Postnatal Depression (PND)
Summary
Postnatal Depression (PND) is a non-psychotic depressive episode occurring within the first year postpartum (typically peaking at 1-3 months). It affects 10-15% of all mothers. It is distinct from the transient "Baby Blues" (common, mild) and "Postpartum Psychosis" (rare, severe emergency). Suicide remains a leading cause of maternal death in the UK (MBRRACE). [1,2]
The Spectrum of Perinatal Mood Disorders
- Baby Blues:
- Incidence: 50-80%.
- Onset: Day 3-5 (Peak Day 4).
- Symptoms: Tearful, labile, irritable.
- Duration: Resolves by Day 10.
- Management: Reassurance & empathy.
- Postnatal Depression:
- Incidence: 10-15%.
- Onset: 2 weeks - 1 year.
- Symptoms: Low mood, anhedonia, guilt, sleep disturbance.
- Management: CBT / SSRI.
- Postpartum Psychosis:
- Incidence: 0.2% (1 in 500).
- Onset: Rapid (Day 0-14).
- Symptoms: Mania, Delusions (often involving baby), Hallucinations.
- Management: Psychiatric Emergency. Admission to Mother & Baby Unit (MBU). Antipsychotics.
Clinical Pearls
Sleep Disturbance: Asking "Has your sleep been poor?" is useless—all new mums are sleep deprived. Ask: "When the baby is finally asleep, are YOU able to sleep?" If the answer is "No, I lie awake worrying", that is a core symptom of depression/anxiety.
Intrusive Thoughts: Many anxious mothers have terrifying thoughts of harm coming to the baby (e.g., dropping them down stairs). Key distinction:
- Anxiety/OCD: Mother is horrified by the thought and avoids risks. (Low risk of harm).
- Psychosis: Mother believes the thought is external or rational/command. (High risk of harm).
Thyroid Check: Postpartum Thyroiditis affects 5% of women. The hypothyroid phase presents exactly like depression (fatigue, low mood). Always check TFTs.
Risk Factors
- Past History: Previous Depression or Bipolar Disorder (50% relapse risk).
- Social: Domestic Violence, Financial strain, Poor partner support.
- Obstetric: Traumatic birth, Preterm infant, Breastfeeding difficulties.
Mechanisms
- Hormonal Withdrawal: Precipitous drop in Oestrogen and Progesterone after placental delivery.
- HPA Axis: Dysregulation of cortisol.
- Psychosocial: Sleep deprivation is a major precipitant ("The torture of the sleepless").
Core Symptoms (ICD-10)
Specific Features
Mental State Examination (MSE)
- Appearance: Poor self-care?
- Behaviour: Poor eye contact? Flat affect?
- Interaction: Observe how she holds the baby. Does she respond to cues?
- Speech: Slow (depression) or Pressured (mania/anxiety).
- Risk Assessment: Suicide and Infanticide risks.
Screening
- Whooley Questions (2-question screen).
- Edinburgh Postnatal Depression Scale (EPDS):
- 10-item self-report.
- Score >12 = Probable Depression.
- Question 10 (Self harm): Positive score triggers immediate review.
Biological
- TFTs: Exclude Thyroiditis.
- FBC: Anaemia aggravates fatigue.
Management Algorithm (NICE CG192)
POSTNATAL DEPRESSION SCREEN
(EPDS > 12)
↓
RISK ASSESSMENT
- Suicide Risk? Psychosis?
- Risk to Child?
┌─────────┴─────────┐
HIGH LOW/MODERATE
↓ ↓
URGENT REFERRAL STEPPED CARE
(Perinatal Psych) ↓
Consider MBU MILD: Health Visitor
Support / Self-Help
↓
MODERATE:
- Psychological (CBT)
- SSRI (Sertraline)
Psychological (Steps 1-2)
- Health Visitor: "Listening Visits".
- CBT: Cognitive Behavioural Therapy.
- Baby Bonding: Parent-infant psychotherapy.
Pharmacological (Step 3) (NICE/BAP)
- Sertraline: First line. Low excretion into breast milk.
- Paroxetine: Second choice.
- Fluoxetine: Generally avoided (long half-life, accumulates in infant).
- Safety: "Benefits of breastfeeding generally outweigh the small theoretical risks of SSRI exposure." Monitor baby for irritability/sedation (rare).
Severe (Step 4)
- Mother and Baby Unit (MBU): Specialist inpatient ward where mum and baby stay together. Keeps the dyad intact while treating the illness.
- ECT: Use in severe, life-threatening depression/psychosis.
- Maternal suicide: Leading cause of death.
- Infant Impact:
- Cognitive: Delayed language development.
- Emotional: Insecure attachment.
- Physical: Poor growth (feeding issues).
- Recovery: Good prognosis with treatment (most recover within months).
- Recurrence: 50% risk in next pregnancy. Requires prophylactic planning (e.g., starting meds immediately postpartum).
Key Guidelines
| Guideline | Organisation | Key Recommendations |
|---|---|---|
| CG192 | NICE (2014) | Antenatal and Postnatal Mental Health. Stepped care model. |
| MBRRACE-UK | NPEU | "Saving Lives, Improving Mothers' Care". Highlights suicide risk. |
Landmark Evidence
1. The PoNDER Trial
- Showed that Health Visitor delivered psychological interventions ("Listening Visits") were effective for mild-moderate PND.
What is PND?
It is a real illness caused by chemical imbalances, hormone changes, and exhaustion. It is NOT a sign of weakness or being a "bad mother".
Is it the Baby Blues?
No. The "Blues" happens in the first week and goes away by itself. PND lasts longer and feels heavier. If you still feel low 2 weeks after birth, it is likely PND.
Will tablets hurt the baby?
If you are breastfeeding, we choose medicines like Sertraline that don't get into the milk in significant amounts. We have years of safety data. It is much safer for your baby to have a happy, recovered mum than a mum who is suffering.
Will Social Services take my baby?
Asking for help is a sign of good parenting. We want to keep you and your baby together. Social services usually only get involved if the baby is being neglected or is in danger. Treating your depression stops that from happening.
Primary Sources
- NICE. Antenatal and postnatal mental health: clinical management and service guidance [CG192]. 2014.
- Knight M, et al. Saving Lives, Improving Mothers' Care (MBRRACE-UK Confidential Enquiries). 2021.
- McAllister-Williams RH, et al. British Association for Psychopharmacology consensus guidance on the use of psychotropic medication during pregnancy and breastfeeding. J Psychopharmacol. 2017.
Common Exam Questions
- Diagnosis: "Low mood + Auditory Hallucinations at Day 5?"
- Answer: Postpartum Psychosis (Emergency).
- Pharmacology: "Safest SSRI in breastfeeding?"
- Answer: Sertraline (or Paroxetine).
- Prognosis: "Recurrence risk?"
- Answer: High (50%).
- Screening: "Tool for PND?"
- Answer: EPDS.
Viva Points
- MBU Criteria: Diagnosis of Psychosis, Severe Depression, or profound bonding disorder.
- Valproate: The "Do Not Prescribe" drug in women of childbearing age (teratogenic). But safe in breastfeeding if started after birth? (Still risky if she gets pregnant again quickly). Avoid.
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.