience anxiety symptoms such as panic attacks, intrusive obsessional thoughts or compulsions during a depressive episode.
Severe anxiety during pregnancy often focuses on fear of miscarriage or stillbirth (particularly if there is a history of reproductive loss) and fetal abnormality. After delivery, fears of a cot death or of being criticised as a mother are common.
Obsessional symptoms often focus on cleaning or hand washing and fears that the baby might become infected with something. Sometimes compulsive checking of the baby to make sure he or she is still breathing can occur. Some women experience distressing intrusive obsessional thoughts that some harm might come to their baby. This can be misinterpreted as intention to harm, and careful clinical assessment is essential to distinguish between obsessional thoughts that a mother is not going to carry out and a woman with thoughts of harming her child that she is at risk of acting on.
Post-traumatic stress symptoms and post-traumatic stress disorder (PTSD) can occur after traumatic deliveries. Women with a history of sexual trauma and/or mental health problems are at increased risk, but perceived poor support in labour from a partner or professionals, being in pain, perceived loss of control, feeling powerless and medical interventions are also important. It can lead to fear of future childbirth (tokophobia), and some women will avoid or terminate a pregnancy of a much-wanted baby, or may demand a Caesarean section as a result.
Phobic anxiety can also require assessment and intervention if it might have an impact on care during pregnancy and labour. Needle and blood phobias can be treated effectively with systematic desensitation, and if they are identified at booking for antenatal care prompt referral is essential so that treatment can start as soon as possible.
Anxiety and depression during pregnancy are associated with a number of adverse obstetric outcomes (see Box 5.3).
Depression and anxiety during pregnancy and after delivery have been associated with cognitive, emotional and behavioural problems in the child that persist throughout their school years. Boys seem to be more vulnerable to these effects, and postpartum they are thought to be mediated via disturbed mother–infant interaction. There is an also an association with sudden infant death syndrome although the mechanism for this is unknown.
Many women who become depressed during pregnancy or after delivery will seek help, but not all do. Some women may not recognise themselves as being depressed or having a problem. Others may be feeling ashamed, stigmatised or fearful that their children may be removed by Social Services. Hence, case-finding for depression during pregnancy and after delivery is recommended by various guidelines including that of NICE (Clinical Guideline 45). Many pregnant or postpartum women also experience a number of symptoms similar to those of depression, particularly disturbances of sleep, appetite and energy levels. Like Shabila in the case study (Box 5.1), they might hope that things will improve but they may not, and what a woman thinks might be normal for a new mother could develop into a depressive illness.
Several different measures are available and validated to use for case-finding for depression in postpartum women. The most extensively researched is the Edinburgh Postnatal Depression Scale (EPDS; see Appendix 5), which has now been translated into over 60 different languages, but the Whooley Questions, PHQ-9 (see Appendix 2) and the Hospital Anxiety and Depression Scale (Appendix 6) are also used, and in the USA, the Postpartum Depression Screening Scale.
At all antenatal bookings, in addition to asking about current depression, women should be asked about any history of serious mental illness, puerperal psychosis, any psychiatric admission or treatment by mental health services. Mood should be monitored by midwives during pregnancy alongside physical maternal and fetal wellbeing.
Most guidelines advocate case-finding for depression on two occasions postpartum. The first coincides with the 6-week postnatal check and can be undertaken by a health visitor or GP, preferably someone who already has a good relationship with the mother and who is familiar with local referral pathways and services. As some depressive episodes onset later, case-finding at 3–4 months after delivery is advocated, but more difficult to complete as it is likely that women will have reduced contact with the health visitor, and may not consult a GP for her own health. Frequent consultations about the baby may indicate underlying anxiety or depression in the mother, and the GP needs to be sensitive to this.
Very severe depressive disorders and particularly psychotic depression can onset rapidly after delivery, especially if there is a history of severe mood disorder. The early symptoms can be quite non-specific, for example, insomnia, agitation, irritability or excess anxiety, and can be easily dismissed; but the woman can develop profound depressive symptoms with thoughts of self-harm, or psychotic symptoms. Thus, in a woman with a past history of postnatal depression, such symptoms should not be dismissed and she should be closely monitored by the GP and health visitor.
Any woman with depressive symptoms should also be asked about thoughts of harming herself or others, and a positive answer to this, or to question 10 of the EPDS –‘the thought of harming myself has occurred to me’ – requires further exploration. It is necessary to establish whether she has thought of methods and made plans, or can resist the thoughts and what is stopping her carrying them out (‘protective factors’). A woman who is actively suicidal or unable to resist thoughts of harming another person, including her baby, requires urgent psychiatric assessment. Postpartum women tend to use violent methods of harming themselves, such as jumping from high buildings, in front of trains, hanging or setting fire to themselves, unlike women in the general population, and are thus more likely to succeed.
It is also important to remember that postpartum women are at increased risk of some serious medical conditions. Women have died because a history of mental disorder meant that symptoms of medical disorders were attributed to their anxiety or depression and they were treated inappropriately (Confidential Enquiry into Maternal Deaths, CEMD). For example, a woman presenting with tachycardia and double incontinence was admitted to a psychiatric hospital. Although she was later transferred to an intensive care unit, she died of sepsis and cardiac arrhythmia. An acute confusional state secondary to subdural haematoma following a fall in a woman with alcohol problems was attributed to depression, and a woman presenting with anxiety accompanying severe upper back pain was diagnosed as suffering from postnatal depression even when she went on to complain of shortness of breath, chest pain and haemoptysis. She was agitated and frightened of dying and later died of pulmonary embolism and aortic dissection.
Women with mild disorders can benefit from guided self-help and an introduction to local support groups, or telephone or online support. Health visitors trained in non-directive counselling or cognitive-behavioural skills can effectively support women with mild to moderate depression.
Those with moderately severe depression can benefit from psychological therapies such as cognitive-behavioural therapy or interpersonal therapy. This can be delivered on an individual or group basis, and access to such therapies has improved with the IAPT initiative in England. Such referrals should be accepted as priority cases by these services.
In women with moderate to severe depression and/or anxiety, antidepressants are indicated. The GP needs to sensitively suggest the need for antidepressants and explore the woman’s views on medication. Women may be reluctant to consider tablets, particularly if they are breast feeding, and need reassurance that antidepressants are safe when breastfeeding. Hannah has been looking at a number of unreliable internet sources and says she would not take antidepressants while pregnant or breastfeeding because they might harm her baby. Health professionals counselling women who need medication while pregnant or breastfeeding should be aware of the resources available to assist in providing accurate evidence-based information so that they can advise women appropriately (see ‘Further reading’).
Signposting women to third sector services, the National Childbirth Trust (NCT) and online support groups can be helpful for women to appreciate that they are not alone. This might be helpful for women like Shabila who could miss the independence and social contact of her job while on maternity leave and not feel supported by her older children. Hannah, who no longer has a partner and lacks support from those around her, would probably also benefit from other forms of support, and an awareness by the GP of third sector support is important.
Women who suffer from severe depression who are actively suicidal and/or have psychotic symptoms such as delusions and hallucinations are likely to require inpatient care. Those with such problems who are in late pregnancy or postpartum should be admitted to a specialist mother and baby unit (with their baby if postpartum). Such units are best placed to treat severe perinatal mood disorders and maintain the mother-infant relationship. However, they are not present in all cities, and large parts of the UK (including all of Wales and Northern Ireland) have none at all, so this may mean admission at some distance from home. Most units have specialist community teams attached who can facilitate early discharge as soon as this is appropriate and support women at home who do not require admission.
Depression and anxiety occurring during pregnancy or after childbirth not only cause distress for the woman concerned but also can have an adverse impact on the pregnancy and baby. Hence it is important that such women are identified and fully assessed, and that appropriate and effective treatment are offered depending on the severity of the disorder. Professionals in contact with pregnant or postpartum women must be familiar with their local care pathways and services.