Antenatal and postnatal mood disorders

• Antenatal depression occurs before the baby is born, during the pregnancy. Ten per cent (one in ten) of pregnant women experience antenatal depression.
• 'Baby blues' is the mildest and most common postnatal mood disorder, affecting about 80 per cent (eight in every ten) of new mothers and occurring between the third and tenth day after birth. Symptoms include tearfulness, anxiety, mood fluctuations and irritability. The 'blues' are caused by a combination of factors such as hormonal changes, exhaustion following labour and birth, and the emotional journey of birth and becoming a parent. They usually pass quickly with rest, understanding and support.
• Postnatal depression affects about 15 per cent (15 in every 100) of mothers.
• Postnatal psychosis affects 0.1 - 0.2 per cent (one in 500 to 1000) of mothers and is the most serious form of mood disorder. It usually occurs in the first three to four weeks after birth. The woman herself may be unaware she is ill as her grasp of reality is affected. Symptoms include severe mood disturbance (either marked elation or depression or fluctuations from one to the other), bizarre thoughts, insomnia and inappropriate responses to the baby. There is usually risk to the life of both mother and baby if this condition is not recognised and treated immediately. With appropriate treatment in hospital, most women recover.

Postnatal depression

• An overwhelming loss of joy in things that previously brought pleasure as well as difficulty in finding pleasure in her baby
• Sleep disturbance unrelated to baby's sleep needs
• Appetite disturbance
• Crying
• Feeling unable to cope
• Irritability
• Anxiety
• Pain
• Fear of being alone or being with people
• Memory difficulties and loss of concentration
• Feeling guilty and inadequate
• Loss of confidence and self-esteem
• Morbid or obsessive thoughts and thoughts of self-harm or suicide

In brief:

• Postnatal and antenatal depression are not conditions to be ashamed of and can happen to any woman of childbearing age.
• Early signs and symptoms of postnatal and antenatal depression are recognisable and help is available.
• Postnatal and antenatal depression can be mild, moderate, or severe. Overall it includes any mother who is feeling consistently unhappy, distressed, anxious or depressed for a period of time and for whom motherhood does not bring joy despite feeling love for her baby.
• Postnatal and antenatal depression occur in all cultures and across all socio-economic classes.
• It is not a modern condition. Each generation calls it something different. What we call postnatal depression today may have been called 'a nervous breakdown' 50 years ago.
• It can happen after miscarriage, stillbirth, normal birth or caesarean birth. Pregnancy is the common factor.
• With appropriate support and professional assistance a mother can recover. Recovery will be gradual with a combination of good days and bad days.

Interventions for recovery

1. Accept the depression
   The first step towards getting better is to accept that you don't feel the way you want to and to seek help for this. This will mean starting to talk to people about how you feel and letting go of the many defences and masks you have created.
2. Medical assessment
   Because depression is a medical condition you will need to make an appointment to see your medical adviser. It is important for you to have a series of basic medical tests to rule out any other conditions.
3. Medication
   Antidepressant medication, in conjunction with support and counselling, is a very effective treatment for many women with either antenatal or postnatal depression. Antidepressants do not necessarily treat the cause of the depression or take it away; they can however help speed up the recovery process and support other forms of treatment.
   Unfortunately there are many misconceptions about antidepressants and many women who could benefit from them refuse to take them because they are afraid the medication is harmful, particularly if they are pregnant or breastfeeding. A more detailed discussion of these issues is in our booklet Postnatal Depression and Breastfeeding.
   Antidepressants do not change your personality; they act on the brain chemicals that are thought to affect depression and anxiety. Antidepressants are not addictive and some can be safely taken while pregnant and breastfeeding.
4. Counselling
   Counselling and support can help you to understand what has contributed to your postnatal depression and help you to adapt to your role as a mother. With any degree of postnatal depression, particularly long term, it is important for you to investigate all the possible contributing factors (for example unrealistic expectations of motherhood, rigid and controlling thinking, past history of child abuse or grief and loss) to help prevent depression with any future pregnancies and to develop problem-solving strategies.
5. Lifestyle Changes
   Although it can be difficult for you to make changes to your daily life when you are feeling very depressed or anxious, making some small changes can be helpful. For example, resting when your baby is sleeping rather than doing the housework, sitting to eat your lunch every day or having a shower every morning can help to restore some normality to your life, even if you don't feel like doing these things. Making time to go for a walk, either taking baby in a sling or stroller, or leaving him with your partner, a trusted family member or friend can allow you some time for yourself.
   Good nutrition is important to health. Your diet needs to be balanced - preferably low in saturated fats, refined sugar and caffeine and high in fruits, vegetables, and whole grains. Any intake of alcohol or other non-prescribed drugs may have an impact on your body's wellbeing.
   Exercise is also an effective form of treatment for depression. Daily physical exercise boosts mood by increasing the levels of positive neurotransmitters, and the release of endorphins will help to create a sense of wellbeing. Relaxation and meditation can also be very effective. The Australian Breastfeeding Association booklet Looking After Yourself has lots of helpful suggestions.
6. Mother the way you want to mother
   Many of the issues the mother with postnatal depression faces are the same as those of all mothers, for example the baby's feeding, settling and sleeping. Part of your recovery will involve a growth in your confidence with making decisions about the care of your baby and how you want to be as a mother, in partnership with your partner.
   For many mothers, being supported to continue breastfeeding is important to their recovery from postnatal depression. The skin-to-skin contact that comes with it can have a positive effect on your relationship with your baby. Sleeping with your baby or having your baby near you when you sleep may also help your relationship. For other mothers who are more anxious, the closeness of the baby can be disruptive. Note that bed-sharing with your baby is not recommended if you are taking medication that may make you sleep more heavily than normal, and never sleep with your baby on a chair or couch.
7. Support
   Support and patience from family and friends are perhaps the most crucial factors in your recovery. All women with postnatal depression need emotional support from family and friends. It can feel much easier to withdraw from friends and family because of how you feel but isolation from others can actually make you feel worse. Belonging to an Australian Breastfeeding Association group, new mothers' group or other support group is an important part of managing your depression, even though it may be difficult to get there. Being with other like-minded mothers, especially those who have experienced or who understand postnatal depression and women who are supportive of breastfeeding, is very helpful.
8. For the future
   If you plan another pregnancy, it is important to consult your medical adviser for guidance, as there is a higher risk of it recurring. Most medical advisers recommend a woman should have discontinued medication for at least a year before attempting a subsequent pregnancy.

In summary:

• Share how you are feeling with your medical adviser and child health nurse.
• Ensure emotional support eg family, friends, PANDA, Australian Breastfeeding Association
• Seek quality information about depression and its treatment, eg PANDA's telephone support, information and referral line, hospital drug information lines and this booklet.
• Speak with someone regularly about how you are feeling
• Ask for and accept practical help from partner, family and friends and/or organise paid help
• Take a routine break from your parenting role.
• Have regular social contact with other mothers.
• Take time for yourself to do something you enjoy.
• Do some regular exercise. Exercise that increases your heart rate for 30 minutes three times per week has a similar effect on brain chemistry as taking a low-dose antidepressant.
• Make sure you have a healthy diet. Avoid caffeine and high levels of sugar.
• Obtain medical help eg medical adviser, psychiatrist, child health nurse
• Assess the need for and regularly monitor antidepressant medication.
• If necessary, consider hospitalisation (ideally in a mother-baby unit).

Breastfeeding

When we talk about breastfeeding we usually think about the physical mechanics and how to do it. It is also important to think about the mother's psychological or emotional states and her social situation.

Some of the emotional factors for successful breastfeeding include:

• Confidence in your body's natural ability to breastfeed, that you will be able to produce enough breastmilk to fully feed your baby and that your milk is good for your baby.
• Confidence and ability to trust your decisions about how to feed your baby and what is best for you and your baby. Central to this is your knowledge that your needs are also important.
• Clear calm thinking, to work out how to solve any problems that may arise.
• Ability to advocate for yourself and your baby, assertiveness to state your needs and to make sure that you are heard and responded to.
• Confidence in yourself and self-assuredness to take control of your situation and to seek help when needed from your partner, family and support services.
• Emotional and physical energy to persevere through the early stage of establishing breastfeeding or through challenging periods of breastfeeding.
• Being able to be emotionally and physically available to your baby and her needs; not to be too absorbed by your own emotions to be able to focus on what your baby needs.
• Ability to read your baby's communications about her needs eg whether baby's cries always mean she is hungry.
• Ability to cope with the unknown and the unpredictable - realising that you won't always know the cause of a breastfeeding difficulty or what will happen, or when or how things might change; that it is okay to not know exactly what the baby wants and to rely on the signs that we do know to reassure yourself that the baby is getting enough breastmilk.

Household

• Accept any offers of help made to you, whether it is folding washing, ironing or cooking. Most people who offer genuinely want to help in some way.
• It is fine to use pre-prepared or frozen meals for a while. They can still be nutritious, and can be great for when you are too busy with your baby to prepare a meal or if you are not able to cook. A list of favourite, simple meals can be helpful when you are finding decision-making difficult.
• Don't stress if household tasks are not done. They will almost always wait for another day. Allocating tasks between family members can help. It may be easier for your partner to wash dishes if you are feeding baby after the evening meal.
• Plan one or two things to do each day, eg wash the clothes or shop for food. Small goals are more achievable. Don't plan too much or it may discourage you if it all becomes too overwhelming. Writing a small list and crossing off things you get done can help you feel you are achieving something. Having somebody to help you when you are out, or to mind baby while you shop, can be very helpful.

The Australian Breastfeeding Association booklet Survival Plan has lots of hints and ideas for making life easier with a new baby.

For partners

• Provide support for her treatment
• Ask for accurate information about postnatal depression and its treatment
• Provide emotional support
• Provide support for the mother's relationship with her baby
• Provide practical support

Concerns for you

• You may feel more tired or even exhausted if your sleep is disturbed or you are worried.
• You may feel anxious and confused about what is happening to your partner and whether she and the baby will be okay. You might feel a sense of loss that the woman that you knew has gone and that you don't know how to help her come back.
• You may feel that the demands of your home life and the extra responsibilities of caring for the children are intruding on your time and demands at work.
• You may also be experiencing a loss of social contacts and feeling unsupported as the need for you to be at home and other family demands increase.
• Make sure that you have time to yourself, away from your work and family, keeping up your hobbies and interests as much as possible.
• There is a risk of depression in men after childbirth (the estimates are around eight per cent), especially if you have experienced depression before.

Suggestions for family and friends

• Find out as much information as you can about postnatal depression.
• Be patient and understanding.
• Ask the couple how you can help.
• Offer to babysit.
• Offer to help around the house.
• Let the woman know you are there for her, even if she doesn't feel like talking.
• Offer to accompany the mother for a regular walk or exercise class, or to a support group such as an Australian Breastfeeding Association group activity.
• Appreciate that the woman's partner may also be emotionally affected by the demands and challenges of new parenthood.

Danger signs to look for

• Talk of harming herself or the baby
• Bizarre thoughts or speech patterns, or risk-taking behaviour
• Behaviour that seems odd or is out of character
• Severe change in mood
• Withdrawal from all social contact
• Extreme despair
• Obsession with morbid ideas, or statements like: 'They'd be better off without me'.

In conclusion

Postnatal depression support services

ACT:

Post and Antenatal Depression Support and Information (PANDSI) (02) 6232 6538 www.pandsi.org

NSW:

Karitane Care Line (24 hours) (02) 9794 1852, 1800 677 961 (country), Tresillian Parent Helpline (24 hours) (02) 9787 0855, 1800 637 357 (country)

QLD:

North Queensland Postnatal Distress Support Group (07) 4728 1911 www.nqpostnataldistress.com

SA:

Helen Mayo House, 24-hour telephone counselling (08) 8303 1183 or (08) 8303 1425, 1800 182 252 (country)

TAS:

Postnatal Depression Support Group (03) 6266 3497, Good Beginnings (South) (03) 6228 1300

VIC:

PANDA Support line: 1300 726 306 (1300 PAND 06), Admin: 03 9481 3377 www.panda.org.au

WA:

Postnatal Depression Support Association (PNDSA) (08) 9340 1622

beyondblue:

National depression initiative, committed to the prevention, early intervention and research of depression, anxiety and related disorders. www.beyondblue.org.au/postnataldepression

Medications Information

Further resources

Judy Gifford
April 2006