Positive Relationships: Mental Health - After the joy

According to the NSPCC report All Babies Count: spotlight on perinatal mental health, more than one in 10 women experience mental health issues of some kind during pregnancy and the first year after childbirth. These include anxiety, depression and other postnatal psychotic disorders that are known collectively as 'perinatal mental health illnesses'.

Postnatal depression is the most commonly known, although not necessarily well understood. Strictly speaking, depression can occur at any time during pregnancy, which is why the term perinatal is often used.

Depression after childbirth is not the same as 'the baby blues', which more than half of new mothers are believed to experience in the days after birth and which doesn't require treatment. These feelings of tearfulness or irritability usually pass within a couple of weeks, leaving mothers able to enjoy, and relate to, their babies.

However, if the feelings linger, worsen or impair the mother's functioning, then it is advisable to talk to a midwife, health visitor or GP, as such feelings are likely to indicate something more serious and it is important to get help as soon as possible.

SYMPTOMS

The charity Action on Depression describes the symptoms of postnatal depression as similar to depression in general, but with the added factor of feelings about the baby. These could include constant feelings of:

• sadness or being low
• exhaustion but unable to sleep - or wanting to sleep too much
• lack of interest in eating/personal appearance/hygiene
• anxiety or feeling overwhelmed
• lacking in energy
• lack of interest in - or over-anxiety about - the baby.

Added to this are intense feelings of guilt and failure at not feeling happy and assuming that you are the only one who can't cope as a parent. This is more than just the general anxiety of being a new parent or having another child to care for. The feelings can be intense and disabling, affecting the parent's ability to relate to their baby and other family.

IMPACT ON THE CHILD

Perinatal mental health, therefore, is inextricably linked with the mental health of the child and can result in developmental delay and other health and emotional issues. Although the mother frequently recovers from the illness, without the right support and recognition of the issues, studies show that the impact on the child can be much longer lasting.

• Low birth weights and pre-term deliveries have also been associated with perinatal depression. Many pre-term and small-for-dates babies thrive well, but there is evidence to suggest that they are more at risk of illness, as well as neurodevelopmental and cognitive problems.
• Children of depressed mothers have been shown to have matching elevated rates of the stress hormone cortisol and decreased levels of dopamine and serotonin. They are likely to be more irritable, be less active and attentive (Field, Diego and Hernandez-Reif, 2006) and show developmental delays at 18 months (Deave, Heron, Evans et al, 2008).
• The relationship between parental depression and outcomes for children is complex and although research doesn't always show a straightforward link with poor parenting, there are studies (for example, Murray, Fiori-Cowley et al, 1996) to suggest depressed mothers are less likely to provide the right sort of stimulation and are generally less able to be responsive to their children's needs.
• Some studies have shown that parental depression can be an indicator for later behavioural difficulties in children. Depressed parents are less likely to be able to offer good models for mood regulation, for problem solving and for setting and following through on behaviour limits (Kochanska et al, 1987).
• Several studies suggest that maternal postnatal depression (and the poor interactions linked with it) can have a negative impact on a child's cognitive development (for example, Murray, Hipwell et al, 1996) and that the impact may be stronger on boys' intellect than on girls' (Sharp et al, 1995). A longitudinal study in 2001 showed that attention problems, special educational needs and difficulties in maths reasoning were more frequent at age 11 in children whose mothers had experienced postnatal depression, although the study did not take account of other determining factors such as the mother's mental health at other times or socio-demographic variables (Hay et al 2001).
• In other aspects of life, mothers with depression were found to be less likely to use preventive healthcare for their children (Minkovitz, Strobino, Scharfstein et al, 2005) but more likely to use 'urgent care' - for example, A&E and emergency doctors (Flynn, Davis, Marcus et al, 2004).
• Crucially, depression is likely to affect the nurturing relationship between a parent and child and is one of the risk factors for insecure attachment - and all the implications that brings in terms of neurophysiological development and emotional health.

CAUSES

There are a wide range of possible causes and risk factors for depression occurring during and after pregnancy and the prevalence is higher among certain vulnerable groups. According to some studies, young, single mothers who experience complications during pregnancy or childbirth or have a history of stress, loss or trauma are more likely to suffer perinatal depression, and socio-economic disadvantage has also been implicated (Muzik and Borofska, 2010). However, it is important to stress that perinatal mental health issues can affect any woman, at any time, as risk factors include a range of biological and psychological reasons as well as social and environmental factors.

Possible risk factors include:

• an unplanned pregnancy
• extensive stress, for example, due to financial or marital problems.
• In addition, risks include isolation and lack of emotional and physical support, relating to:
• being a lone parent
• relationship difficulties
• personal or close family history of depression or mental ill health
• unresolved issues relating to loss or childhood trauma
• recent adverse life experiences, for example, bereavement
• complications in pregnancy, with labour or baby's health
• stillbirth or death of a newborn
• problems with breastfeeding or other baby care difficulties
• having experienced maternal rejection or own mother's depression as a child.

It is important to note that these are not indicators or determining factors, but the presence of one or more of the above can increase a person's vulnerability and reduce their resilience to mental health issues during and after pregnancy.

PSYCHOSIS

About one in every 1,000 mothers may develop more serious mental health issues collectively known as 'puerperal' or 'postpartum psychosis'.

Symptoms include hallucinations and delusions, irrational thinking, hyperactivity and suicidal thoughts. The condition is rare, but early detection and treatment is crucial as the illness carries a greatly increased risk of child neglect, abuse and even death. As with perinatal depression, early detection and the right care will likely lead to a full recovery for most women.

One of the key issues is the importance of supporting the relationship between mother and child, which is why the NSPCC recommends that every new mother needing inpatient psychiatric care should be able to access a nationally accredited mother and baby unit.

IT'S NOT JUST MOTHERS

Perinatal depression is not limited to mothers; fathers and non-biological parents can experience it too and the impact on children can be as strong.

The Fatherhood Institute provides a review of studies in paternal perinatal depression (www.fatherhoodinstitute.org.uk) and points out the importance of the father/partner's role as a support person when a mother is experiencing depression. A GMTV survey in 2009 found that 70 per cent of new mothers turn to their partners for emotional support compared with 47 per cent in the 1960s.

Although a father's depression can impact negatively on a child, some studies suggest that the father can provide a 'buffer' for the mother's depression. The Fatherhood Institute recommends visiting www.postpartumdads.wordpress.com, which has some sound advice for dads supporting new mums, including the reminder to try not to take their partner's depression personally nor to expect to be able to 'fix' the problem alone.

Post-adoption depression is also now recognised. Given the importance of the attachment relationship for children who have experienced trauma and insecurity, it is vital adoptive parents receive knowledgeable support for some time after their children have been placed with them.

NOT ALONE

The common factor in all cases of perinatal mental ill-health would seem to be the intense feelings of failure and guilt at not being able to enjoy the often longed-for experience of parenthood or the arrival of a new child into the family.

This makes it even harder for a parent to seek help, particularly if they feel they run the risk of having their children removed from them. In all but the most serious cases, recovery often begins when the parent realises that they are not the only one ever to have experienced such debilitating feelings and that this is more about 'feeling sad' than 'being bad'.

Although professional help is important, often the best people to help are parents who have experienced perinatal mental health issues themselves, either locally, or through national organisations such as Association for Postnatal Illness.

Early detection and intervention can make all the difference to outcomes for parents and along with health visitors, midwives and GPs, early years practitioners are best placed to notice and provide the support and reassurance needed by parents struggling with depression. We are also part of the important 'back-up team' that can make all the difference to the child, by providing the strong, supportive secondary attachments needed when they are away from home, and by helping to strengthen the primary attachment bond between young children and their parents

MORE INFORMATION

• Maria Muzik, MD MS and Stefana Borovska, BS ‘Perinatal depression: implications for child mental health’. Mental Health in Family Medicine, Dec 2010; 7(4): 239–247, at: www.ncbi.nlm.nih.gov/pmc/articles/PMC3083253/
• Murray L, Fiori-Cowley A, Hooper R, Cooper P ‘The impact of postnatal depression and associated adversity on early mother-infant interactions and later infant outcome’. Child Dev. 1996; 67:2512–26
• Kochanska G, Kuczynski L, Radke-Yarrow M, Welsh JD ‘Resolutions of control episodes between well and affectively ill mothers and their young children. J Abnorm Child Psychol. 1987; 15:441–56
• Murray L, Hipwell A, Hooper R, Stein A, Cooper P ‘The cognitive development of 5-year-old children of postnatally depressed mothers’. J Child Psychol Psychiatry. 1996; 37:927–35
• Sharp D, Hay DF, Pawlby S, Schmücker G, Allen H, Kumar R ‘The impact of postnatal depression on boys’ intellectual development’. J Child Psychol Psychiatry. 1995; 36:1315–36.
• Prevention in Mind: All Babies Count - Spotlight on Perinatal Mental Health by Sally Hogg NSPCC, www.nspcc.org.uk/Inform/resourcesforprofessionals/underones/spotlight-mental-health_wdf96656.pdf
• Maternal Depression and Child Development : Canadian Pediatric Society www.ncbi.nlm.nih.gov/pmc/articles/PMC2724169/
• www.actionondepression.org/information/depression/types-of-depression/depression-during-and-after-pregnancy
• Post-Adoption Depression: information available online at www.nhs.uk/Livewell/adoption-and-fostering/Documents/Adoption%20UK%20Factsheet%2014%20-%20Post-adoption%20depression%20June%202013.pdf
• National Childbirth Trust, www.nct.org.uk
• Association for Postnatal Illness, www.apni.org
• www.postpartumdads.wordpress.com
• www.fatherhoodinstitute.org
• www.beyondtheblues.info/about.htm

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