Management of postnatal depression
BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a736 (Published 08 August 2008) Cite this as: BMJ 2008;337:a736
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
A very thorough review of postpartum dpression, which emphasises the
need to recognise the development of postnatal depression early.
I have been lucky enough to shadow a perinatal psychiatry team both
in the community and at a formal mother and baby unit. My understanding
is that women who are vulnerable to develop postnatal depression and are
sought early, are the ones who go on to do well, as the appropriate
support network is put into place. My feeling is that recognising women
vulnerable to developing postnatal depression is not just a job for
doctors. On several occasions, the midwives and health visitors played a
pivotal role in both the recognition and management of postanatal
depression. Midwives and health visitors also tend to spend more time
with expectant mothers/mothers and so are key players in alerting
appropriate health care professionals if they feel a woman is at risk.
It would be very beneficial if the authors were able to advise the
ideal way in which health professionals should communicate if they come
across a woman giving them any cause for concern.
Competing interests:
None declared
Competing interests: No competing interests
I agree that the term postnatal depression is often applied
indiscriminately. But Musters, Macdonald and Jones (1) go on to state that
the main differential diagnoses of distress after childbirth are
postpartum blues and postpartum psychosis. They write about birth as if
it occurred in a social vacuum and fail to mention any social causes of
depression. Yet as long as 40 years ago Brown and Harris published The
Social Origins of Depression (2) and a few years later Oakley produced
Women Confined (3) which also examined social causes of distress.
The authors refer to hormonal and genetic causes and find the most
plausible explanation of postnatal depression 'an abnormal sensitivity to
the normal physiological changes of childbirth.' Curiously, they ignore
poverty, poor housing, being a prisoner or failed asylum seeker who has
her baby taken away from her, and, for many women, medical management in
which the patient is tethered to machines, surrounded by strangers,
treated primarily as a failed reproductive machine, and left feeling that
birth was like rape. They explain distress as the outcome of a psycho-
pathological process, locating the causes as inside the woman herself and
the result of her faulty functioning.
Many women who are struggling with post traumatic stress, constantly
on red alert and tortured by nightmares, flashbacks and panic attacks, are
wrongly diagnosed as depressed. Treatment with anti-depressants makes PTSD
more severe and they feel further manipulated, isolated and disempowered.
Above all, they need to be listened to, their experience validated,
and come to realize that this is a normal reaction to abnormal stress. (4)
(5)
1. Musters C, McDonald, Jones I, Management of postnatal depression,
BMJ 2008;337:a736
2. Brown G, Harris T. The Social Origins of Depression, Tavistock,
London 1978
3. Oakley A. Women Confined: Towards a Sociology of Childbirth,
Martin Robertson, Oxford 1980
4. Kitzinger S, Birth Crisis, Routledge, London, 2006
5. Kitzinger C, Kitzinger S. Birth trauma; talking with women and the
value of conversation analysis. British Journal of Midwifery 2007; 15; 5;
256 - 264
Competing interests:
None declared
Competing interests: No competing interests
Sir,
Musters et al have given a balanced view of the management of postnatal
depression and their treatment regime is based on a multifactorial
aetiology of depression.1
There are suggestions that postpartum depression(PPD) is an
evolutionary adaptation by way of expressing negative emotions of
helplessness in order to get greater level of investment from others.2
Evolutionary psychologists propose that humans and non humans will not
invest in their offspring when the cost outweigh benefits. Reduced care,
abandonment, and killing of offspring have been documented in a wide range
of species. In many bird species, both pre and post hatch abandonment of
brood is common. Unlike non-human offspring, human infant demands
extraordinary parent care. Postpartum period is a stage show for many of
the evolutionary human instincts.
In ancient cultures, there is a time-honoured practice of 40 days of
“confinement”, and the family and relatives relieve her of household
chores so the new mother gets enough rest for revitalising before she
resumes her normal activities. As a matter of fact there is less incidence
of PPD in traditional cultures. Such a finding probably points towards a
prominent psychosocial aetiology in majority of the cases of PPD, and
tally with the observation that there is a higher incidence of PPD among
single mothers.In general depression is a psycho bio-social condition.
In biological depression, there is more noticeable cognitive emptiness and
affective blankness and these are indicators where biological causes
predominate in PPD: such cases probably warrant more psychopharmacological
intervention.PPD is also a testing arena for potential cases of bipolar
disorder.
1.Musters Charles, MacDonald Elizabeth, Jones Ian. Management of postnatal
depression.BMJ.2008;Vol 337:399-403
2.Trivers R.L. Parental investment and sexual selection. In B
Campbell (Ed0 Sexual Selection and The Descent of man.1072; p136-
179.London:Helinemann.
Competing interests:
None declared
Competing interests: No competing interests
Postpartum thyroiditis is a relatively common form of autoimmune
thyroid dysfunction during pregnancy.
There is a mysterious link between thyroid autoimmunity and pregnancy
outcomes (higher risk of miscarriage)and a higher propensity for
postpartum depression.
In 30% of patients with post-partum thyroiditis, the thyroid goes through
a transient period of hyperthyroidism, which could be confused with a
manic episode of bipolar disorder, the thyroid might sometimes evolve into
frank hypothyroidism, which could also manifest as depression among other
symptoms.
If one doesn't think or measure thyroid function in the postpartum
period especially in women with goiter and symptoms suggestive of anxiety
and or depression, it would be very easy to miss the diagnosis.
Based on this association, I recommend thyroid function test (thyroid
stimulating hormone and free thyroxine) and thyroid perxidase (TPO)
antibodies in all my postpartum patients who are being evaluated for
depression. Since vitamin B12 deficiency is common in patients with
autoimmune thyroid disease and that this vitamin deficiency could cause
depression, I also check vitamin B12 level during this period.
Before diagnosing depression or bipolar disease in the postpartum period,
one should ascertain that autoimmune thyroid disease is not the culprit.
References:
1. Charles Musters, Elizabeth McDonald, and Ian Jones
Management of postnatal depression
BMJ 2008; 337: a736
3. Amino, N., Mori, H., Iwatani, Y., et al. High prevalence of
transient post-partum thyrotoxicosis and hypothyroidism. N. Engl. J. Med.
1982, 306, 849-52.
4. Pedersen CA, Johnson JL, et al.
Psychoneuroendocrinology 2007 Apr;32(3):235-45
Antenatal thyroid correlates of postpartum depression.
5. Kuijpens JL, Vader HL, et al.
Thyroid peroxidase antibodies during gestation are a marker for subsequent
depression postpartum. Eur J Endocrinol. 2001:145(5):579-84.
6. Harris, B, Othman, S, et al
Association between postpartum thyroid dysfunction and thyroid
antibodies and depression.
BMJ 1992; 305:152.
7. Pedersen, CA.
Postpartum mood and anxiety disorders: a guide for the nonpsychiatric
clinician with an aside on thyroid associations with postpartum mood.
Thyroid 1999; 9:691.
8. Kent, GN, Stuckey, BG, Allen, JR, et al. Postpartum thyroid
dysfunction: clinical assessment and relationship to psychiatric affective
morbidity. Clin Endocrinol (Oxf) 1999; 51:429.
Competing interests:
On the Speakers' Bureau Abbott Pharmaceutical
Competing interests: No competing interests
The review of postnatal depression by Musters et al (1) was very
useful but omitted some important aspects which must be borne in mind by
the treating clinician. The ‘serious consequences’ that postnatal
depression can have for a child were alluded to but not elaborated upon.
Recent research has highlighted many concerning transgenerational effects,
including reduced cognitive development (2), violence (3), and
disturbances in behaviour and patterns of play (4). Cognitive therapies
often have prohibitively long waiting lists of months or even a year, and
mothers, particularly if breastfeeding, have a difficult decision to make
regarding whether to accept psychotropic medication for their depression.
Doctors will no doubt remember to warn the mother of the risks of
medication passing through breast milk, but also have a duty to give women
a balanced view of the long-term risks that untreated depression may
potentially pose to their child’s social, intellectual and cognitive
development, as well as to the quality of attachment and the later
relationship between mother and child.
Another neglected area is the existence and consequences of
depression in fathers, which has received almost no public or professional
attention, despite the commendable recent increase in publicity given to
postnatal depression in women. Health professionals need to be aware of
this condition and the similarly negative consequences it appears to have
upon children (5), and be proactive in their efforts to seek and treat
depression in new parents, whether male or female.
1 Musters C, McDonald E, Jones I. Management of postnatal depression.
BMJ 2008:337;399-403.
2 Sharp D, Hay DF, Pawlby S, Schmücker G, Allen H, Kumar R. The
impact of postnatal depression on boys’ intellectual development. J Child
Psychol Psychiatry 1995; 36(8):1315-36.
3 Hay DF, Pawlby S, Angold A, Harold GT, Sharp D. Pathways to
violence in the children of mothers who were depressed postpartum. Dev
Psychol 2003; 39(6):1083-94.
4 Murray L, Sinclair D, Cooper P, Ducournau P, Turner P, Stein A. The
socioemotional development of 5-year-old children of postnatally depressed
mothers. J Child Psychol Psychiatry 1999; 40(8): 1259-71.
5 Ramchandani P, Stein A, Evans J, O’Connor TG, the ALSPAC study
team. Paternal depression in the postnatal period and child development: a
prospective population study. The Lancet 2005; 365:2201-2205.
Competing interests:
None declared
Competing interests: No competing interests
Thank you BMJ for an excellent clinical review of the common problem,
postnatal depression. [1] However, 'PND' is rarely a disorder of just one
person: the new Mother.
The review misses the Family dimension of this treatable condition.
The baby whose birth triggers the presentation of PND is likely to be
affected for years to come, as are older siblings and even siblings as yet
unborn, as the illness can distort the whole pattern of attachments within
a household. Family violence is a major antecedent of PND, and increased
marital dysharmony AFTER maternal onset of the illness is common:
especially in first-time mothers under 20 years, we observed frequent
desertion of depressed women by their men. The 'Respect' community
research shows that depression and abandonment affecting the mother is a
most common feature of anti-social behaviour orders implemented against
the household... in the Respect Tsar Louise Casey's language 'out-of-
control children' making 'neighbours from Hell'. PND is more common in
the poorest families with the least fiscal and social capital. The same
young parents may present with co-morbid alcohol problems, amplifying
their low self-efficacy and the risk of injury to infants (and partners).
First-hand assessment of the home environment, and the family system
connected to the new Mother, is essential for adequate management of these
problems.
1 Musters C, McDonald E, Jones I. Management of postnatal depression.
BMJ 2008; 337: 399-407.
Competing interests:
Have (in the past) been involved in research on postnatal depression.
Competing interests: No competing interests
As a specialist in post natal depression, I found the review in the
BMJ both informative and authoritative. However, I'm not sure that NICE
adopted the Whooley questions. When I assessed the draft guidelines as
part of the team at the British Psychological Society, there were only two
questions. I (we) suggested the third.
Can the authors acknowledge the BPS team for alerting NICE to the
need for the third question? I don't think it would have been there
without us.
Competing interests:
None declared
Competing interests: No competing interests
Please help more families stay together. Early diagnosis of post-natal psychosis makes a real difference.
The charity Families Need Fathers Both Parents Matter Cymru works to
help maintain meaningful relationships between children and their parents
following a parental separation. We cannot help noticing that there is a
tranche of dads who ask for our help, who are totally bewildered as to why
their partners left them. They are experiencing what can only be
described as irrational and often scary behaviour from partners they loved
and often still love dearly.
Consequently we have taken an interest in post-natal psychosis which
might explain the mother's behaviour. Between one to two mothers in a
thousand develop post-natal psychosis. Recent research points to post-
natal psychosis as having a genetic link and it is possible that in the
foreseeable future, pregnant mothers may be screened for this gene so that
early intervention may be available to support the family.
Sadly, if mother decides to leave father, the legal advice to the
father can be that suggesting the mother may need medical help, would be
taken as evidence of mental cruelty towards the mother.
We would welcome an increased awareness of the problem in the medical
world, including midwives and Health Visitors because we believe that
these women do need help. And we believe that with help, the family
would stand a better chance of staying together.
Competing interests: No competing interests