 | | | | by Ellie Lee |
'Political correctness gone mad.' This was how Dr Liam Fox, the UK's shadow health secretary, described a new scheme in Basildon, Essex, which provides men with counselling for postnatal depression (PND).
| The service is called 'Fathers Matter', and according to reports, leaflets will be given to all new fathers providing a 'helpline' phone number so that they can get counselling, and special support groups will be set up. Male volunteers, who have been diagnosed with postnatal depression themselves, will staff the helpline after attending a 10-week training course in 'listening skills' (1).
| 'Whatever next?', asked Fox. Fathers couldn't possibly have post-natal depression, he stated, because they don't give birth. This seems like a pretty sensible reaction to a pretty daft proposal. Unfortunately, the notion that diagnosing fathers with PND is 'political correctness gone mad' fails to recognise the very mainstream trend that lies beneath it: the presentation of all aspects of parenthood as a problem.
| The idea that parenthood is very difficult - or, as the leaflet for the Basildon service puts it, 'harder than ever' - is now a view that is very well established and widely endorsed. The notion that more should be done to enable parents to 'parent effectively' has also become deeply entrenched. As a consequence, there is a tendency to diagnose and treat an ever-expanding category of parental depression - which, for some time, has been seen to include fathers.
| The need to include men in support and treatment for PND and has been promoted for some time. Fathers Direct, the charity commissioned by the UK government to write the new-fathers handbook, The Bounty Guide to Fatherhood, argues that while postnatal depression in women is a problem for one in 10, postnatal depression in men is a significant and unrecognised problem (2).
| The charity Men's Health Forum claims that up to 10 per cent of men suffer from depression following the birth of their baby, and argues that the subject of male depression should be discussed at antenatal classes so that men know what they are suffering from if they develop the condition (3). It should, therefore, come as no great surprise to find the Basildon scheme has emerged as part of health service provision for new parents (and no doubt more such schemes will follow).
| Contrary to Liam Fox's view, it has been a long time since postnatal depression has been defined in narrow way, and viewed as an illness that affects a small proportion of new mothers after childbirth. Increasingly, it is presented as a common feature of motherhood, which affects a growing number of mothers and a significant proportion of fathers too. But what is postnatal depression anyway? How can it possibly affect men? Most importantly, who benefits from the notion that parenthood is more depressing than ever?
| What is postnatal depression?
| It is first worth discussing the definition of PND. The notion that it is barmy to diagnose men with PND is predicated on the idea that it is definable illness, the development of which is related clearly to the process of giving birth - this is, of course, implied in the term itself. And, according to one psychiatrist asked to comment on the Basildon scheme, PND in women is 'a separate entity from other types of depression, because it involves major hormonal factors, and major physical factors', namely the effects of giving birth.
| But is this really the case? My research indicates that things are not so clear-cut.
| PND is, in fact, a relatively new problem. 'Until the mid-1960s, there was little interest in this subject', explain Katharina Dalton and Wendy Holton. 'Puerperal psychosis was recognised...[at] the other extreme there was the blues.' (4). Psychiatrists noted the development of atypical, extreme forms of behaviour in some women after childbirth, which they diagnosed as psychosis, and which, according to many accounts, was apparently first identified in Ancient Greece. After childbirth there was sometimes a shortlived disturbance, 'the blues', which had been recognised by midwives for many years, but this phenomenon was not considered to be related to mental illness, and was not of interest to psychiatrists.
| It was not until 1968 that PND was first named as specific form of illness, when the psychiatrist Brice Pitt published what is widely viewed as the seminal study of depression in new mothers (5). Pitt's study gained notoriety because only two of his 27 interviewees were found to have 'the classical picture of depressive illness', and he therefore decided to describe the kinds of feelings and forms of behaviour described by the mothers he studied as 'atypical' and worthy of a new title (6).
| From this point, interest amongst psychiatrists in PND increased, and research and discussion about it - its causes, symptoms, and whether there are particular 'risk factors' for its development - came to feature in psychiatric literature. But it was in the 1980s and 1990s that research expanded most rapidly. Between 1980 and 1990, over 100 studies of 'postnatal psychological illness' were published in key medical and psychiatric journals (7). Yet despite all of this research, it seems to have proved very difficult for psychiatry to find a precise explanation for the problem.
| British psychiatrist R Channi Kumar, co-editor of Motherhood and Mental Illness, asked in 1982: 'Is there really such a thing as postnatal depression?', and continued: 'What is not at all clear..…is when postnatal depression becomes ordinary depression on the timescale after delivery, and whether there are any special clinical or other features which distinguish postnatal depression from episodes of depression'.
| Fourteen years later the psychiatrist Ian Brockington wrote of PND, 'One must examine with scepticism, the scientific value of this concept. Depression after childbirth is clinically very similar to any other depression' (8). 'Significant questions have been raised that consider whether [PND] is a distinct entity from nonpuerperal major depression', state Grace Evins and James Theofrastous (9). A study published recently in the British Medical Journal also drew attention to this issue. The authors argued that the idea of PND existing as a specific syndrome 'is a popular myth' (10).
| This heightened interest in PND, and the disagreements over what it is, has resulted in a psychiatric definition of what 'counts' as PND. On the basis of the severity and duration of symptoms, PND is considered to lie mid-way between postpartum psychosis and the 'baby blues'. As the psychiatrist Michael W O'Hara puts it, the 'custom' in the literature is to distinguish 'three phenomena: postpartum blues, postpartum psychosis and postpartum depression' (11).
| What causes PND also appears to be very open to question. From the outset the possibility that there is a causal link between PND and giving birth has been a key focus for research. But O'Hara argues that psychiatric studies have not clearly demonstrated an association between depression and childbirth, and notes several studies that found no significant difference in prevalence rates of depression for childbearing and non-childbearing women.
| When it comes to research findings that do link childbirth with the onset of
depression, O'Hara reasons that where childbirth is used as the 'anchor' for the interview, women may identify their symptoms as having begun following the birth of child. Consequently, he suggests that the timing of the onset of depression is 'difficult to determine', and there may be 'judgement biases by both subjects and investigators' at work (12).
| John Cox, widely regarded as the British authority on motherhood and mental illness, argues that while there is 'substantial support' for the idea that biological changes cause illness in mothers, 'the interaction between biological, psychological and social factors is extremely complex', and that factors including a woman's hostile relationship with her own mother - claimed to be important in some psychoanalytic approaches - and 'social factors', defined as marital status, number of children and the circumstances surrounding the birth, may all be relevant (13).
| Perhaps unsurprisingly, following their discussion of the findings of research about PND, Evins et al conclude (inconclusively) that PND 'represents a heterogeneous group of depressive disorders of which some are specific to the postpartum period' (14). Overall, the consensus view seems to be that PND has many causes, and is hard to distinguish from 'regular depression'. But we all are familiar with the term PND, and we all think we know what it means. Why is this? In part it is because means have been developed to diagnose the condition.
| Screening for PND
| There is little agreement about what PND actually is. Yet within psychiatry, there is a great deal of confidence in being able to define a population of PND patients.
| The claim that appears most frequently in psychiatric literature on PND is that 10 per cent of mothers have the illness. 'How common is it?' asks a factsheet from the British Royal College of Psychiatrists. 'Very!' it replies. 'Again and again it has been found that no less than one in 10 women suffer depression after childbirth.' Given that there are 680,000 live births to women in Britain per year, this would mean that 68,000 women experience PND annually.
| How has this figure come about? Most obviously because means have been developed to diagnose women as suffering from PND. 'What counts [for psychiatry] is that there are effective screening instruments', argues Nicolson (15). The most important of these instruments is the Edinburgh Postnatal Depression Scale (EPDS). The scale was developed in 1987 by psychiatrists in Edinburgh for use in primary care and it has had a spread rapidly through psychiatry worldwide, to become influential in many countries.
| The EPDS is based on a series of 10 statements with four possible responses relating to mood and feelings. Statements include: 'I have been able to laugh and see the funny side of things'; 'I have felt worried and anxious for no good reason'; 'Things have been getting on top of me'; 'I have felt sad or miserable'; 'I have been so unhappy that I have been crying'. Responses to each of the statements are rated on a scale of zero to three, with the former constituting an absence of symptoms, the latter maximum severity. A score of 14 or more out of a maximum of 30 indicates that the mother may be depressed; that is, if the EPDS indicates it, she can be diagnosed with PND.
| One particular claim made in favour of the EPDS is that it allows the concept of PND to be made 'real' for women. The Royal College of Psychiatrists (RCP) thus claims that, 'It helps many a mother to be told "You've got PND". At least she knows her enemy. She can be reassured that she is not a freak or a bad mother, and that many others are in the same boat'. Therefore, using the scale to provide a diagnosis is viewed as a useful thing to do.
| No doubt diagnosis can help some women. Being able to put a name to the problems they are experiencing helps. But the impetus to help women this way has turned into a very worrying trend: the promiscuous use of diagnosis of PND. The notion that it is helpful to be diagnosed as ill as a mother (or a father) is now applied thoughtlessly, without paying attention to the possible detrimental consequences of doing so.
| There is a current tendency among health professionals to label more and more aspects of life as possibly 'depressing', and to draw more and more people into the orbit of 'treatment' and 'support'. This is demonstrated clearly by Mary Alabaster, the manager of maternal mental health services for the local NHS Trust in Basildon. She says that PND in men is 'triggered by a wide variety of causes' and that 'it really has to be taken seriously'. 'The hope is that there will be more emphasis on the psychological needs of dads', she explains (16).
| In other words, meeting dads' 'psychological needs' and treatment for mental illness become blurred into the same thing. There seems to be no boundary left between illness, and what used to be called life. How has this come about?
| Encouraging illness definitions
| The visibility of PND has increased in the past decade, in part through a burgeoning body of 'self-help' literature about it. The overriding message of these books is that it is vital that women understand, as quickly as possible, that the problems they experience when they become mothers actually mean that they are ill. Some, through titles such as The New Mother Syndrome: Coping with Postpartum Stress and Depression, make it clear that they aim to encourage women to identify their problems in medical terms.
| A common feature of such literature is that it presents PND as a very serious problem, which needs greater recognition. The author of one book thus argues that the medical community has 'trivialised' the illness. This book includes a chapter on the 'medical disregard' of depression in mothers, and ends with a dire warning of its consequences, in a chapter entitled 'Mothers Who Killed' (17). The most common means through which the seriousness of the problem is emphasised is through drawing attention to the numbers of women who are depressed when they become mothers.
| In other words, the aim is to normalise PND. Karen Kleinman and Valerie Davis Raskin state that PND is 'the most common complication of pregnancy' (18). And it is often argued that many more women than is usually suggested (that is, 10 per cent) have PND. In order to make this case, the feelings and experiences of very large numbers of women are presented into evidence that they are ill.
| The 2002 edition of the American 'pregnancy bible', What to Expect When
You're Expecting, claims that between 60 and 80 per cent of new mothers suffer from 'some form of baby blues or depression'. It is notable that, when first published in 1984, the figure quoted was 50 per cent, and the section of the book about PND was half the size it is in the most recent version (19). Heather Welford contends, in her book about PND, Feelings After Birth, that while psychiatric text books put the figure of women who suffer from PND at 10 to 15 per cent, 'if you include in your definition of postnatal depression all post-childbirth distress and misery, including the more shortlived forms, it's probable that the majority of mothers recognise many of the symptoms'.
| In these accounts, there is a significant modification of the three-part definition of the mother's mental states characteristic of psychiatry (psychosis, depression, and 'baby blues'). All become variations of a single illness. Thus Sharon L Roan, author of the US manual Postpartum Depression: Every Woman's Guide to Diagnosis, Treatment and Prevention, claims: 'It's no wonder that as many as 80 per cent of new mothers experience a period of depression popularly known as "the baby blues"'. Welford argues that there are three different forms of 'postnatal distress': the blues, PND and psychosis. Through this approach, PND comes to be represented as common, in one form or another, to all mothers.
| It is not only self-help books that positively promote the notion that postnatal depression is a common experience to new mothers, which should be more widely diagnosed. On a broader cultural level, it has become fashionable to treat motherhood as increasingly problematic, and to see these problems in medical terms. In this regard, some feminists' discussion of PND is very interesting.
| | Pathologising motherhood
| Since the late 1990s, there has been an explosion of prominent titles by feminists, dealing with PND and other problems facing new mothers. These include Naomi Wolf's Misconceptions: Truth, Lies and the Unexpected on the Journey to Motherhood (2001), Life After Birth by British feminist writer Kate Figes (1998), and Susan Maushart's The Mask of Motherhood (1999). All of these books strongly advocate the need for greater recognition of PND.
| This is notable because, in the past, feminists often argued strongly against 'pathologising' childbirth, and contested the way in which women's problems were represented in medical terms. Yet recent feminist work often does just the opposite.
| The arguments made by Wolf and others pay a great deal of attention to the feelings generated by the experience of motherhood: for the author in particular, and by extension for women generally. Many of these recent books do consider issues that have always featured in feminist work about motherhood, for example the need for better childcare provision. But their overriding demand is a new one. This is the demand for a shift in culture, to generate a public discourse that has the emotional difficulties of the experience of motherhood at its centre.
| 'The turmoil of new motherhood is still a taboo subject,' writes Kate Figes. 'It is almost as if there is a conspiracy of silence surrounding the transition to motherhood'. Naomi Wolf contends: 'Only by listening to the full spectrum of stories that women confess to one another, including stories that cultural reasons dictate we must not speak out loud, can the taboo against voicing our fears and bowdlerizing our experience be broken'.
| Susan Maushart complains about the 'collective denial about the chaos that is motherhood in contemporary society', a problem she describes as, 'the mask of silence'. She says: 'we owe it not only to our own mental health but to the very future of the species to take motherhood seriously, to strip off the masks we have been wearing, and to see with clear eyes and speak with open voices about the realities we experience'.
| In these claims, the feminist project is couched in overtly therapeutic terms. It is through 'speaking of experience' and demanding that others listen to women's feelings that change is considered to come about. Indeed, a key complaint is that society is organised through a 'conspiracy of silence' in regard to mother's experiences. The problem of the public realm is defined by its refusal to listen to what women say about their experiences.
| For Maushart, therefore, 'At least part of the problem is that our society propagates a ridiculously positive myth of pregnancy'. The strongest forces that constrain women, she argues, are those that, 'minimize the difficulties we face, insisting that motherhood is no big deal after all'.
| Wolf writes scathingly of books that present motherhood in positive terms and that, in her view, do not talk enough about women's about negative feelings. She attacks What to Expect When You're Expecting on this basis, for what she considers its problematic reluctance to make it clear to women that motherhood is an ordeal. What is most distressing, 'is not the prospect of a woman hearing about some of the tougher aspects of labour and delivery...but, rather, the psychic cost to the mother-to-be of literature that is determined to focus on happy talk and sentimentality'.
| Figes' explains that her aim is to 'emphasise the positive aspects of motherhood' but also 'be honest' by talking about the negative ones. If by doing so, her book prevents 'the births of unwanted children, because women have their suspicions confirmed that motherhood is not for them, then I am proud of that', she explains.
| In this approach, which emphasises the emotional strain of motherhood, it is easy to see why PND appeals. It can give legitimacy and weight to claims that negative emotions feature centrally in women's experience as mothers. The problem of PND, in its most diffuse form, provides a means of claiming that motherhood is a huge ordeal. Figes therefore argues strongly that PND is not something that is experienced by just a few women but is, in fact, the common experience: 'It [PND] is a sliding scale, starting with the 'baby blues' affecting 80 per cent of women, and ending with puerperal psychosis...The vast majority of women sit somewhere on this scale'.
| There has been some criticism of this case for a culture shift. Sunday Times columnist India Knight has pointed out that there is a trend 'for women of a certain type to enter into parenting expecting an apocalypse... those women who look forward to the whole business are considered stupid, retrograde and unaware that a sadistic joke is being played on them' (20). The feminist journalist Katha Pollitt, with reference to Wolf, has also criticised what she views as a wider tendency for feminists to write about their own experience and draw general conclusions from it (21).
| But much media response has been supportive. Figes herself notes that 'the taboos surrounding new motherhood are beginning to crumble slowly', and argues that where journalists used rarely if ever to write about the negative aspects of new motherhood, they now do so regularly. It is certainly the case that articles drawing attention to the problems of motherhood have become commonplace, with articles titled, 'The truth about life after birth', 'Mother's ruin', and 'Motherhood and the big lie'.
| Those who write self-help books and feminists like Naomi Wolf often complain that one of the problems with PND is that it is under-recognised by a medical profession that is cavalier about women's health. But evidence suggests a different story, and one that is worrying for quite the opposite reason. With all the negative publicity surrounding motherhood, and the way this has been reinforced through an ever-expanding category of PND, it was only a matter of time before the attention turned to men too. Parenting in general has come to be seen as a difficult, stressful process, for which people need increasing amounts of medical intervention and support, the effect of which is far from beneficial.
| Treating parents
| Since the mid-1990s, those involved in designing and implementing interventions directed at mothers have, in fact, been very keen to draw attention to the psychological problems that mothers experience, and have gone to great lengths to advocate that more should be done to identify and treat PND. Perhaps more than anything else, it is this development that has given greater visibility to PND, and which has encouraged its spread to men.
| In Britain, particularly over the past five years, PND has come to increasing prominence, as part of the broader trend to define social problems in relation to mental ill health. Recent policy documents from the UK Department of Health (DoH) emphasise the issue of mental ill health and define its causes very broadly, to include poverty, poor education, unemployment, major life events such as bereavement, and poor parenting.
| Within this agenda, post-natal depression has been highlighted as a central, growing problem and new mothers have been targeted as group in need of greater attention. For example, the government document Supporting Families, produced in 1998, suggested that midwives and health visitors should be able to assess the quality of relationships between woman and their partners, assess if factors are present that might contribute to PND, and if so encourage the woman to seek help (22). Articles published in medical journals have argued that family doctors need to do more about identifying and treating PND, and have criticised them for constantly failing to identify PND, or to recognise it for what it is.
| Advocacy of the need for health professionals to do more is also emphasised through drawing attention to the lack of self-diagnosis by women, and a consequent lack of preparedness to seek help on their part. The problem, according to an article in the British Journal of General Practice, is that only one third of women who were identified by researchers as having PND believed themselves to be suffering from it, and over 80 per cent had not reported their symptoms to any health professional (23). The disparity between women's own perceptions of what is 'wrong' with them, and the need to diagnose their feelings and behaviour as PND, appears frequently in discussions of the problem.
| Identifying PND has become particularly prominent in discussion about the role of the health visitor. The Community Practitioners' and Health Visitors' Association (CPHVA) published Postnatal Depression and Maternal Mental Health: A Public Health Priority in 2001, and has established a Postnatal Depression and Maternal Mental Health Network for its members, 'to support practice and service development in what the Association recognises is a key area of practice for our members' (24). New initiatives and services have been developed in many areas of Britain, within which a key aspect of contact with women is extensive use of the Edinburgh Postnatal Depression Scale (EPDS), to identify women at risk and ensure they are offered treatment, in particular counselling.
| The use of the EPDS by has, in fact, become a matter of dispute. According to the National Screening Committee (NCS), a body responsible for advising government health ministers in Britain on screening policies, the EPDS falls far short of the criteria considered necessary by the NCS for use at a national level. The scale, claims the NCS, is inaccurate because of variability in the way women's responses are interpreted in scores allocated, is not always acceptable to postnatal women, and there is little evidence of 'value for money' resulting from its use.
| While noting these findings, however, the CPHVA has argued that health visitors should continue using the scale. The Association argues that continuing the 'explosion of local activity' by spotting PND through use of the scale, developing new strategies and care pathways through which mothers can come into contact with health visitors more regularly, and treating it through 'innovative means such as baby massage', are considered to be the priority despite the NCS' criticisms (25). Why has it come to be deemed so important to spot and treat PND?
| A key claim links depression in mothers to inadequate child development, which allegedly leads to problems in later childhood and possibly adult life (26). 'The real concern for those working in public health', argues a briefing for British health visitors, 'is the growing body of research highlighting the potential long term effects of maternal depression on children and families' (27). According to one summary of the literature, the concern is because, 'The negative effects of PND on the infant appear to happen very early in life...The behavioural effects are long lasting, especially in boys from lower socio-economic classes' (28).
| This, according to Janice Gerrard, is why nurses in Britain need to be clear that PND matters. It is not just a 'woman's problem', but has 'ramifications for the family and society' (29). For Gerrard the real problem is the impact on the child, because depressed mothers cannot parent effectively, which in turn leads to the development of social problems, in the form of the activities of disturbed young people. She draws particular attention to the effects of PND on 'boys from lower socio-economic classes', who are 'most vulnerable' and are most likely to have socially damaging behavioural problems if their mothers are depressed.
| And it is through this link, between PND and the problem of parenting, that the need to spot and treat depressed fathers enters the picture. They, just like 'depressed mums', are feared to constitute a risk-factor in their child's development. Thus, argues Gerrard, 'targeted support from health professionals' for fathers, especially in the first weeks after a baby is born, is critical.
| This view should come as little surprise. We live in a context where everyone now takes fatherhood seriously, and bringing up kids is no longer seen as 'women's business'. This is positive, to the extent that fathers are increasingly deemed just as important as mothers to their children. But it is in keeping with the spirit of our age that fathers' involvement is seen to make them a potential risk to their offspring's development.
| 'For many years, fathers have had a raw deal, because the focus is on the mother,' says Mary Alabaster. In her view, this is why it is high time that men's 'psychological needs' are given priority. So pathologising the experience of fathers, just like that of mothers, is seen as the latest blow for equality.
| Conclusion
| For some women who are severely depressed following childbirth, it is very important that they are diagnosed and receive treatment. But we should take a sceptical and critical attitude towards the trends and arguments outlined above that encourage us to think of parents' problems in terms of illness. They reflect and encourage some deeply troubling aspects of today's society.
| The view that it might be helpful for parents to think of themselves as ill reflects a perception that people cannot, and should not be expected to be able to, find a way by themselves to sort out their problems. Thus it is not enough to expect new mothers (and new fathers) to find their own ways of handling and managing the new, and sometimes difficult and frustrating experiences they have. Rather, someone else, a health professional, policy maker or 'society', must step in and do this for them.
| Therefore, the Fathers Matter leaflet informs us, 'There is nothing weak or effeminate about realising as a man, and a father, that you have thoughts and feelings you do not understand'. The clear message is: make sure the minute you experience these feelings, you call the helpline. Don't imagine it makes sense to try and work out what is going on, and how best to deal with it, yourself.
| It is not obvious to me why leaving parents to work through negative and troubling experiences themselves is such a problem. I am not at all convinced of the advantages of living in a society of the kind that Naomi Wolf of Kate Figes seem to want, where there is endless public recognition of our negative experiences as mothers and fathers. Do we want life to be like some great big Oprah show, where our emotional experiences are endlessly 'recognised' and our 'psychological needs' endlessly met?
| Maybe it is the case that children who grow up in families where parents are very severely depressed will not flourish as well as they should. And maybe the small number of children in this situation might need some extra help (together with their parents). But what is being argued these days goes far beyond this. It is almost normal to be depressed as a parent, we are told. Thus everybody is considered to be potentially in need of 'support'.
| Ultimately, it is the loss of belief in individuals' ability to manage their emotions that has made PND into a men's problem. A very low expectation of people and their capacity to behave in an adult and responsible manner seems to have taken hold. To say it is political correctness 'gone mad' trivialises what has happened. We need to work much harder than that if we are to explain, and hopefully limit, the pathologisation of parenting.
| Ellie Lee is coordinator of the Pro-Choice Forum, and lecturer in social policy in the School of Social Policy, Sociology and Social Research at the University of Kent. She is the author of Abortion, Motherhood, and Mental Health: Medicalising Reproduction in the United States and Great Britain, Walter de Gruyter, 2004 (buy this book from Amazon (UK) or Amazon (USA)). She is also the editor of Abortion: Whose Right?, Hodder Murray, 2002 (buy this book from Amazon (UK) or Amazon (USA)); Designer Babies: Where Should We Draw the Line?, Hodder Murray, 2002 (buy this book from Amazon (UK) or Amazon (USA)); and Abortion Law and Politics Today, Palgrave Macmillan, 1998 (buy this book from Amazon (UK) or Amazon (USA)).
(1) Men to get NHS counselling for 'postnatal depression', Adam Lusher and Brian Welsh, Sunday Telegraph, 24 August 2003; Advice for baby blues dads, BBC News, 24 August 2003
(2) New fathers get advice, BBC News, 10 September 1999
(3) Men suffer from baby blues, BBC News, 4 May 1999
(4) Depression After Childbirth, Katharina Dalton and Wendy Holton, Oxford: Oxford University Press, 2001
(5) Postpartum Depression and Child Development, Lynne Murray and Peter Cooper, New York and London: The Guildford Press, 1997
(6) 'Neurotic disorders in childbearing women', R Kumar, in Motherhood and Mental Illness, ed I Brockington and R Kumar, London: Academic Press, 1982, p 71-118
(7) Post-Natal Depression, Psychology, Science and the Transition to Motherhood Paula Nicolson, London: Routledge, 1998
(8) Motherhood and Mental Health, Ian Brockington, Oxford: Oxford University Press, 1996
(9) 'Postpartum depression: a review of postpartum screening', Grace Evins and James Theofrastous, Primary Care Update for Ob/Gyns 4 (6): 241-246, 1997
(10) Depression during pregnancy more common than after, BMJ study says, Daily Reproductive Health Report, 3 August 2001
(11) 'The nature of postpartum depressive disorders', Michael O'Hara, in Postpartum Depression and Child Development, ed L Murray and PJ Cooper, New York and London: The Guildford Press, 1997, p 3-34
(12) 'The nature of postpartum depressive disorders', Michael O'Hara, in Postpartum Depression and Child Development, ed L Murray and PJ Cooper, New York and London: The Guildford Press, 1997, p 3-34
(13) Postnatal Depression, A Guide for Health Professionals, John Cox, London: Churchill Livingstone, 1986
(14) 'Postpartum depression: a review of postpartum screening', Grace Evins and James Theofrastous, Primary Care Update for Ob/Gyns 4 (6): 241-246, 1997
(15) Post-Natal Depression, Psychology, Science and the Transition to Motherhood, Paula Nicolson, London: Routledge, 1998
(16) Men to get NHS counselling for 'postnatal depression', Adam Lusher and Brian Welsh, Sunday Telegraph, 24 August 2003
(17) A Mother's Tears: Understanding the Mood Swings That Follow Childbirth, Arlene Huysman, New York: Seven Stories Press, 1998
(18) This Isn't What I Expceted: Overcoming Postpartum Depression, Karen Kleinman and Valerie Davis Raskin, New York: Bantam Books, 1994
(19) 'What to expect this time', Jennifer Huget, Washington Post, 7 May 2002
(20) 'Who are they trying to kid', India Knight, Sunday Times, 9 September 2001
(21) 'The solipsister', Katha Pollitt, New York Times, 18 April 1999
(22) Postnatal Depression, Janice Gerrard, London: Nursing Times Books, 2000
(23) 'The pathway to care in post-natal depression: women's attitudes to post-natal depression and its treatment', A Whitton, R Warner and L Appleby, British Journal of General Practice 46 (408): 427-8, 1996
(24) 'Use of the Edinburgh Postnatal Depression Screening Scale', CPVHA, Community Practitioner 75 (4), April: 42-43, 2002
(25) 'Use of the Edinburgh Postnatal Depression Screening Scale', CPVHA, Community Practitioner 75 (4), April: 42-43, 2002
(26) 'The challenges of antenatal prevention of maternal depression', Peter Cooper, in Postnatal Depression and Maternal Mental Health, a Public Health Priority, ed CPHVA, London: CPHVA, 2001, p9-12; 'How postnatal depression can affect children and their families', Lynne Murray, in Postnatal Depression and Maternal Mental Health, a Public Health Priority, ed CPHVA, London: CPHVA, 2001, p20-23
(27) 'The challenges of antenatal prevention of maternal depression', Peter Cooper, in Postnatal Depression and Maternal Mental Health, a Public Health Priority, ed CPHVA, London: CPHVA, 2001, p 9-12
(28) 'Evaluation of Screening for Postnatal Depression against the NSC Handbook Literature', Judy Shakespeare, Document prepared for a National Screening Committee workshop, 2002
(29) Postnatal Depression, Janice Gerrard, London: Nursing Times Books, 2000
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