Dr Andrew Mayers

Perinatal mental illnesses

Overview

Postnatal depression is often an overused term, and one that hides a much more complex set of conditions for mothers (and fathers, for that matter). I prefer the term perinatal mental health, because that illustrates how a series of problems with mood, anxiety, and perceptions of reality that can afflict families during pregnancy and for some time after the birth of their baby. This page provides an overview of some typical conditions. For more details about signs, symptoms and treatments please always refer to qualified sources, such as NHS Choices. To discover what support is available, please visit the resources page. Fathers can also develop mental health problems during the perinatal period, and often need help to provide support for their wife/partner should she become unwell. To read about that, refer to the fathers mental health page.

Postnatal depression

Up to 75% of mothers experience 'baby blues' in the first few days after giving birth. Symptoms might include low mood and tearfulness. For most mothers this is very temporary and is rarely a matter of concern and should not require direct treatment. Should these symptoms continue (or worsen) into weeks and months, this is more likely to be postnatal depression. This often does require treatment, with medication and/or psychological therapy. Postnatal depression is a formal diagnosis of major depressive disorder within a specified time after the birth of the baby. About 1 in 10 of new mothers are diagnosed with postnatal depression. A diagnosis may be confirmed from the presence of low mood and/or a lack of motivation (to do those things one normally tends to undertake), plus several indicators from symptoms such as guilt, poor sleep, anxiety, poor concentration, and thoughts of death and dying. Depression might also be diagnosed during pregnancy. Either way, it is important this depression is treated, for the sake of the mother and her baby.

NHS Choices - postnatal depression

Postpartum Psychosis

A diagnosis of 'depression' tends to focus on low, or negative, mood. In some (often more serious) cases, mothers and pregnant women may diagnosed with a bipolar disorder. This is a series of conditions where mood can fluctuate between 'depressive states' and 'mania' (a state of abnormally elevated or irritable mood, arousal, and/or energy levels) or 'hypomania' (a similar state, but less severe and shorter in duration). In manic states, people can start behaving in way that might be damaging to themselves or those around them. When this is diagnosed in the perinatal period, the consequences can be very serious indeed. Treatment is essential.

Postpartum psychosis is a rare (but very serious) condition, affecting around 1 in every 1000 births. In these conditions, thought processes, cognition, behaviour, and sense of reality can be severely compromised. Mothers and pregnant women with psychotic symptoms might present delusions (about themselves or baby), experience hallucinations, express little or no mood, shows signs of extreme immobility (or excessive activity), and may engage in 'odd' behaviours and speech. This is clearly very serious indeed. It requires immediate treatment and attention, sometimes hospitalisation.

This excellent Pretty52 blog, featuring my great friend and fellow campaigner Eve Canavan, describes the experience of postpartum psychosis very well.

NHS Choices - postpartum psychosis

Maternal OCD

NHS Choices refers briefly to obsessive-compulsive disorder (OCD) in new mothers; in reality Maternal OCD is a major concern for women during pregnancy. Central to OCD is the tendency to ruminate on unwanted thoughts, images or urges, which are countered by the need to engage in repetitive behaviours. The latter are an attempt to reduce the anxiety of the former. It is often, mistakenly, assumed that maternal obsessions focus on cleanliness. More commonly, the intrusive thoughts dwell on an excessive need to protect the baby (or foetus in pregnancy) from harm.

Read Diana's story (Diana Wilson is a co-founder of the Maternal OCD charity).

Birth trauma (and post-traumatic stress disorder: PTSD)

NHS choices mention PTSD in their guidelines on maternal mental illness, and suggest 'birth trauma' as one of many causes. While that’s true, birth trauma is so much more than that. Birth trauma can be any unexpected event, including unplanned caesarean, through to blood loss, obstetric complications, and potential loss to mother and/or child. It has been argued that some of those complications could be avoided if services were fully funded, supported, and better informed.

When trauma does occur, many mothers (and fathers) get little support and information about what is happening and what to expect next. Still further, traumatised mothers get  little ongoing support. A proportion of mothers will subsequently develop PTSD. Since we know some of those risk factors, we can implement more support during and after trauma to reduce the impact, and distress, and lessen the likelihood of PTSD occurring. I am working with birth trauma support groups, academics and professionals to influence change. I will update you on progress about those campaigns. More details about support can be found on the resources page. In the meantime, please have a look at the Making Birth Better website.

Perinatal eating disorders

When a woman with a history of eating disorders becomes pregnant, it is possible that all those prior negative thoughts about body image might re-emerge. We do not know nearly enough about that yet, so I have been involved in some new studies that seek to address that. I hope to be able to share some of that work soon.

Are perinatal mental illnesses any different to those seen generally in adults?

The short answer is 'Yes'! Quiet apart from anything else, postnatal mental illness (for either parent) can have a long- lasting impact on their child's development (although there's much we can do to help and support that). However, there is an even great impact for maternal mental illness (antenatal and postnatal). Take postnatal depression for example. I am often asked if dads can get 'postnatal depression'. Fathers can certainly experience symptoms that we might associate with postnatal depression. But, is it the same as we see in mothers? No, not really. It's for these reasons (at the very least):

1. Guilt: The guilt we often see in depression is experienced many times over in some mothers. Motherhood is supposed to be a joyous time (such is the public perception). A mum who feels so low, or demotivated, that she is struggling to bond with her infant can feel desperately guilty.

2. Good enough mum: Related to the above, mothers with postnatal depression can feel that they are not good enough, and have failed at being a mum. This can erode self-worth more than we might see in other adult depressed women.

3. Medication: When an adult female is depressed, one treatment option is medication (perhaps an antidepressant). But, is it as simple as that for a pregnant women or a mother who is breastfeeding? Can that medication be passed on to the foetus or baby? Is it safe? Many medications are safe (depending on type and dose), but some are not. We need more evidence on that (something I am currently working on). In the meantime, this is just another doubt for the mother at this most troubling of times.

4. Breastfeeding: Regardless of potential medication complications, breastfeeding can become complex in postnatal depression. Much of the evidence suggests that 'breast is best', and it probably is. What does not help is when mothers, already distracted emotionally and cognitively by the mood symptoms, feel under so much pressure to breastfeed. Furthermore, the illness (and some medications) can interfere with milk production. Mums need more support and less judgement.

General tips on seeking help and support

Medical advice should always be sought, usually a GP. However, there are some excellent websites support groups that can guide mothers, carers, families and professionals about what to look out for and what can be done (check out the resources page for more information).

Some women may need to be seen as soon as pregnancy is confirmed, especially if there is a history of mental illness. In some cases, women may be referred (usually by a GP) to local perinatal mental health services. Unfortunately, not all areas have these services - or the extent to which they can be delivered might vary from area to area. Potentially, this leaves many women, who might be acutely ill, without proper care. Furthermore, many pregnant women and mothers do not report mental illness for fear of stigma and the judgement of other people. Quite often, there is a fear that their child may be taken from them.

Another barrier to services is poor recognition. The mother, or her family, may not fully appreciate the consequences of mental illness. Health professionals (including some GPs, midwives, and health visitors) may not be fully trained in spotting the signs of mental illness in mothers, or how to deal with this effectively if recognised. Where there are local perinatal mental health services, they can often only take relatively acute cases (mostly due to commissioning and financial restrictions). Women deemed to be less severely ill, are returned to primary care. In some cases, a proportion of these mothers are referred to local 'Early Years Centres', 'Children's Centres' and/or 'Sure Start Centres'. These centres often have great programmes, aimed specifically at local mothers with low mood, and other mental health issues.

Nonetheless, there are still many women left in the local community with no support at all. These women may not be aware of what help is available or may not know that they are in need of help. I am working with friends and colleagues nationally to press for better NHS and community (peer) support. Refer to the campaigns page to learn more about that. I am also involved with some programmes that are designed to help train health professionals.