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Perinatal Depression

Perinatal Depression: What is it, causes, prevention and treatment | KKH

Perinatal Depression - What it is

​Pregnancy and childbirth are special times in the lives of many women. And many of us, women, will experience motherhood, or at least come in close contact with pregnant women. But sometimes, instead of being excited, joyful and in the brink of good health, a picture which we have come to associate with motherhood, you can find yourself struggling to cope with depression.

Pregnancy is a period that can bring on worrying changes in the psyche of a woman, as she navigates a dramatic transition within herself. This booklet aims to provide information on depression occurring during and after pregnancy, the symptoms and possible causes, and what can be done to help you if you suffer from perinatal depression.

Antenatal Depression

Whilst the previous emphasis and awareness have been on postpartum depression, research has suggested that antenatal depression, or depression during pregnancy, may be even more common than postnatal depression. Locally, about one in five pregnant women is likely to have depressive symptoms associated with impairment of functioning, and about one in ten will have clinical depression - that is, depression requiring medical attention.

We also now understand that antenatal depression often marks the onset of depressive illness in women and increases the risk of postnatal depression. As the common features of depression such as loss of appetite, poor sleep, feeling tired and forgetful are so similar to those of pregnancy, women can sometimes dismiss these symptoms. More useful symptoms to look out for would be pessimism and mood swings.

The symptoms of antenatal depression are:

  • Low mood
  • Irritability
  • Loss in interest
  • Poor sleep
  • Poor appetite
  • Excessive self-blame or guilt
  • Feeling hopeless, or that life is meaningless

Women can also look out for sign of their mood swings affecting their ability to relate to those around them, or their ability to cope with work, housework or other responsibilities.

Causes for Antenatal Depression

When a pregnant woman is tearful or emotional, the common reaction is “It’s her hormones!”. But whilst this may be partly true during the first trimester, when estrogen levels are low, and progesterone levels are relatively higher, and morning sickness adds to the misery, hormonal changes alone do not conclusively account for antenatal depression, otherwise every pregnant woman will be depressed!

The causes for antenatal depression are usually multifactorial, as with other types of depression and most psychiatric disorders. Often, it is an interplay of various factors, which leads to the onset of depression during pregnancy. As a pregnant woman, you will need to undergo a significant psychological adjustment as you adapt to the pregnancy and the notion that you will be nurturing a new life that you are fully responsible for.

If this is your first baby, the adjustment can be more challenging, especially :

  • if the pregnancy was unwanted or unplanned
  • if you have had a difficult relationship with your own mother. The unresolved emotional conflicts will be awakened as you prepare to be a mother
  • if you are working. You may not be able to convince yourself to let go of your career or you may have colleagues who are not understanding and supportive
  • if you are a teenage or very young mother. The psychological adjustment needed to become a mother may be particularly difficult, as you are still very much in need of mothering

Other factors that may contribute to antenatal depression include:

  • Having a complicated pregnancy
  • Fetal abnormalities
  • If you have previous episodes of depression

Finally, the same factors that contribute to depression at any other time in a woman’s life will similarly affect her during her pregnancy:

  • Marital difficulties
  • Interpersonal problems
  • Financial and occupational problems
  • Lack of social support
  • Loss of a loved one
  • Substance abuse and dependency

Lastly, if this is a precious pregnancy, or you have had difficulty conceiving or previous miscarriage, there is also an increased risk of depression.

What Can Be Done to Help You if You Suffer from Antenatal Depression

If you are pregnant and depressed, you may hesitate to get help for depression because of the fear of what others might think and the concern about the medications prescribed.

However, the management of antenatal depression involves looking at the stresses and causative factors, counselling, gathering support for you, and other forms of psychological therapy. Only when the depression is severe, will medication be recommended. Furthermore, there are certain medications that are compatible with pregnancy, and are safe for both the mother and growing fetus.

If depression is left untreated, it will worsen and lead to adverse effects for you and your baby.

The first trimester is often a difficult period with uncomfortable symptoms of morning sickness and tiredness. The early hormonal changes during this stage may also contribute to depression. However, antidepressants should be avoided at this stage, as this is the time that the baby’s organs are developing. During this time, gathering assistance such as arranging for the family to help with the care of the older child, or household chores will be helpful. This will allow the woman to have much needed rest. Therapy and counselling are often beneficial too, as they will enable you to talk about your stresses and work through any difficult emotional conflicts.

In the second trimester, antidepressant use may be considered if the depression is at least of moderate severity, and is not improving with non-pharmacological methods.

During the last few weeks of pregnancy, it is recommended that antidepressants be gradually tailed off. This is because some medications may cause withdrawal symptoms in the newborn.

However, if you suffer from a pre-existing depressive illness that is severe, and require long-term antidepressant maintenance, the risk-considerations may sometimes necessitate that you remain on antidepressant medication throughout pregnancy. Risks will be kept minimal by using minimal possible dose, keeping you under close supervision, as well as utilising all other treatment modalities that are appropriate for you.

Case Example

Agnes was a 34 year-old mother, who experienced mood swings, loss of appetite and interests and was unable to concentrate at work. She also had excessive self-blame, but did not have any suicidal feelings. The main stressor she experienced was her breech pregnancy, and her worries of the outcome. This was also a long awaited pregnancy, which was precious – the couple had been married for six years, and she had had one previous miscarriage.

As she was already in her third trimester, her doctor did not prescribe her medication as it could affect the baby. She received supportive therapy, and her husband was encouraged to spend time with her. Her in-laws, who had mistakenly believed that she was somehow responsible for the complicated pregnancy, were also advised and educated on the nature of breech pregnancy.

Fortunately, she had an uneventful delivery by Caesarean operation, and delivered a healthy baby girl.

Postpartum Depression

When the baby comes, your family and friend will tend to expect you, the mother, to be happy and perfectly at peace with the arrival of the new addition. Also, whilst others will shower special attention and care during pregnancy, oftentimes the focus is on the newborn after delivery, and the mother sometimes is just relegated to being seen as the milking machine or the nappy changer.

The pressure you have can then become immense. Your needs no longer seem important, whereas the needs of your baby come first. If there is inadequate support and help, especially from your husband, it may be even harder for you to adjust to the changes. Added to that, the lack of sleep in the initial weeks, and the hormonal changes can all be overwhelming.

The common postnatal depressive syndromes that can affect you include postnatal blues, postnatal depression and postnatal psychotic depression. You should note that postnatal blues are not strictly considered an per se, and may in fact be a normal emotional change during a period of transition. But as it is often confused with postnatal depression, we shall try to explain more here.

Postnatal Blues

As common as occurring in two-thirds of women, the blues hit in the first week after delivery, and are usually short lasting, and can be resolved spontaneously within a few days to weeks.

Symptoms of postnatal blues:

  • feelings of irritability
  • weepiness
  • moodiness
  • anxious thoughts about caring for the baby
  • feeling frustrated with the baby’s crying

Postnatal blues are more commonly seen among firsttime mothers who have no previous experience with motherhood, and those with poor support.

Most mothers with ‘the blues’ do not need medical attention, and can benefit from the support, encouragement and reassurance from loved ones. This is because the symptoms are usually short-lasting, and are not severe.

However, if their symptoms persist longer than two weeks, they should seek further advice from their doctor, as it is then likely that they may be suffering from postnatal depression.

Postnatal Depression

Between ten to fifteen per cent of the recently delivered women will develop postnatal depression. Postnatal depression usually develops within the first three to six months after delivery, although it may have a delayed onset anytime during the first year after delivery.

Some of the symptoms you may experience include low mood, irritability, poor sleep, tiredness and a loss of interest in activities, or in severe cases, even thoughts of dying. Bodily symptoms such as aches and concurrent anxiety symptoms are also common, as are negative feelings towards the baby.

Early detection and treatment are also crucial for depressed mothers as the development and well being of the child can be hampered.

Depressive illnesses can range from mild to severe. Severe depression affects about three to five out of a hundred mothers.

The symptoms of depression include:

  • Low mood, irritability, tearfulness
  • Poor sleep and appetite (or comfort eating)
  • Loss of interest
  • Loss of confidence, and feeling guilty for no good reason
  • Feeling hopeless or even suicidal in severe depression

Often, there is accompanying anxiety symptoms, such as:

  • Feeling tense
  • Palpitations, feeling breathless, chest tightness
  • Panic attacks - strong feelings of terror that come suddenly
  • Excessive worries

Some women also have obsessional symptoms, such as:

  • Intrusive unpleasant thoughts about harm coming to your baby or family.
  • Irrational fears of dirt and disease, leading to urges to clean or wash repeatedly.

The symptoms usually start soon after childbirth, but are often unnoticeable until two to three months after delivery. The symptoms may vary a lot.

Causes of Postnatal Depression

Like antenatal depression, there are usually many factors that contribute to the development of postnatal depression woman: hormonal, biological, psychosocial and emotional changes.

Some of the causes for postnatal depression are:

  • Distress about weight gain, body shape changes
  • Sleep deprivation from having to attend to baby’s night-feeds
  • Marital discord
  • Lack of social support
  • Financial difficulties
  • Family problems
  • Emotional difficulties adjusting to the new role of being a mother
  • Unpleasant confinement experiences

If you have had past episodes of depression, whether if they were related to childbirth or not, or if you have a family history of depression, you may then have a higher risk of postnatal depression.

Management of Postnatal Depression

If you suffer from mild depression postnatally, you can recover with support and counselling, which may be provided by your family physician, or family and friends. However, if your depression is at least of moderate severity, you should consult a specialist for treatment.

If postnatal depression is left untreated, it can persist and worsen, and affect not only your well-being, but also the emotional and cognitive development of your infant. If you are depressed, you may see yourself as a bad or unloving mother, as your symptoms make it hard for you to care for your baby. You may also bear negative thoughts, and excessive self-blame and guilt which will then affect the bonding process and relationship between you and your child. Thus, receiving help early is beneficial.

Psychological treatments shown to be useful in postnatal depression include interpersonal therapy which focuses on interpersonal relationships, and cognitive-behavioural therapy which addresses faulty thinking and patterns of behaviour.

Many women suffering from postnatal depression have also found support groups to be particularly useful, as they provide an avenue for them to talk about their difficulties, learn coping strategies from one another, and benefit from the realisation that they are not alone in their pain.

When the depression is more severe, medication will be required. The choice of medication will take into consideration the possible side effects as well as your particular needs, especially your need to breastfeed. There are certain medications that may be used if you wish to continue nursing.

If you are pregnant and have had depression during your last pregnancy, we recommend that you seek early advice. If the previous episode of depression has been particularly severe, we advise you to consider taking prophylactic antidepressants as the risk of a relapse during a subsequent pregnancy can be as high as fifty per cent.

Case Example

Nancy started feeling depressed, weepy and tired about two months after the delivery of her first son. She also had difficulty sleeping and had no interest in doing anything. Although she has eagerly awaited the arrival of her son after trying to conceive for two years, she was alarmed that she felt resentful and frustrated with his incessant crying, and sometimes even had an urge to smother him. She also felt it hard to adjust to being at home with the baby the whole day, when before, she had a career as a high-powered executive.

When her husband sensed something was wrong, he brought her to see a psychiatrist. She was diagnosed with postnatal depression, and started on a course of antidepressant medication. Her mother was also roped in to help with the care of her son. And as her mood lifted, she received psychotherapy, which helped her come to terms with her own inner conflicts.

Postnatal Psychotic Depression

This is the most severe form of postnatal depression which occurs in about 0.1% of recently delivered women. It usually surface within the first two weeks after delivery.

Symptoms include a loss of touch with reality, dramatic mood changes, confusion, as well as hallucinations and delusions.

Typically, hospitalisation is required for this illness, which is considered a psychiatric emergency, as it possesses a high risk of selfharm and infanticide. Close follow-ups are necessary as the risk of recurrence during subsequent pregnancies is as high as seventy per cent.

Conclusion

Depression may affect you during pregnancy and in your postnatal period, and cause difficulties not only to you, but also for your baby and family.

However, with early recognition and treatment, chance of recovery can be good. The goal for early detection and treatment is to enable you to have the wonderful experience of caring for your baby.

Women's Mental Wellness Service

Women's Mental Wellness Service at KK Women's and Children's Hospital is dedicated to women who suffer from a spectrum of psychiatric disorders and to help improve the lives of these women and their families.

Clinical care will be complemented by research that will enable better-informed clinical care and dissemination of important findings that emerge across the field of women's mental health.

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Perinatal Depression - Causes and Risk Factors

Perinatal Depression - Diagnosis

Perinatal Depression - Treatments

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