Is motherhood more depressing than ever?
Postnatal depression is assumed to be on the rise, and scarce medical resources are being marshalled to deal with the problem. But how will this help new mothers?
Having a new baby may be enough to make you cry at times. But does that mean you are suffering from postnatal depression (PND)?
Today, PND is assumed to be more prevalent than previously thought, and scarce primary-care resources, such as health visiting and general practice, are to be focused on helping identify this problem and supporting women who suffer from it.
On Friday 22 June 2001 the Community Practitioners and Health Visitors Association (CPHVA) is hosting a conference at the Royal College of Physicians on PND and maternal mental health – a response to the National Service Framework for Mental Health, which states that health trusts and primary care groups have to have formalised programmes for promoting maternal mental health.
The danger, however, is that current attempts to highlight the prevalence of PND will only confuse the distinction between PND and the everyday worries and problems often experienced by new mothers.
PND, traditionally understood as a form of clinical depression, tends to occur in the 12 months following childbirth. It is more prolonged than the ‘baby blues’ which occur in the first week after delivery, but less severe than the much more rare ‘puerperal psychoses’, which almost always necessitate admission to a psychiatric unit. John Cox, a professor of psychiatry, believes the diagnosis should be restricted to mothers with a depressive illness who do not usually have false beliefs (delusions) or experience sensations in the absence of a stimulus (hallucinations) (1).
The following are reported to be strongly associated with PND: history of a psychiatric disorder (usually depression), mood disorder (again, usually depression) during the pregnancy, a poor marital relationship, lack of social support, and recent stressful life events (2). In general, however, these risk factors resemble those found in depressive disorders occurring outside the postnatal period.
There have been no controlled trials that demonstrate that depression in women is more common postnatally than at any other time in women’s lives (3). A study in 2000 that followed women for five years following their baby’s birth reported that, while most mothers experienced periods of depressed mood after the birth of their baby, these periods were generally of short duration and of less severe intensity than a major depression. The symptoms did not continue beyond a few weeks. Many of the cases of depression experienced during the five-year period represented a recurrence of a previous experience of depression (4).
But now, the depression that some women experience after having a baby – PND – is reported to affect anything between 10 and 20 percent of all women within the first year of a baby’s birth.
There are approximately 680,000 live births per year in the UK. If the 10 to 20 percent claim is true, 68,000 to 136,000 women should suffer clinical depression following the birth of a baby. The leaflet ‘Postnatal Depression’, jointly produced by The National Childbirth Trust and the supermarket Tesco (and available in your local store), helps to reinforce the idea that PND is very common; indeed, that it is a familiar response to childbirth.
Meanwhile, family doctors (GPs) are thought to underestimate the prevalence of depression in between 22 and 25 percent of cases, and are consequently accused of failing to identify women thought to suffer from PND (5). Health visitors, nurses who specialise in family health who see all women with a new baby, are reported to miss 75 percent of PND cases (6).
Can it really be true that health visitors miss signs of severe clinical depression in three-quarters of its sufferers? Or is it rather that the definition of PND is being broadened, almost to the point of becoming meaningless?
The diagnosis of PND is becoming increasingly imprecise, with no agreed and universally accepted symptoms. It is not uncommon for health professionals to make up their own definition of the condition. In current discussions, it is often used as a blanket term to describe a wide spectrum of distress experienced by new mothers, and the interpretation of the distress appears to depend on both the professional and the context.
We are advised that a postnatally depressed mother can present with a combination of symptoms – ‘tearful, despondent, smiling but depressed, with a jovial manner masking despair, may attend a baby clinic or GP surgery with physical health problems or frequently reporting problems with the baby’ – some, or all, of which can contribute to a diagnosis of PND (7).
A screening questionnaire, the Edinburgh Postnatal Depression Scale (EPDS), is a 10-point self-reporting tool that was developed in 1987 to help identify women with PND. The EPDS scale consists of 10 statements with four possible responses related to mood and feelings. Responses to each of the items on the scale are given a score of between zero and three. A score of zero indicates absence of symptoms, three represents maximum severity, while scores of one and two are intermediary statements.
Respondents are asked to indicate their reaction to each of the items in the scale during the previous week (8). Studies to validate the use of the tool in the UK and elsewhere have indicated that the EPDS may correctly diagnose 86 to 95 percent of cases of PND (9). Health visitors and GPs are thought to be well-positioned to help administer the questionnaire during the second or third month following the birth. Only in exceptional circumstances are professionals allowed to help women with its completion.
The statements are:
— I have been able to laugh and see the funny side of things
— I have looked forward with enjoyment to things
— I have blamed myself unnecessarily when things went wrong
— I have felt worried and anxious for no good reason
— I have felt scared or panicky for no good reason
— Things have been getting on top of me
— I have been so unhappy that I have difficulty sleeping
— I have felt sad or miserable
— I have been so unhappy that I have been crying
— The thought of harming myself has occurred to me.
A score of 14 or more, now revised down to 12, out of a maximum of 30, indicates that a mother may be depressed and in need of a clinical assessment of her mood. This would help elucidate depressive symptoms and suicidal thoughts, and help her explore her feelings for and attachment to the baby. Though the scale should not replace the clinical judgement of the health visitor, it can and does. I was told of a health visitor who totalled the scores incorrectly back at her clinic base and was so concerned at the resultant high figure that she returned to see the mother, unannounced, and in the middle of a dinner party the mother was having.
In a number of trials, an increased detection of PND (between 50 and 57 percent) was reported by health visitors as a consequence of using the EPDS (10). In the Health Trust I work for, health visitors training to use the EPDS estimated that six percent of women on their case-load might be affected by PND. In the subsequent pilot project of 297 mothers, they were surprised to have identified 19.2 percent as having PND (11).
But given that the EPDS depends on such general expressions of a mother’s state of mind, should health visitors be surprised that more women appear to suffer from PND than they originally think? It would be surprising if any young mother had not felt ‘sad or miserable’ in the previous week, or worried that things were getting on top of her. Her view of the previous week could also be prejudiced if she is having a bad day when completing the questionnaire.
A diagnosis of PND has consequences. Although most women will recover spontaneously over a period of three to six months without treatment, non-directive counselling by health visitors is now encouraged. This takes the form of ‘listening visits’ over a period of weeks, which force health visitors, currently criticised for dwelling too much on the physical needs of mother and baby, to concentrate exclusively on the woman’s emotional state.
In a 1989 study (before the days of Prozac), it was found that recovery rates following non-directive counselling by health visitors was 100 percent more effective than pharmacological interventions (12). Women, for whom this type of support is inappropriate or ineffective, can be referred to their GP, or to psychology or psychiatric services.
But the drive to add health visitors to the army of counsellors already operating from GP surgeries raises broader questions. In an age of evidence-based healthcare and nursing, the basis for screening and intervention with respect to PND remains dubious. It is also understood that the emphasis on listening rather than taking/giving advice may not solve the woman’s problems. The rationale is that it may help her tolerate her problems until she succeeds in overcoming them.
Accepting the offer of ‘listening visits’ is not mandatory for women – but they will clearly feel compelled to do so. While health visitors are encouraged to consider other support available to the mother, they are also advised to ‘determine whether the non-compliance represents a potential or actual child-protection concern’ (13). It is recognised that depression can directly affect the way a mother interacts with her child; the way she responds to and perceives the child. In cases of PND, the interests of the child remain paramount, as decreed by the 1998 UK Children Act. Professionals who suspect that the care offered is not ‘good enough’ are encouraged to make a child protection referral to Social Services.
Though it may be entirely appropriate and necessary, the intervention of social workers into family life is rarely viewed positively by families. Imagine how further undermined ‘depressed’ mothers must feel in such circumstances.
In the EPDS trials, women reported a number of social problems, including financial and housing problems, as well as a lack of social and emotional support. Some health visitors at a study day I attended were sceptical about the value of the ‘listening visits’ in such circumstances, when their experience over the years has told them that support with practical issues is much more of a priority.
Does not dwelling on emotional distress, frequently the result of intractable social and family problems, not help to reinforce the inadequacy many women may already feel by virtue of having been identified as ‘depressed’ by a health visitor and in need of ‘listening visits’? While not denying the need for emotional support for women after childbirth, it is questionable whether professionals are the best people to provide this support. In getting the mother to talk about her problems, professionals hope to improve her coping skills. But equally, causing the mother to dwell on her problems in this way could prolong and intensify her problems, and deter women from building their own support network, in the way mothers have always done.
The impact of the new focus on PND is to present PND almost as a normal response to childbirth. Offering screening to every new mother, and counselling by health visitors to those who score above the average on the EPDS, adds to the assumption that PND is an ever-more prevalent problem. Yet if, as a result of this, women are treated as suffering from PND when, in fact, they are simply feeling the pressure of having a new baby, there is a danger that they will lose confidence in their ability to cope with their child.
‘Having a baby is meant to be the most exciting and joyful experience you’ll ever have’, suggests the Child Psychotherapy Trust (14). But even so, a new baby is not always easy, and looking after him or her is not always fun. To imply that mothers who don’t see their new role as always ‘exciting’ and ‘joyful’ are depressed, and in need of some kind of therapeutic intervention, is as demeaning of the reality and severity of clinical depression as it is unhelpful to women wrongly diagnosed with PND.
Before rushing to meet the Department of Health targets on dealing with PND, health professionals should perhaps consider whether they want to continue to collude with this rather unscientific approach to healthcare.
Bríd Hehir is a contributor to Alternative Medicine: Should We Swallow It? (Hodder & Stoughton, 2002). Buy this book from Amazon (UK).
(1) Postnatal depression. A guide for health professionals JL Cox, 1986, Churchill Livingstone, Edinburgh
(2) ‘The management of postnatal depression’, in Drugs and Therapeutic Bulletin: 38, 2000, p33-37
(3) ‘The nosology of puerperal mental illness’, I Brockington and A Cox-Roper, in Motherhood and Mental Illness 2: Causes and Consequences, R Kumar and IF Brockington, eds, Wright, 1998, pp86-97
(4) Postnatal depression – myth and reality: maternal depression before and after the birth of a child’, Social Psychiatry & Psychiatric Epidemiology 35 (1): 19-27, JM Najman et al January 2000
(5) ‘Postnatal depression in the community’ in British Journal of General Practice 48, G Hearn et al 1998, p1064-1066
(6) ‘Detecting and preventing post natal depression’ in Community Nurse 4 (3) J Borrit 1998, p19-20
(7) ‘The management of postnatal depression: a manual for primary care staff’, in The Sainsbury Centre for Mental Health S Elliott et al, 1993
(8) ‘Detection of postnatal depression. Development of the 10 item Edinburgh Postnatal Depression Scale’ in British Journal of Psychiatry: 150, JL Cox et al 1987, p782-786
(9) ‘A cross cultural analysis of the use of the EPDS in Health Visiting practice’ in Journal of Advanced Nursing Vol 30 (3), C Clifford et al, 1999, p655-664
(10) ‘The role of health visitors in postnatal depression’, in International Review of Psychiatry 8, J Holden, 1996, p79-86
(11) ‘Report on a pilot project for the screening of postnatal depression in Camden and Islington Community NHS Trust’, January 1998
(12) ‘Counselling in a general practice setting: controlled study of health visitor’s intervention in treatment of postnatal depression’, British Medical Journal 347, Holden et al, 1989, p223-226
(13) ‘Postnatal Depression: Protocol for health visitors to use in identifying, supporting and referring women with postnatal depression’, January 2001, Camden and Islington Community Health Services NHS Trust
(14) ‘Postnatal depression – a problem for all the family’, L Emmanuel L and R Pick, Child Psychotherapy Trust leaflet
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