Post-Natal Depression

Question 1

What is postnatal depression defined as?

Answer 1

Non-psychotic illness occurring during the first postnatal year

Question 2

What should the term ‘postnatal depression’ not be used as?

Answer 2

An umbrella term for all mental health problems following delivery

Question 3

What are the different scenarios in which post-natal depression can occur?

Answer 3

• De novo
• Recurrence of depressive condition occurring prior to pregnancy
• Part of wider problem, e.g. bipolar disorder

Question 4

How does the overall prevalence of PND compare to depression at other times?

Answer 4

Probably not significantly more common in the post-natal period than other times

Question 5

What is the prevalence of PND in the developed world?

Answer 5

10-15%

Question 6

What % of women with PND symptoms seek or obtain medical advice?

Answer 6

As few as 15%

Question 7

What are the strongest risk factors for PND?

Answer 7

• Previous history of mental health problems
• Psychological disturbance during pregnancy
• Poor social support
• Poor relationship with partner
• Baby blues
• Recent major life events

Question 8

What are the less strong risk factors for PND?

Answer 8

• Unplanned pregnancy
• Unemployment
• Not breast-feeding
• Antenatal parental stress
• Antenatal thyroid dysfunction
• Longer time to conception
• Depression in father of child
• Having 2 or more children
• Current, or history of, substance misuse
• Neonatal low birth weight or illness, stillbirth, or SIDS

Question 9

What are the weakest risk factors for PND?

Answer 9

• Obstetric complications
• History of abuse
• Low family income
• Lower occupational status

Question 10

How does PND present?

Answer 10

Same as depression in other circumstances, including;

• Low mood
• Low enjoyment and pleasure
• Anxiety
• Disturbed sleep
• Loss of appetite
• Poor concentration
• Low self-esteem
• Low energy levels
• Loss of libido
• Thoughts of death/suicidal thoughts

Question 11

What needs to be considering when a patient presents with symptoms of PND?

Answer 11

Some of these symptoms can be normal in the early post-natal period, e.g. sleep disturbance, tiredness, anxiety about the baby

Question 12

What should HCPs be aware of regarding the symptoms of PND?

Answer 12

Women may be unwilling to disclose symptoms of depression and other mental health problems

Question 13

Why might new mothers be unwilling to disclose symptoms of depression and other mental health problems?

Answer 13

• Fear or stigma
• Fear the baby may be taken into care
• Concern they will be perceived as a poor mother
• Problems with alcohol or substance dependence

Question 14

What can screening questions for PND be asked?

Answer 14

At booking at postnatal checks

Question 15

What screening questions for PND can be asked at screening and postnatal checks?

Answer 15

• During the past month, have you often felt bothered by feeling down, depressed, or hopeless?
• During the past month, have you often been bothered by having little interest or pleasure in doing things?

Question 16

What should be done if the answer to the screening questions for PND is yes, or if there is clinical suspicion?

Answer 16

Further assessment is required

Question 17

What can be used to help the assessment of a woman who answers yes to the screening questions for PND, or there is clinical concern?

Answer 17

Formal assessment tool, e.g. Edinburgh Postnatal Depression Scale

Question 18

What are the general principles of the management of PND?

Answer 18

• Empowerment
• Communication
• Wider family environment

Question 19

What is involved in empowerment in PND?

Answer 19

• Involve women in decisions about their care
• Reassure that postnatal depression is not uncommon
• Be optimistic about its resolution

Question 20

What should be done if a mother with PND lacks capacity?

Answer 20

Follow Department of Health guidelines and code of practice accompanying the Mental Capacity Act

Question 21

What communication is important in PND?

Answer 21

• The woman, her relatives, and carers should be given information in a form that is culturally appropriate
• Communication between all HCP involved is vital for integrated care

Question 22

What needs to be considered in PND regarding the wider family environment?

Answer 22

Consider needs of other children, dependent adults, and the effect the illness may have on the relationships with partners

Question 23

What always needs to be considered in the management of PND?

Answer 23

Welfare of the baby

Question 24

What should the choice of treatment in PND be decided based on?

Answer 24

• Efficacy
• Previous response to treatment
• Incidence of side effects
• Likely compliance
• Patient preference
• Safety during breastfeeding

Question 25

How should mild to moderate PND be managed?

Answer 25

Consider facilitated self-help strategies

Question 26

How should mild to moderate depression be managed when there is a history of severe depression?

Answer 26

Consider anti-depressant

Question 27

What are the management options for moderate to severe PND?

Answer 27

- High intensity psychological intervention - Antidepressant treatment - Combination of psychological therapy and antidepressants

Question 28

Give an example of a high intensity psychological intervention

Answer 28

CBT

Question 29

When should antidepressants be used in mild to moderate PND?

Answer 29

- Risks are understood and accepted - Woman declines psychological therapy - Psychological therapies have failed

Question 30

How should severe PND with thoughts of suicide or harming the baby be managed?

Answer 30

- Immediate referral for urgent psychiatric assessment | - Child protection procedures may need to be invoked

Question 31

Can antidepressants be used in breastfeeding women?

Answer 31

Evidence remains unclear about role and safety of antidepressants in breast-feeding women, and so decisions have to be made on an individual basis

Question 32

What do the NICE guidelines say about antidepressants and breastfeeding?

Answer 32

Women should be encouraged to breastfeed, unless they are taking; - Lithium - Sodium valproate - Carbamazepine - Clozapine

Question 33

How does the threshold for pharmacological therapy in the treatment of depression vary in pregnancy compared to other times?

Answer 33

It is higher

Question 34

Describe the course of PND

Answer 34

Widely variable, and will depend on predisposing factors and response to treatment

Question 35

By when do most cases of PND resolve?

Answer 35

3-6 months

Question 36

What proportion of women will have symptoms of PND after 6 months?

Answer 36

1/4

Question 37

What is untreated PND associated with?

Answer 37

Adverse effects on the infant

Question 38

What adverse effects on the infant are associated with untreated PND?

Answer 38

Short-term and long-term poor cognitive, emotional, social, and behavioural development

Question 39

When are the adverse effects of PND on the infant seen?

Answer 39

When the mother is unable to engage actively with the infant

Question 40

What does NICE recommend for the prevention of PND?

Answer 40

Women are proactively screened for mental health problems, and high-risk patients identified

Question 41

When should HCPs screen for depression and anxiety?

Answer 41

- Booking | - Postnatally at 4-6 weeks and 3-4 months

Question 42

What questions should be asked to screen for depression and anxiety?

Answer 42

- Past or present severe mental illness - Previous treatment by psychiatrist/specialist mental health team, including inpatient care - Family history of severe perinatal mental illness in first-degree relative

Question 43

What past or previous severe mental illness should be asked about when screening for PND?

Answer 43

- Schizophrenia - Bipolar disorder - Psychosis in postnatal period - Severe depression

Question 44

What should done when a woman is identified as high risk of developing severe depression, or with a history of severe mental illness?

Answer 44

Referral to secondary care mental health services