Sarah Donnelly is a regular patient who visits your pharmacy, asking to speak with the pharmacist in private. She gave birth seven weeks ago to her third child. She explains that her mood has been very low, she is not enjoying the things she normally would and is having trouble bonding with her baby. She feels overwhelmed caring for her new baby alongside her two other children. Her husband has raised his concerns with her about her low mood and behaviour. She expresses concern as she did not feel this way after the birth of her two other children. What advice could you give her?
Postnatal depression (PND) is a type of depression that parents may experience after having a baby. It is a common problem affecting one in every ten women. Symptoms can develop any time within the first year after giving birth. PND can affect fathers and partners too.(1) Most patients will get better within three to six months, with one in four patients remaining depressed by the time their child is one year old.(2)
What are the symptoms?
Most women will feel a bit low, tearful or anxious in the first week after giving birth. This is often referred to as the ‘baby blues’ and is considered normal. However, the ‘baby blues’ do not last for more than two weeks after giving birth.(1)
Symptoms of PND usually include one or more of the following:(1,4)
- persistent feelings of sadness and low mood
- lack of enjoyment and loss of interest
- lack of energy and feeling tired all the time
- difficulty bonding with their baby
- problems concentrating (forgetting or losing things) and making decisions
- feelings of guilt, rejection or not being good enough
- feeling unable to cope
- feeling agitated and irritable
- trouble sleeping at night
- changes in appetite
- negative or guilty thoughts such as harming their baby or themselves
- withdrawing from contact with other people
- feeling anxious about their baby’s health.
Many women may not realise they have PND because the symptoms can appear gradually over time.(1)
What causes PND?
The exact cause of PND is often not clear and can be related to a number of factors.
Some possible factors include:(3,4)
- a history of mental health problems such as depression
- lack of support from family or friends
- marital or relationship problems
- recent stressful events such as a bereavement, financial worries or major life events
- physical health problems during pregnancy or after birth, including trauma from a difficult birth
- physical factors such as an underactive thyroid or low levels of vitamin B12.
However, PND can start for no obvious reason, without any of these risk factors. In addition to this, patients with any or many of these symptoms will not necessarily develop PND.(4)
Diagnosing postnatal depression
Pharmacists can check for PND in all women who have recently given birth, as well as their partners. The following questions can be useful:(3)
- During the past month, have you often been bothered by feeling down, depressed, or hopeless?
- During the past month, have you often been bothered by having little interest or pleasure in doing things?
It is important to encourage patients to be honest about how they are feeling. The answers to these questions will give you an idea about whether other questions should be asked. You should be mindful that the COVID-19 pandemic may have heightened these feelings of isolation and anxiety for new parents. If you suspect the patient may have PND, you should refer them to their GP to have their diagnosis confirmed.(4)
Treatment of PND involves a combination of self-help strategies, talking therapies and medication. The patient can speak to their GP and decide the best treatment option and support for them.
Pharmacists can provide advice on self-help strategies that may be beneficial for patients. These include encouraging patients to:(1)
- Talk to their partner, close friends or family to help them understand how they’re feeling and what they can do to help.
- Accept the offer of help from friends and family in caring for their baby or doing tasks such as housework or cooking – this can give the patient time to rest or relax.
- Make time for themselves. Finding time for activities that they enjoy or find relaxing can be helpful eg reading, having a bath or going for a walk.
- Try to eat healthily and regularly.
- Take every opportunity to get some sleep and rest. This can be difficult when caring for a baby. Asking their partner or family to help with feeding the baby at night, and even if the patient cannot sleep, use the time to rest and relax.
- Try to do some exercise eg walking with their baby in the pram.
- Try using a mindfulness app.
- Reach out to local postnatal support groups. It can be helpful to speak other mothers and women who feel the same way. Their health visitor can be a useful point of contact in locating these services in their local area.(3)
Giving patients the opportunity to talk about how they’re feeling to a trained counsellor or therapist can be helpful. Often they will find this easier than expressing their feelings to someone close to them.
- Cognitive behavioural therapy (CBT): This is based on the idea that unhelpful and unrealistic thinking leads to negative thoughts. CBT aims to break this cycle and create new ways of thinking to help patients behave in a more positive way.
- Guided self-help: This is based on the same ideas as CBT. Patients will be given information via text, video or computer to go through at their own pace. They will have the support of a therapist on a regular basis who will support them to work through the course.
- Interpersonal therapy: This involves patients talking to a therapist about their problems. This can help identify problems in relationships with family and friends and how these may be related to their PND.(3,4)
For those suffering from moderate or severe PND, or that which has not improved with self-help or talking therapy, antidepressants may help. These can help to alleviate symptoms such as low mood, poor sleep, poor concentration and irritability. There are several types of antidepressants that may be used in the treatment of PND, with differing side effect profiles. It is important to remind patients that antidepressants take at least two weeks to start working and therapy will continue for at least six months after they start taking them.(3) Some antidepressants can be excreted in breast milk. You should advise those who are breastfeeding to let their GP know. Patients can be advised that medicines are available with good safety records for breastfeeding mothers.(4)
A small number of women may need help from mental health services. GP referral to a perinatal mental health service may be necessary. Community mental health teams also provide support for women with more severe PND. Few women will need to go into hospital for treatment of PND. They will usually be admitted with their baby to a specialist mother and baby unit. Many women believe if they speak about how they feel, they may have their baby taken away from them. It is important to reassure these patients that the healthcare professionals involved in their care, want them to get better and will provide support so they can enjoy and care for their baby at home.(4)
Can PND be prevented?
Approximately, three in ten mothers who have experienced PND in the past will have another episode of PND if they have another baby.(3) Pharmacists should be mindful of this and provide advice and support to patients who may be at risk. Support available for these patients includes:(4)
- attending antenatal/postnatal classes or new mothers groups
- keeping in touch with their GP and health visitor if they have had PND before
- speaking to others about how they are feeling
- accepting offers of help from friends and family
- making a Wellbeing Plan about the support they may need in pregnancy and after the birth – a template can be downloaded from the Tommy’s charity website.
Other organisations pharmacists can signpost their patients to, for support with PND include:
- NHS (2018) Postnatal depression
- JH. Goodman. Postpartum depression beyond the early postpartum period. J Obstet Gynecol Neonatal Nurs 2004; 33:410-20 DOI: 10.1177/0884217504266915
- Patient.info. (2017) Postnatal depression
- Royal College of Psychiatrists (2018) Postnatal depression.