Sour Milk

Sour Milk

Farah Hughes

Essay Postnatal Depression (PND): the myths and realities Mr Raja Gangopadhyay (Consultant Obstetrician and Perinatal Mental Health Lead, West Hertfordshire Hospitals NHS Trust) Miss Harriet Sharp (Medical Student, University College Hospital, London) Introduction Postnatal depression (PND) is the occurrence of depression following childbirth. It affects 10-15% mothers after the baby is born.

The onset is usually gradual and manifests 4-6 weeks in the post-partum period, but can occur at anytime up to one year.1 In one third of PND, the depression continues right from the pregnancy.2 This is different from ‘Baby Blues’, which is quite common (50-80%) and reflects normal emotional and behavioural changes following childbirth. ‘Baby Blues’ commonly occur 3-5 postnatal days, usually lasts for 48 hours and resolves without any specific treatment.

Why PND Matters?

Time after the childbirth should be moments of joy, happiness, fulfilment and celebrations of parenthood.

But PND (and other PMH illnesses) can adversely affect both physical and emotional wellbeing of the mums and their families. This could make the necessary psychological and social adjustments and care of the new-born baby very challenging.2 Moreover, PMH illnesses are still a leading cause of Maternal Death in the UK. PMH illnesses can adversely affect the family, social and overall quality of life of the mum: • Bonding and attachment with the baby • Inability to carry out household chores • Could affect professional life • Social isolation • Relationship breakdown • Rarely suicide/ infanticide • Development of chronic depression.

Development of secure attachment (especially at early stages) with the baby is now thought to be a key factor for social and behavioural development of a child in forthcoming years.

Symptoms: The grades of severity of the PND could vary from mild to severe and some of the symptoms are same as depression outside pregnancy: • Persistent low mood (may have diurnal variation) • Early morning awakening/ insomnia • Impaired concentration • Loss of appetite • Loss of enjoyment in life • Tiredness • Difficulty in coping with the tasks of everyday life The following symptoms of PND are related to motherhood and to the new-born baby: • • • •

Feeling incompetent as mother Anxiety and intrusive thoughts Panic attacks Thoughts of self-harm/ suicide and rarely infanticide

If someone has suicidal/infanticide thoughts, this must NOT be ignored.

She must immediately call local Mental Health Crisis Team or Samaritan (116 123) or attend the nearest A&E. Feelings and emotions contributing to PND There could be a sense of guilt and ‘failure’ if the expectations around the birth events are not met, such as not able to have a vaginal delivery (if Caesarean Section is needed) or needed epidural for pain relief (if not included in the Birth Plan).

Difficulties with feeding the baby could also bring up feelings of ‘failed mum’.

This could be compounded by other factors such as crying or sick child (especially admitted to SCBU) or inability to sleep.

Traumatic birth experience could result in a sense of ‘loss of control’, which could predispose mums to feelings of guilt and low self-esteem.

PND is NOT any fault or wrongdoing of the mum.

Denise CL et al,3 suggest: “Motherhood is often seen as something that is natural and fulfilling, and it quite often is. But motherhood can also be very difficult and challenging at times, both physically and mentally. And women often do not get the support and help they need. So it is not surprising that some women develop depression after trying to cope with the struggles and difficulties for a while.”

Psycho-social contributory factors of PND The exact cause of PND is not known.

The predisposing factors are as follows (often multiple factors are present): • • • • • • • • •

Previous PND Family history of severe depression Depression before or during pregnancy Recent life events Lack of social support Childhood abuse High levels of anxiety during pregnancy Stillbirth, infant death, traumatic birth experience IVF pregnancy.

Reasons for delayed recovery The most important factor for early recovery is an early diagnosis and treatment.

Therefore it is advisable that if low mood persists, mums must discuss their symptoms with their GPs, Community Midwives, Health Visitors or Obstetricians, at the earliest opportunity.

The Community Mental Health Team (CMHT) should be contacted first if they already know the mum.

There are many reasons why mums are reluctant to speak about their mental health conditions: • Social stigma • Fear of involving the social services (and child being taken away) • Denial • Lack of awareness • Feelings of – ‘no one will believe me’ If the mum is not noticing progress with the symptoms, it is important that the concerns are expressed immediately to the HCPs She might need further assessment by the Perinatal Mental Health Team.

‘Its OK to tell’ and ‘It’s OK to ask’ (MBRRACE 2015) The recent Confidential Enquiry into the Maternal Deaths in the UK (MBRRACE 2015)4 also highlighted that the post-partum period is a time of very high risk of developing serious mental health conditions and it can deteriorate very quickly.

Therefore symptoms should not be ignored.

The following other factors could also delay recovery: • Incorrect diagnosis: feeling anxious or low could be symptoms of many other

mental health conditions apart from PND, such as OCD, Eating Disorders or

Bipolar illness.

• Non-compliance with medications (when required) due to fear of affecting the

baby during breast feeding.

• Stopping medications/ other forms of treatment early, without medical/

professional advice.

• Inadequate dose of medication • Underlying other medical conditions such as under-active thyroid (hypothyroidsm) • Lack of social/ family support • Adverse life events • Lack of sleep • Problems with feeding the baby • Sick child • Complications of childbirth/ delayed recovery (such as wound infection, post par

tum haemorrhage and anaemia) • If I start antidepressant for PND, I have to on it for life.

Fact: It is often possible to gradually stop the medication under medical advice.

Very rarely it needs to be continued longer depending on clinical need.

Planning pregnancy after PND Occurrence of PMH illnesses could be a very traumatic experience for the mums and their families, even when fully recovered. Many of them could have symptoms similar to Posttraumatic Stress Disorder (PTSD).

This could interfere with plans for future pregnancy.

Similarly mums with previous PND or other PMH illnesses, could have extreme fear of recurrence in subsequent pregnancies.

Myths The following are widely-held beliefs but not true facts: • PND is a sign of weakness and lack of confidence

Fact: This is certainly not true: PND is a health condition, which needs treatment

and care.

•

PND is a sign that you are not a perfect mum and you have failed as a mum.

Fact: No mum is a failed mum, irrespective of the outcome of the pregnancy.

•

PND happens only to certain mums Fact: This can happen to ANY mum irrespective of their professional/ social back ground, ethnic origin or previous mental health history.

•

Any mental health condition after childbirth is PND Fact: Many other mental health condition (could be even serious) can develop in the postpartum period.

• If the mum discloses her symptoms, the child will be taken away by the Social Services

Fact: Social Service involvement is NOT required for all mums with PMH

illnesses. Removal of the baby very rarely required for Mental Health condition.

In fact, it is always advisable that the baby stays with the mum.

This helps in the recovery.

It is advisable that mums with mental health illnesses should have pre-conceptional counselling, if facilities available.

This is especially important for the following: • Currently on medication • Known severe mental health conditions such as Bipolar, Schizophrenia,

schizo-affective disorders, Eating disorders, severe depression, previous Post-partum Psychosis (or psychotic episode outside pregnancy), severe PND and previous admission to Mother and Baby Units (MBU).

GPs must review their medication and advice from specialist Perinatal Mental Health services should be sought, if required.

With appropriate support, care and treatment, full recovery is possible.

Treatments of PND The treatment depends on the severity of the condition. Early diagnosis and treatment is key to recovery.

However response to the treatment many vary depending on the severity and other associated psycho-social factors.

Usually the treatment comprise of the following: • Health Visitors’ ‘Listening Visits’ • Psychological therapies • Antidepressants

Role of Peer Support There is now good evidence to suggest Peer Support could play an important role during the whole journey of PMH illnesses.

It is crucial that mums must not feel that they are alone. Peer Support could create an opportunity to share experience with others, reduce stigma and necessary emotional support and motivation.

Peer Support is currently available locally (in many places), nationally and also in Social Media.

Breastfeeding while on antidepressants Breastfeeding must be encouraged for the mums with PMH illnesses, whenever possible.

Antidepressants are secreted in the breast milk in various degrees; therefore mums must be given adequate information by the HCPs, regarding the safety of medication during breastfeeding.

It is important that the Community Midwife, Health Visitors, GP and Paediatricians (if involved) are aware of any on-going treatment.

It is especially important if the baby is born premature, as these babies are more susceptible to the side effects of medications secreted in breast milk.

Neonatal Withdrawal/Abstinence is rare but mums should be advised to monitor symptoms in their babies (such as for irritability, excessive crying, post-feeding vomiting or sedation) while they are on antidepressant treatment.

Medical advice must be sought immediately. However in majority of the cases, these symptoms are self-limiting and do not require any specific treatment.

Role of HCPs All HCPs caring for the mums and their families must ensure that they have necessary training for recognition of the symptoms of PMH illnesses.

They should be aware of the necessary referral pathways.

It is very important that medical information is appropriately (and timely) shared among all the HCPs within the multidisciplinary teams.

HCPs must listen to the mums and must not ignore their concerns Conclusion The effects of untreated PMH conditions such as PND could be devastating.

Due to stigma and other fears, many mums do not disclose their symptoms and continue to suffer in silence.

All mums are vulnerable to develop PMH conditions following delivery. Therefore HCPs should acknowledge symptoms and ensure that the mums are getting appropriate help and support.

With specialist help and advice, full recovery is possible.

Further advice and support: Tommy’s: Midwife-led telephone line Mon-Fri 9-5pm. Phone 0800 0147 800.

Email support: midwives@tommys.org Association of Postnatal Illness: Telephone support available Monday to Friday 10.00am to 2.00pm on 020 7386 0868.

Email support: info@apni.org Action Postpartum Psychosis: Online support www.app-network.org/pptalk Maternal OCD: Email support: info@maternalocd.org Samaritans: Phone 116 123 (UK and Ireland). Email jo@samaritans.org Reference 1. Oates M. Postnatal affective disorders. Part 1: an introduction.

The Obstetrician & Gynaecologist 2008;10:145–150 2. www.rcpsych.ac.uk/healthadvice/problemsdisorders/postnataldepression.aspx 3. Dennis CL, Dowswell T. Psychosocial and psychological interventions for preventing postpartum depression. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD001134. DOI: 10.1002/14651858.CD001134.pub3 4. MBRRACE-UK (2015).

Saving Lives 2015: Lay Summary. www.npeu.ox.ac.uk/mbrrace-uk/reports

Case Study I would like to thank Emma Campbell for letting me share her story to raise awareness on Perinatal Mental Health (PMH) illnesses.

Emma suffered from anxiety and depression following delivery of her son 18 years ago.

This was her second child.

Her pregnancy and delivery were uncomplicated. She did not have any prior history of mental health condition.

It is important to remember mental health conditions can develop for the first time after childbirth, even if someone do not have a known history of mental health illness in the past.

Therefore mental health symptoms should not be ignored if one has not experienced this before.

Sadly few weeks before her delivery, her father died. On the day of her delivery, it was found that her 17months old daughter was seriously ill with meningitis and needed resuscitation (a life-saving series of medical interventions for critically ill person).

Adverse life events (such as bereavement and life-threatening illness in family members), during pregnancy or around/ after childbirth, could predispose to post-partum mental health conditions.

Therefore mums with such experiences should have more support from healthcare professionals (HCPs).

She had difficulty with sleep and spent sleepless nights looking after the sick child.

Sleep deprivation is an important cause for the development of post-partum mental health conditions.

The separation from her new-born child ‘increased her stress’, as she had to care for her sick daughter. She still has the guilt for not being emotionally attached/ close to the child. In spite of challenging circumstances she ‘kept going’, without adequate support. She continued to have low mood and at one point she ‘could not recognise her son. Sadly she was also separated from her husband.

Feelings of guilt and ‘not being able to be the perfect mother’ could potentially lead to mental health illnesses after the childbirth. On the other hand PMH illnesses could impair the bonding and attachment with the child. Such conditions could strain the relationships too.

She was finally diagnosed with an Eating disorder and had to have Cognitive Behavioural Therapy (CBT is a special type of psychological treatment). Subsequently she was advised to take an anti-depressant to treat the low mood.

Anxiety and low mood could be manifestation of many other mental health conditions apart from postnatal depression (PND) only.

Therefore if the symptoms are not improving, HCPs must consider assessment by specialist mental health professionals.

She has recovered from the Eating Disorder and the low mood is also under control at present.

But she ‘could still feel the pain’.

With adequate treatment, full clinical recovery is possible. But, the traumatic experience of PMH illnesses could last for many years to come. Therefore it is important that all necessary steps are taken to diagnose and startthe treatment early.

Emma strongly feels that many mums do not disclose their symptoms due to the fear of being judged by the ‘punitive society’.

She worked for the Social Services in the past. She also feels that the social services need to do more to reduce the fear of the child being taken away.

Many years down the line, she still feels that the attitude of the community has not changed towards the PMH illnesses.

It is very important to raise awareness regarding the devastating effects of PMH illnesses on the personal, family and social life. Stories from real life like this would also help to remove the stigma and encourage many mums to seek help early and not continue to suffer in silence.

“Uniting women’s stories retrospectively allows closure to the women who have suffered and proves to thoers that it is possible to escape from the dark cloud that once lingered.”

Farah Hughes