Six-week-old Sasha has been brought to your emergency department because she won’t stop crying. As the nurses handover her chart they catch your eye, “This is the third time her mum has brought her in. There’s nothing wrong with the baby. Why don’t you find out how the mum is coping?”
Doctors and nurses in the emergency department are ideally placed to recognise postnatal depression (PND).
Postnatal depression has a prevalence of 13.2% at 6 weeks and 9.8% at 12 weeks.
The Edinburgh Post-Natal Depression Scale is a validated tool that can be used to screen for postnatal depression.
Children of mothers with post-puerperal psychosis are at potential risk of neglect or harm. Early recognition may prevent this.
Why should we care about postnatal depression?
Approximately 80% of women feel an emotional low shortly after giving birth. Whilst the majority of them move through this tough period, some women get stuck in a downward spiral of feelings of inadequacy and inability to cope. Leahy-Warren et al suggest a prevalence of 13.2% at 6 weeks dropping to 9.8% by 12 weeks.
They may think there is something wrong with their child when they are perfectly healthy. Frequent attendance in the neonatal period represents an opportunity to ask about the parents’ mental well-being. A mother that has experienced postnatal depression is twice as likely to suffer from an episode of depression within 5 years.
Severe depression can also adversely affect the interactions and attachment between mother and child. Take a look at this video on Tronick’s classic “Still Face Experiment” and imagine the baby gazing at the mask-like face of their depressed mother.
What are the risk factors for postnatal depression?
A large number of women experience a low shortly after their baby is born, probably related to the hormonal changes of the post-puerperal period. Whilst this is short-lived in the majority, in some mothers it may progress to something more serious.
Some mothers are more at risk from postnatal depression than others. Known risk factors include:
- a past history of depression, anxiety, or other mental health problems
- alcohol or substance problems
- social isolation
- current or past history of psychological, physical or sexual abuse
- traumatic childbirth such as unexpected Caesarean, stillbirth or miscarriage
How might it present in the Emergency Department?
There is a fine line between the normal degree of tiredness and emotional lability following the birth of a child, and a potentially pathological response. Where some doctors might consider postnatal depression just past part of normal motherhood, it is important to recognise that it can lead to potential harms to both the mother and the child. Mothers may feel that their child will just not settle or that there is something wrong.
Symptoms of depression at this time are similar to those at other stages of life. Parents may report feeling low or numb, feeling inadequate or unable to cope. In more serious cases they may complain of difficulty functioning on a day-to-day basis or of having thoughts of harming themselves or their baby.
Consider using a validated rating scale such as the Edinburgh Postnatal Depression Scale as a screening tool. You can find an online version here.
What can we do to help?
Just asking the question can help. So often we are afraid too ask “Are you ok?” because we worry that we won’t be able to help. As well as validating their concerns we can refer them back to their GP for counselling and cognitive behavioral therapy or provide links to on-line or telephone support services (see below) that they may not have been aware of such as that provided by PANDA (Post and AnteNatal Depression Association). If there are any concerns regarding the wellbeing of the mother or child they should be referred to your Crisis Assessment Treatment Team.
What about the extreme end of the spectrum, puerperal psychosis?
This extreme form of postnatal depression usually manifests within a few days of birth with intrusive thoughts of harm to self and others (specifically the baby). Like a lot of psychoses there may be a mixture between hyperactive/manic symptoms (hallucinations, delusions and verbal diarrhoea) and hypoactive/depressive symptoms (poor appetite, poor sleep feelings, or worthlessness).
It is vital that this is recognised in order to protect both the baby and the mother. This invariably requires hospitalisation of the parent with in-patient initiation of mood stabilisers and possibly electro-convulsive therapy.
What about Dad?
Dads can suffer from postnatal depression too but it is often under-recognized. The standard Edinburgh Postnatal Depression Scale has not been validated in this population group. Men may feel the added burden of not only coping with the new addition to their family but also having to support a struggling partner.
If you want more information or training beyondblue has created an online module for health care professionals. You can access it here.
You take the time to talk to Sasha’s mum about what is really concerning her. She’s recently moved to the area and her support network is a long way away. The move has meant her partner has had to work all hours and she is on her own every day for hours on end. She is finding it hard to cope with what she perceives is constant crying, and is not looking after herself. You refer her to your hospital CATT team with a presumptive diagnosis of post-natal depression.
Sources of Support
PANDA – National Perinatal Depression Helpline – 11300 726 306
Mensline – telephone and online support for Australian men 1300 78 99 78
beyondblue – 1300 22 4636
Chan, C. , Lee, A. , Lam, S. , Lee, C. , Leung, K. , Koh, Y. and Tang, C. (2013) Antenatal anxiety in the first trimester: Risk factors and effects on anxiety and depression in the third trimester and 6-week postpartum.Open Journal of Psychiatry 3, 301-310
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.
Leahy-Warren, Patricia, Geraldine McCarthy, and Paul Corcoran. “Postnatal depression in first-time mothers: prevalence and relationships between functional and structural social support at 6 and 12 weeks postpartum.” Archives of psychiatric nursing 25.3 (2011): 174-184.
Pope, Sherryl. Postnatal depression: A systematic review of published scientific literature to 1999: An information paper. National Health and Medical Research Council, 2000.
Wynter, Karen, Heather Rowe, and Jane Fisher. “Common mental disorders in women and men in the first six months after the birth of their first infant: A community study in Victoria, Australia.” Journal of affective disorders 151.3 (2013): 980-985.