Postnatal depression

Also known as postpartum depression

Postnatal depression is moderate to severe depression occurring in a woman within the first 3 to 12 months after childbirth. It is more common than most people realise. With treatment and support, women can make a full and quicker recovery.

Types of depression after childbirth

There are three types of depression which can occur after childbirth.

Postnatal or maternity blues are very common and involve a brief period of the mother feeling down and tearful in the week after her baby is born. This feeling passes after a few days.

Postnatal depression, a much more serious condition, is also common. The woman becomes seriously depressed in the first months following the baby's birth.

Postnatal psychosis (sometimes called postpartum psychosis) is rare and involves symptoms of psychosis (being out of touch with reality) associated with changes in mood – either a depressed or an extremely high mood. It usually begins in the first two weeks after the child is born.

This article focuses on postnatal depression, that is, any lasting depression associated with childbirth. This may happen to women who have never been mentally unwell before, while others will have had depression in the past.

Regardless of what has happened before, the symptoms and treatment are similar. The major difference is there is a concern for the care of the baby, as well as the mother.

Risk factors in postnatal depression

Ten to 15 percent of women will develop postnatal depression in the months after the birth of a baby. It may also start during pregnancy, and, if untreated, continue and perhaps get worse after the baby is born.

There are a number of risk factors which increase the chances of developing postnatal depression.

Risk factors before pregnancy and birth

  • Past history of depression or other mental health problem.
  • Relationship difficulties, especially with the father of the baby or with own mother.
  • Having little social support.
  • Onset of depression during pregnancy.
  • Life stresses or difficulties such as money or housing problems.

Risk factors related to the birth

  • Birth complications, such as caesarean delivery.
  • The birth did not go as planned (eg. birth in hospital or with intervention when the woman wanted a home or natural birth).
  • Birth of a brain-damaged or ill baby.

Risk factors after birth

  • Persisting postnatal blues.
  • Not wanting to hold the baby or feeling detached, having negative thoughts about the baby.
  • Sleep problems.
  • The baby is fussy, has problems feeding, or has colic or reflux.

It is important to identify which of these risks are present through pregnancy, birth and afterwards, as the woman and those involved in her support and care can work to resolve any factors which may be reversible. They can also be alert for signs of any developing depression.

This is particularly important as the weeks and months following the birth are a critical time for mother and baby to establish a good bonding relationship. A long period of depression can interfere with this important process.

See also: Risks associated with postnatal depression

Causes

As with all mental health conditions, the exact cause of postnatal depression remains unknown. All the clearly identified risks can be contributing factors to it.

For all women, childbirth is rated high on the scale of life stress, with many adjustments to be made and many stressful situations, including the birth itself. For women who are vulnerable to depression, (and who may have had a previous episode) there is an increased risk due to factors such as significant loss of, or disturbed sleep.

Women with postnatal depression and their families and whanau may believe they developed it because of the stress of giving birth and being a new parent. Other people with postnatal distress may agree with the view that their mental illness is biological in origin and due to the huge hormonal changes that happen during and after birth. A lot of people with postnatal distress believe it is a combination of these things.

Sometimes people think their mental illness is a punishment for their moral or spiritual failure. It's important to remember it is not your fault you have depression.

Myths about postnatal depression

NOT TRUE: Postnatal or any depression is a sign of a weak character.

Postnatal depression can strike any woman after the birth of a baby. While some particular personality types may be more likely to develop depression, the vast majority of women who develop the condition have been previously healthy and led normal lives.

NOT TRUE: Women with postnatal depression can 'snap out of it' or just choose to 'pull their socks up'.

One of the most disabling symptoms of depression is that it saps the will and makes doing anything an enormous effort. Depression is an extremely unpleasant experience, and most women with this condition would (and do) do anything to get well.

Symptoms

The signs or symptoms of postnatal depression are similar to those for depression. Symptoms can vary from person to person and over time. Not everyone with depression will complain of sadness or a persistent low mood. They may have other signs of depression such as sleep problems. Others will complain of vague physical symptoms.

The symptoms of depression are often divided into three categories: mood, physical, and cognitive (related to thoughts and beliefs) symptoms. Some women will also have anxiety symptoms. For a diagnosis of depression to be made, mood symptoms and some or all of the other signs must have been present for at least two weeks.

See also: Symptoms of postnatal depression

Diagnosis

There is no medical test which can diagnose depression (or psychosis). A diagnosis is made when the woman has some or all of the typical symptoms outlined below. For this reason, it is very important for a health professional to get a full understanding of the difficulties the woman has had, from herself and her family or whanau or others who know her well, if there is any indication of depression.

If you are developing postnatal depression or postnatal psychosis it is most important to seek help as early as possible. These can be effectively treated, and you are likely to recover. The earlier effective treatment is started, the better the chances of recovery.

The Edinburgh Postnatal Depression Scale (EPDS)

This is one of the most well-known assessment tools for postnatal depression. It consists of a set of 10 screening questions that can help assess symptoms that are common in women with depression and anxiety during pregnancy and in the first year after having a baby. This is not intended to provide a diagnosis – only trained health professionals should do this. 

View the tool online Mothers Helpers (NZ)

Treatment

As soon as you recognise symptoms of depression or anxiety in yourself or someone you know, go and see your GP or health professional for an assessment and discussion. They will talk with you about the treatment options in your region. These can include talking therapies, medications, support groups, online programmes, apps, books and much more. 

Counselling & talking therapies

There are a range of talking treatments that have been shown to work for all types of depression and anxiety. Cognitive behaviour therapy is one of the most well known. Talking therapies are provided through face to face, phone, group or online programmes. 

Often you can refer yourself to a private counsellor or psychologist. For funded services, ask your health provider what the options are in your region and for a referral. 

Perinatal Depression and Anxiety Recovery and Prevention Course (Sessions available in the Auckland area and online). Mothers Helpers (NZ)

Medication

Sometimes medication is helpful or needed. Talk about the pros and cons with your doctor and together find one that works for you and has least side effects for your baby. 

Once you start taking antidepressant medication, keep taking it everyday. It takes several weeks to work and most side-effects are mild and go away with time. If you have any concerns about possible side-effects, talk with your pharmacist or doctor right away.

Read more about some of the common myths of antidepressants Mothers Helpers, NZ.

How long will postnatal depression last?

The course of postnatal depression is variable. Without treatment, an episode may last 6 months or more. With treatment, 70 to 80 percent of women will recover much sooner. In the majority of women, there is a complete recovery.

Twenty to 30 percent of women will improve but still have some symptoms of depression persisting for months or even years later. For a minority (5 to 10 percent) there is no improvement and the woman remains unwell for two or more years.

Early access to treatment increases the chance of full recovery. Over time, some women have a single episode and remain well following the birth of future children. However, some will have postnatal depression following any future births, particularly if the risk factors persist. Others will go on to have other episodes of depression outside of the specific post-childbirth period.

Self care

If you have depression, it can be hard to do the very things you need to do to take care of yourself. Your motivation tends to bottom out, leaving you stuck in a whirlpool of negative emotions.

As much as you can, try to put these feelings to the side and choose to act. By choosing every day to do one small thing for yourself, you will slowly start to feel better.   

From the following ideas find what works best for you for those times when you feel down or anxious. You may find it helpful to develop a list of things which help you and that you can keep pinned to the fridge. 

  • Track your mood. You may find there are times of the day when you feel better and can get more done. Likewise, you may find triggers or activities you find more draining. Discuss these findings with your doctor or health providers. Daily mood chart (pdf) Mothers Matter NZ
  • Keep active. Physical activity is very helpful for everyone and an excellent way to help manage anxiety and low mood, reduce stress hormones etc. 
  • Establish good sleep routines. While interrupted sleep is normal once you have a baby, there are things you can do to foster good sleep routines. Try to keep to develop a good bedtime routine which gives you time to unwind before bed and keeps bedtime and wake times relatively regular.
  • Structured problem-solving. Some people are naturally good problem solvers. Most of us are not, especially when tired, stressed or depressed. This is an evidence-based approach and easy to learn. View our structured problem-solving factsheet for six easy steps. 
  • Plan activities. Plan some specific activities a week ahead. Having something to look forward to, someone to catch up with, or some relaxation time while someone cares for baby are all great activities to improve balance and wellbeing. Planning ahead and writing it down also helps with getting the day to day activities done. Set yourself small goals each day you can achieve and feel good about. Weekly activity schedule Mothers Matter NZ
  • Develop a good support system. This is so important. Reach out to friends and family, accept their offers of help and build your support network. Join a local mothers' group, playgroup or coffee group. Ask your Plunket Nurse or contact Parent's Centre for groups near you, or join Mothers Helpers private Facebook group – NZ PND Support and Social Group. Spend time with people who make you feel good and are emotionally supportive. 
  • WRAP: Wellness recovery action plan. This is another proven strategy anyone can set up and benefit from. Write a list of things that help you when you're having a bad day or feeling down eg, ring a friend, take the baby for a walk, play some music, dance, do something creative, put some nice clothes on and do your hair, journalling, join a class and learn something new.
  • Find ways to give and help others. There is always someone worse off and better off than yourself. Look for little ways to help brighten someone else's day and in doing so it often brighten's yours.

Support

Finding affordable/free counselling Mothers Helpers NZ
Parent’s groups Mothers Helpers NZ
Support and services for mothers at-risk of or have developed postnatal depression Mothers Helpers NZ
Perinatal Depression and Anxiety Recovery and Prevention Course Mothers Helpers NZ
Support for Dads Mothers Helpers NZ
The Journal Free personalised online programme to help you to stay positive, create lifestyle changes and learn steps for problem-solving.
Support and education for women with experience of depression ThroughBlue, NZ
Perinatal Anxiety and Depression Aotearoa (PADA)

References

Cox J, Holden J, Sagovsky R. (1987) Detection of postnatal depression: development of the 10-item Edinburgh postnatal depression scale. Brit J Psychiatry 150: 782-86.
Depression in the antenatal and postnatal periods Special edition, Best Practice Journal, Nov 2010

Credits: Mental Health Foundation. Latest update July 2015 by Health Navigator's editorial team.