Robert Lindsey

PERINATAL MOOD DISORDERS: DEFINITIONS, TREATMENT AND IMPLICATIONS

by Robert Lindsey
Clinical Nurse Specialist, Rozelle Hospital

Source: Central Sydney Area Mental Health Winter Symposium - July 2004

pdf Print whole
2004 Proceedings

ABSTRACT

Perinatal mood disorders affect both men and women. Most parents are more vulnerable after the birth of their children than at any other time in their life cycle. In this paper I have undertaken a literature review of perinatal mood disorders with my primary aim being that it could be used as an aid in the commencement of an education program for Nursing and Allied Health staff.

In Western cultures, emphasis is placed on the notion that childbirth is a normal life event that expectant parents should just naturally know how to cope with and therefore, unrealistic expectations are often placed on parents resulting in increased anxiety for them. In fact, it is more unrealistic to expect that all men and women will be totally prepared and able to cope with becoming parents when they do find themselves expecting a child. Different people cope in different ways, and of course, some people will be able to cope better than others. The time it takes for parents to adapt their lives once a child arrives also will vary from couple to couple.

In this paper, I have looked at seven types of mood disorders relating to the postnatal period and the effects that these mood disorders have on family structure. I will also describe the treatments available to those suffering from these mood disorders and the current trends in mental health and public health care policies. I believe it is imperative that Nursing and Allied Health staff are educated on perinatal mood disorders so that they are able to recognize the various symptoms and then be able to commence the appropriate treatment as soon as possible. An education program on perinatal mood disorders is not only beneficial to Nursing and Allied Health staff, but also to those who may suffer from perinatal mood disorders but are unaware that they do.

Pregnancy and childbirth

Pregnancy and childbirth should be associated with feelings of happiness and fulfilment but for some parents it can lead to emotional turmoil that could last for a year or more. Unlike some societies where mothers are excluded from some aspects of work and supported by other women, in Western culture emphasis is placed on the normality of childbirth and the expectations that life continues as before, i.e. coping strategies are utilized and a return to work or household chores will be commenced shortly after giving birth (Bewley, 1999).

Pregnancy and Childbirth involve changes that may influence emotional well-being. The NSW Health Department’s Resources for Assessment and Management of Postnatal Depression (2001) identifies the following key factors:

It is unique for each person and therefore each person needs to explore its meaning and endeavour to make sense of it. This takes time and often partners will be in conflict and their experiences and perceptions vary. Individual changes, reworking of new skills and knowledge all need to be undertaken.
Although it has different meanings for both men and women both genders are impacted by the change.
Each new parent now has to integrate multiple and diverse roles.
The birth may be one of a series of significant and often unanticipated change, e.g. unemployment, grandparents become increasingly unwell and often a need to move to new homes, states or countries.
The reality of the experience of giving birth and caring for a baby is usually very different from what is portrayed.
Both men and women are more psychologically vulnerable after birth than at any other time in their life cycle (Health 2001).

In what way does the birth of a child affect parents? For the mother they can feel elated, delighted, tender and protective of their baby. At the same time they may feel angry, frightened, guilty and not in control of their lives. Expectations are sometimes unrealistic and might include:

Motherhood is always happy and will fulfil your desires.
A baby will improve your marriage.
Mothers instinctively know how to breastfeed, comfort, and settle a baby.
Mothers should be constantly available; always putting the baby’s needs first and never have time off.
Only bad mums scream whilst shopping.
Good mothers don’t have negative feelings about the children.
Every other mum is coping.

Perinatal mood disorders can often be a general name for various emotions experienced by both males and females, before and after the birth of a child. Although in obstetrics, perinatal refers to the period up to the first post partum month, perinatal mental health encompasses the emotional well being of parents and infants from conception to the second year, and has emerged as being of growing significance in the last decade (Austin 2003).

ANTENATAL DEPRESSION

Depression during the antenatal period is often not identified until late in the pregnancy, if at all. This has broad implications not only affecting self esteem, relationships and ability to work but it may also impair a woman’s capacity to make healthy decisions concerning her lifestyle and the subsequent consequences on the foetus especially relating to her diet, smoking, drugs and alcohol. Austin (2003) suggests that up to 40% of post natal depression actually commences in the antenatal period.

Risk factors

Personal history of depression (including previous history of postnatal depression)
Family history of depression
Ambivalence about the pregnancy.
Unprepared for pregnancy.

Symptoms

These are very similar to other types of depression and can include:

Feeling low all the time
Having poor self esteem
Lacking confidence
Feeling numb, empty and despondent.
Blaming yourself for the things that seem wrong in your life.
Feeling guilty
Finding it difficult to concentrate and make decisions.
Being unusually irritable and impatient.
Sleep problems
Eating problems
No longer enjoying normal pleasurable activities
Substance abuse
Self harm
Suicidal thoughts
Reduced energy
Social isolation
Pessimistic about the future PaNDa ( 2001)

Risks of antenatal depression to the foetus

Maternal suicidal behaviour
Associated drug and alcohol abuse
Poor self care
Inadequate nutrition.
Poor antenatal clinic attendance with subsequent lack of foetal monitoring (Austin 2003)

Mauthner (1997) found that some facilitators of ante natal classes did not cover postnatal depression or how the emotions of the mother would change after birth for fear that this would lead to depression. In fact the author found that the majority of mothers wanted discussions on postnatal depression, its prevalence, symptoms, support organizations and empowerment.

Mauthner’s (1997) findings were found to have relevance in Australia. In 1994 the Women’s Consultative Committee found that in excess of 89% of women thought they and their families would be greatly assisted by discussions on postnatal depression in the antenatal period and over 93% believed that the community would benefit from these discussions. The Women’s Consultative Committee confirmed the belief that some health care professionals were concerned, parents were more likely to experience postnatal depression if it was discussed with parents. (Women’s Consultative Committee 1994).

Treatment

Emotional support from family, friends and support organizations.
Medications
Assistance with household chores and child care.
Psychological treatment ( GP, psychologist or counsellor)
Medical – Psychiatrist.
Hospitalisation preferably in Mother – Baby unit.
Support the Partner and children

POSTNATAL MOOD DISORDERS

There are seven mood disorders relating to the postnatal period. The three most common disorders are baby blues, postnatal depression and postnatal psychosis, and these will be discussed later. The remaining mood disorders are:

Dual diagnosis which occurs when the postnatal depression is combined with other conditions and most of the pre existing conditions will be exacerbated by the depression e.g. personality disorder and depression
Post Traumatic Stress Disorder (PTSD), which can occur after a traumatic birth and there is a direct threat or the mother experiences a perceived threat to the baby, mother or extreme helplessness. It can also occur where there was an easy birth but the mother experiences psychological trauma due to previous sexual abuse.
Mixed anxiety and depression in which the anxiety is more evident than the depression, e.g. the mother is too anxious to be home alone with her baby and her decision making abilities is poor.
Personality Disorder can occur when a crisis is experienced in motherhood and their past personal and family history have usually created difficulties in the areas of intimacy and personal responsibilities. (Health 2001)

1. Postnatal baby blues

Postnatal baby blues affects up to 80% of women. Symptoms normally occur in the first two weeks and peak around days three to five. This time frame coincides with the onset of lactation. What then causes the blues? There are two hypotheses; firstly hormonal withdrawal can influence the change in mood, there is a high level of estrogen when giving birth but this quickly drops soon after delivery. Over the next few days there is a slow drop in progesterone, which then affects the neurotransmitters in the brain causing mood disturbances. Secondly the blues stem from low oxytocin levels, which regulate the mother – infant attachment behaviour (Miller 2002).

Symptoms

Physical –

Lack of sleep
No energy
Food cravings
Loss of appetite
Feeling tired after sleeping

Mental state –

Anxiety and excessive worry
Confusion
Excessive concern over physical changes
Confusion
Nervousness
Feeling that this is not me
Lack of confidence
Sadness
Overwhelmed

Behavioural reactions –

Crying more than usual
Hyperactivity
Excitability
Over sensitivity especially towards feelings
Irritable
Lack of feeling for baby (Kruckman & Smith undated)

Treatment

Medications are usually not indicated for treatment of baby blues. Support and reassurance, monitoring for signs of depression and advice on where to obtain further assistance is crucial.

2. Postnatal depression

Postnatal depression can occur at anytime within the first twelve months and parents may remain depressed for six to fifteen months. NSW Health (2001) outlines the following symptoms of postnatal depression:

Feelings of inadequacy, inability to cope, hopelessness, helplessness, exhaustion, anxiety, panic including usual signs of panic disorders – headaches, numbness, tingling in limbs, chest pains, heart palpitations, hyperventilating, phobias, fear of being alone, social contact, going out, fear of the baby, guilt, sadness, tearfulness for no reason, shame, unworthiness.
Disturbance of mood – anxious, depressed, irritability, angry, sleep disturbances, eating disorders, gastrointestinal dysfunction, menstrual disorders, thought disorders and obsessional ideas.
Loss of energy, concentration, libido.
Poor self image, self care.
Self harm, suicidal and homicidal ideation

Causes

Firstly there may be biological factors that contribute to postnatal depression including normal physical changes of pregnancy and childbirth, hormonal changes of pregnancy and childbirth, heredity, previous episodes of postnatal reactions, complications of pregnancy and childbirth, breastfeeding and weaning, premenstrual syndrome or other menstrual problems and thyroid imbalance. Depression and anxiety can occur in women with postnatal thyroiditis.

Secondly there may be psychological factors that contribute to postnatal depression including normal physiological changes accompanying childbirth, expectations about motherhood, lifestyle changes including loss of freedom and increased workload, previous psychological problems, childhood experiences, unresolved losses, recent stressful life events, personal resources for self coping (Dunnewold & Sanford, 1994).

Risk factors

Miller (2002) observes that cultures with a low prevalence of postnatal depression usually have strong social support for new mothers, especially in the area of childcare and parent-craft. However in developing countries where the environment is more hostile, we see a high risk in the child’s first year. Rahman, Harrington and Bunn (2002) discuss the effects of the link between maternal depression and the health of the infant. In numerous developing countries, we see overcrowding, poor sanitation and lack of food. Whereas a five year old, or even a two year old can seek food, the young infant is completely dependant on their carer and any deficiencies in this care will lead to a decline in the child’s physical well being.

Poor psychosocial functioning of mothers can lead to malnourished children. These mothers often had chronically disruptive lives, unsupportive partners and fewer social contacts. Often these depressed parents had children with more physical health problems such as allergies, asthma, colds, coughs, headaches and indigestion. Due to the inadequacy of antenatal care in developing countries, postnatal depression could increase the incidences of low birth weight, infant morbidity and mortality and risk taking lifestyles such as smoking and unhealthy eating poses further risk to the baby.

Although most people believe that postnatal depression relates just to parents of new born babies, we must also realise that it does occur after miscarriage and stillbirth and for women with no prior depression history, the level of risk is comparable with women delivering a live newborn. The risk of major depression after miscarriage is especially high for childless women and occurs also in women who were unhappy about the pregnancy. For both miscarriage and stillbirth, elevated risk of depression is highest in the first six months after the loss of pregnancy. Women who show no signs of grief during the first two weeks and for those whose grief does not abate six to nine months after loss are at an especially high risk for depression (Miller 2002). Other risk factors cited include:

No partner or support person on discharge.
Multiple births
Sick baby.
Abnormal appearance of the baby.
“Wrong gender”
Temperamentally challenging baby or one with reflux.
Lack of parenting skills.
Unrealistic expectations regarding parenting.
Negative parenting experiences with other children. (Kowalenko, Barnett, Fowler & Mathey, 2000).

Diagnosis

Postnatal depression could be diagnosed under two disorders, according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders DSM IV (American Psychiatric Society 1994). Firstly a diagnosis of major depression requires the presence for at least two weeks of the following:

Depressed mood or loss of pleasure, and represents a change from previous level of functioning, and four additional symptoms from: change in appetite or weight; sleep disturbance; increase or decrease in psychomotor activity; decreased energy; feelings of worthlessness or guilt; difficulty thinking concentrating or making decisions; recurrent thoughts of death, suicidal plans or attempts.
The symptoms must be newly present or clearly worsened compared to the person’s pre illness status and must be present for most of the day, nearly every day for two consecutive weeks. Distress and impairment in functioning must accompany symptoms.
With a diagnosis of major depression with postnatal onset, the episodes of depression usually begins within four weeks of giving birth, which corresponds to the hormonal changes occurring within the postpartum period.
The Diagnostic and Statistical Manual of Mental Disorders 4th edition Text Revision (American Psychiatric Society 2000) whilst not distinguishing postnatal depression from major depressive disorder, does include the modifier” onset within four weeks after childbirth”

The second diagnosis that could be used is adjustment disorder. This is used for presentations that are a response to a specific stressor and do not meet the criteria for other specific disorders. The stressor would be childbirth or other social adversity during the perinatal period. To establish the diagnosis of adjustment disorder, the following criteria need to be present:

Development of clinically significant emotional or behavioural symptoms in response to specific
stressors occurring within the first three months of the onset of the stressor.
Secondly – distress in excess of what might be expected and there should be impairment in postnatal social functioning; predominant features are those of mixed anxiety and depressed mood. (American Psychiatric Society 1994)

It is often difficult to make a diagnosis of postnatal depression. Parents may present well disguising their difficulties and often are hesitant to reveal their own concerns about their health, however, evidence has shown that early intervention reduces the impact of postnatal depression and helps to reduce the detrimental effects that this imposes on the family (WSAHS 1995). Also post natal depression may not occur in each pregnancy, sometimes it may not be evident on the first pregnancy but occur on the second or third.

According to the World Health Organization (1997) 40 – 50% of childbearing women with bipolar disorder will experience one or more episodes of postnatal depression. Women who become ill during the postnatal period are also likely to experience recurrent episodes with subsequent pregnancies. Relapse may occur as a result of hormonal changes in the postnatal period, stress of pregnancy and parenting or absence of usual psychotropic medications during pregnancy, which is essential as some of these medications, can cause deformities in the first trimester (World Health Organization 1997).

Models

Nicholson (1998) discusses two models of postnatal depression. Firstly, the medical model where emphasis is on individual characteristics that predispose women to become depressed after childbirth and secondly, the social science model which stresses external psychological factors which act as stressors. Jebali (1993) states that postnatal depression is often seen in the Medical Model and is perceived to be an illness and dealt with medications or counselling.

Effects on males

There appears to be little research on postnatal depression for males. However, it is well known that fathers can suffer from postnatal depression, especially if their wives or partners are depressed and males can be of a higher risk for postnatal depression if they are in a stepfamily relationship. Postnatal depression can cause stress in relationships. PaNDa (1998) accessed on the internet on the 22nd October 2001, states that most women with postnatal depression report feeling very irritable towards their husbands and don’t understand why. Postnatal depression is one of the major causes of marital stress and divorce, yet one of the most reluctant to talk about. (PaNDa, 1988)

In fact partners should be included in antenatal education. Holden (1991) found that providing information to fathers on practical and emotional support to their partners during and after pregnancy will increase the father’s participation, decrease the likelihood of postnatal depression and prevent deterioration in the relationship. For the father they experience the pregnancy, labour, delivery and parenting in a different way to mothers and differences in their daily experiences, mismatched expectations of each other can lead to build up of resentment in their relationship. Some men, although looking forward to parenting, do not wish to be involved in the pregnancy or birth, whereas others are fully involved from conception.

Unlike women, men do not usually discuss personal issues with friends or ask new fathers how they coped, so there is little opportunity for information or support. Some beliefs, which are unrealistic, can affect the style of parenting for men and these include:

Fathers won’t bond with their children if they were not at the birth.
A baby won’t change a man’s business, social or sexual interests.
Fathers can’t give proper emotional support to their children.
Men should be family providers and protectors.
Looking after house and children is women’s work.
Men shouldn’t have to change nappies after working all day.
Fathers don’t need to be involved in daily household events. (NHMRC 2000)

Men are often expected to be strong and continue to provide economic support for the family yet up to 14% of men show significant features of depression six months after the birth of their child. Ten percent of males will experience depression in their life and most of these episodes will last between four to twelve months. Often dad’s feel marginalized, exhausted and depressed and little help is available for them from health professionals.

New fathers have reported that they experience less sleep, freedom, attention, and sexual activity, limited support from colleagues and increased work, performance anxiety and responsibility. If men become stressed at home, it can affect their work negatively. The two major stresses for men are:

Role overload (feeling that their responsibilities in one area are making them less effective in another.
Arguments with their partners and children.
Children with actively involved dads are;
More ambitious
Less susceptible to peer pressure
More competent
Self protective and self reliant
More confident with the respective female/male identities.
(St John of God – Raphael Centre, Factsheets on Fathers, accessed on the internet 24/2/04)

According to a report published in the Sydney Morning Herald dated October 23, 2003, dads are almost as likely as women to experience obsessional thoughts after the birth. Among their concerns are the death of the child from SIDS, suffocation, being hurt in an accident and the intentional harming of the child. The report outlines the results of a survey undertaken at the Mayo Clinic in Minnesota USA in which parents were asked to report unwanted thoughts about their newborn child, including SIDS, intentional harming, unacceptable sexual thoughts and risk of contamination from other people or objects. Sixty nine per cent of mothers and fifty eight per cent of fathers responded stating that they had these thoughts.

In a further study conducted by Flinders University and reported in this article, many men were ill prepared for the impact that raising a child would have on their sex lives. The decline in satisfaction and frequency of intercourse in the year after their birth can cause significant distress among men. Some of the subsequent traits included increased use of alcohol, withdrawing socially and becoming detached from the child. (Wyld 2003)

Effects on the child

If undiagnosed, postnatal depression can lead to self abuse, child abuse and suicide. One research study undertaken in the United Kingdom found that the majority of new mothers with postnatal depression were not referred immediately to the Mental Health Team but were referred eight months postnatal (Allen 1993). Dalton (1996) discusses infanticidal fears that women with postnatal depression experience. She established that it was not uncommon for mothers not to confide their infanticidal and suicidal ideations due to many factors, not least the community shock value and possibility of the baby being removed.

Mothers may have signs of obsessive compulsive disorder during the postpartum period, which gives the idea that they wish to harm the infant. Some of these signs include avoiding the baby for fear of succumbing to the obsessions thus giving an impression of being indifferent and uncaring (Chandra, Venkatasubramanian & Thomas, 2002). According to Oates (1997), statistics reveal that although 25% of all homicides in England and Wales involve children, 60% of all child homicides involve a child under the age of 5 years and what is even more disturbing is that 22% of all child deaths under the age of one year occur on the first day of life. Almost all child homicides in the first twenty four hours of a baby’s life are attributable to the mother. The father on the other hand is more likely to injure older babies and children and cause more serious injuries and death than women.

Beardslee, Versage and Gladstone (1998) report that children of affectively ill parents are at increased risk of general difficulties in functioning, more concerns about guilt, and attachment difficulties. The authors also report that children whose parent’s affective illness began before age 20 appear to be at greater risk for experiencing an episode of major depressive disorder than children whose parents became affectively ill later in life. The authors also cite the impact that postnatal depression has on the ability to parent effectively, evidenced by depressed mothers showing less sensitivity and responsiveness in their parenting skills, less positive behaviour towards their children who in turn exhibit less positive behaviour in interactions towards their mothers.

This could lead to the ‘parentified child’. Parentification could be described as the expectation that one or more children will fulfil the parental role in the family system. At risk children usually experience at least four of the following before age two:

Perinatal stress.
Mother with little formal education.
Low socioeconomic status.
Family troubled by marital discord.
Divorce.
Desertion.
Alcoholism.
Mental illness.

Often these children will have serious learning or behavioural difficulties by age ten years and forensic, mental health or teenage pregnancy by age eighteen years. An example of a parentified child was Gloria Steinem. Steinem was a famous American feminist, founder and editor of MS magazine who as a little girl cared for her mentally ill mother in a rat infested house on the edge of a freeway in America. Gloria led an isolated childhood as a result of her mother’s illness and absent father. She was shy and lived in an isolated world. Her sister who was nine years older lived elsewhere and a male sibling was stillborn. Her mother was bedridden with depression and had to be fed and cared for by Gloria who at a young age was concerned about her weight, believing she was too fat. She detached herself emotionally from her family and life by immersing herself in a world of books and consoling herself that she had been a wanted child and that her parents were doing the best they could.

Although as an adult she founded MS magazine which provided her with a home, family and occupation, she remained insecure and her relationships with men were always problematic. She always remained an outsider and did not want children, believing that motherhood meant mental illness and did not want to be responsible for anyone else and end up like her mother. It took Gloria fifty years to create a proper home for herself after caring for her mother. Clearly it would appear that Gloria had strong traits of borderline personality disorder – the need for care, wanting to be loved and valued, fear of expressing anger as it may result in rejection (Barnett & Parker 1998).

There is a school of thought that believes postnatal depression early in the postnatal period is more damaging than if it occurs later. Sands (undated, accessed on the internet 7/5/01) states that the brain undergoes rapid development from birth to six months and the infant is highly dependant on stimulation, touch, talk, smell, play, mood, being soothed when unhappy and fed when hungry. It is often the stimulation that is the first to go when the mother becomes depressed and this causes problems later and for some, intellectual damage can occur.

Murray and Cooper (1997) reported on various surveys which revealed an association between postnatal depression and adverse cognitive and emotional infant development. For example, they found that at age 19 months, infants of postnatally depressed women had lower rates of interactive behaviour, less concentration, poor sleep, eating problems, more negative responses and often separation difficulties. Strongly linked with maternal depression is attachment insecurity. What is attachment? According to the Western Sydney Area Health Service Resource Folder for Generalist Nurses (1999), attachment is the emotion in the relationship between the child and the caregiver. It is seen in the child’s behaviour, i.e. he stays close to the person whom he feels comfortable with. Attachment provides the child with the ability to explore the world, develop confidence, form relationships and ask for help when needed. Attachment is not bonding and this will be explained later in the paper.

The founder of attachment theory was John Bowlby, a British psychoanalyst whose theory of attachment related to both normal and abnormal child development. Bowlby noticed that children who were in institutions for a long time reacted in three ways. Firstly by protesting against the separation, cries out and searches for the lost person. Secondly despair, where the child appears hopeless about the caregiver ever returning. Thirdly, detachment in which the child emotionally detaches himself from the caregiver. The longer the separation, the more upset and detached the child became and it was this theory that had a profound effect on child care and developmental psychology (WSAHS 1999).

Bonding is the process of forming an attachment, involving a set of behaviours that will hopefully lead to an emotional connection i.e. attachment. The behaviours that we undertake in bonding include – holding, rocking, singing, feeding, gazing, kissing and any other nurturing behaviour. Crucial to bonding includes time together, face to face interactions, eye contact, physical proximity, touch and sensory experiences such as smell, sound and taste. These behaviours cause specific neurochemical activities in the brain, which are responsible for attachment. Thus, it can be said that bonding is a connection between two or more people.

Why then, is bonding and attachment so important in early childhood and how does this affect the family? During the first three years of an infant’s life, the human brain develops to 90% of the adult size and puts in place the majority of systems that will be responsible for all future emotional, behavioural, social, physiological functioning for the rest of the infant’s life. The critical period, relating to the capacity of the infant and care giver to give a positive interactive relationship is within the first year. So what happens if this period is missed? An example of this could be postnatal depression of the parents, where if depressed they would most likely be unable to provide this stimulation. The impact could be devastating for the child without any of these bonding behaviours the capacity to form any meaningful relationships could be lost. In most cases, the severity of problems is related to how early in life, how prolonged and how severe the emotional neglect was (Perry 2001).

In research undertaken by Hiscock and Wake (2001), the relationship between postnatal depression and sleep disturbances in infants aged six to twelve months of age was examined. Almost fifty per cent of mothers reported infant sleep problems including waking frequently, and for longer periods, sleeping in their parent’s bed and requiring an adult to settle them. These sleep problems were associated with a high postnatal depression score. Although the above are learnt behaviours, some reasons could include: depressed mothers sleep more poorly and are more aware of their infants waking than non depressed women who sleep through the night; and infants of depressed women are more likely to be more difficult to settle and therefore disrupt their mother’s sleep resulting in maternal sleep deprivation and symptoms of depression.

As a result of parental depression, children can be at risk of developing various mental health problems, including depression, conduct disorders, anxiety and first onset psychosis (Health 2001). A serious mental health problem in later teenage years is suicide. Risk factors for suicide in young people include:

Family background of socially disadvantaged status.
Parental loss through separation and divorce.
Impaired parent – child relationship.
Parents with a mental disorder including mood disorder.
Experience a greater number of life stressors.

It thus becomes very evident that a child whose parent is suffering from postnatal depression is a prime target for suicide risk when one considers the above risk factors. As shown in this paper, parents with postnatal depression are often socially disadvantaged, have a mood disorder, often experience many life stressors and have an impaired relationship with the child. Suicides in teenagers are ever increasing and early intervention for parents and children may help to reduce this figure (Commonwealth Department of Health and Aged Care, 2000).

3. Postnatal psychosis

The history of postnatal psychosis dates back to 700BC when Hippocrates described it in great detail, as did Galen, Celsus and other authors. During the 19th century Marce published his study on the negative emotional reactions with childbirth in his book “Traits de la Folie des Femmes Enceinte”. However in the later 19th century and mid twentieth century, the belief was that afflicted women were suffering from manic depression, dementia praecox, toxic confusion or neurosis and as a result many psychiatrists believed that postnatal psychosis did not exist as a separate clinical entity.

Diagnosis

The Diagnostic and Statistical Manual DSMII (1968) listed it as a separate entity, “294.4 Psychosis with childbirth”; however the DSMIII (1980), eliminated this stating there is no compelling evidence that postnatal psychosis is a distinct entity and this continued with DSMIV and the DSM IV TR which views it as an affective disorder occurring in the postnatal period (Kruckman & Smith, undated, accessed on the Internet 27/7/02). Postnatal psychosis should be regarded as a psychiatric emergency and hospitalisation planned. Often the mother is insightless and may refuse to seek help. There are several psychological instruments available including Beck Depression Inventory, Postpartum Depression Screening Scale and Edinburgh Post Natal Depression Scale.

Postnatal psychosis occurs in one to two per thousand of postnatal women. It has an onset of two or three weeks postpartum and can occur up to three months. It is considered a form of affective psychosis or manic depression and symptoms can include confusion, extreme mood disorders, delusions and hallucinations (WSAHS 1995). The mother’s thoughts and behaviours may appear illogical or chaotic. Her moods vary from extreme agitation to elation. She may display disturbed sleep and psychomotor disturbances ranging from hyperactivity and agitation to severe retardation. Speech may be rapid, incoherent or mute (Baker, Mancuso, Montenegro & Lyons 2002).

Mothers who have postnatal psychosis may appear well but become profoundly depressed or psychotic. During these psychotic episodes, those who harbour thoughts of infanticide are more likely to act upon these thoughts. She may also experience visual or auditory hallucinations advising her to harm her baby or that the child is evil and possessed (Miller 2002). No one is sure what causes postnatal psychosis however some related factors include:

Biological changes involved in childbirth.
Previous mental illness.
Environmental stress factors. (McAllister, undated, accessed on the Internet 28th August 2002)

Treatment

If postnatal depression is treated with medications, often side effects are a great problem and a false coping strategy occurs. Poor self esteem and self blame is often reinforced and the actual cause of the problem is never discovered. Motherhood may create feelings of anxiety or guilt and in Australia it is often seen to be culturally unacceptable to admit to feeling unhappy as a new mum (or indeed as a dad). This then convinces her that she is a bad person and possibly going mad. It is therefore necessary that care is taken to address the sense of hopelessness, emptiness, low self esteem and destructive behaviour by managing feelings, parenting skills and developing social support (Creedy & Shochet, 1996). According to the World Health Organization (1997) indications for antidepressant medications include:

Severe depression
Psychomotor disturbances
Concomitant panic disorder
The individual is not psychologically minded and therefore may not benefit from counselling alone
There has been no response from non pharmacological treatment.

However, it is very important that pharmacotherapy always be accompanied by counselling, as the psychosocial issues must also be addressed. Wisner, Parry and Piontek (2002) suggest that the dosage of antidepressants should be halved when first prescribed. All antidepressants are excreted in breast milk so the lowest effective dose in a lactating woman should be prescribed, coupled with careful observation of the infant’s behaviour. The authors also report that in a survey, colic was reported in some breastfed infants in which mothers were taking Fluoxetine (Prozac), and that a decreased weight was noticed. Cognitive Behaviour Therapy is often used to replace dysfunctional thoughts with more appropriate realistic thoughts. This type of therapy is useful for personality disorders, history of depression, and treatment resistive patients(World Health Organization, 1997).

Electro convulsive therapy especially during pregnancy causes dilemmas amongst clinicians. The decision to treat must take into account the risks associated with alternative treatments, risk to the mother and fetus by withholding ECT and any complications of the pregnancy which may increase the risks of ECT and anaesthetics. There is little data available regarding the use of ECT during the first trimester but according to Royal Australian and New Zealand College of Psychiatrists, ECT can be used during the second and third trimesters. Bowman (2003) states that ECT may be possible in the first trimester, where alternative psychotropic medications such as lithium, carbamazepine and sodium valproate may pose risks to the foetus.

Other strategies that can be utilised include prenatal education on depression, parenting, relaxation, coping strategies and infant massage. Community support networks including Tresillian, Karitane, Mental Health Nurses offer groups or provide referrals to professional organizations expert in this field.

CONCLUSION

In recent years various public health policies have been formulated. The second National Mental Health Plan (1998–2003) has focused on the promotion, prevention and early intervention for mental health particularly in the perinatal period. In NSW the Integrated Perinatal Care (IPC) promotes the integration of mental health service provision with the primary health care sector, with key focus on the adoption of prevention and early intervention strategies. Families First are targeting vulnerable families from conception to eight years by home visiting. Over the past two years antenatal psychosocial assessment and early intervention programmes for at-risk women and families have been trialled at the Royal Hospital for Women and also at Liverpool Hospital.

The NSW Department of Health has now developed antenatal psychosocial questionnaires and in 2002, the Beyond Blue Depression initiative began to evaluate the benefits of antenatal and postnatal screening for depression using the Edinburgh Depression Scale. The NSW institute of Psychiatry offers Diploma and Masters programmes in infant mental health and the institute includes a module on perinatal psychiatry as part of its training for psychiatric registrars.

We can see from the above paper, that perinatal mood disorders have an immense impact on the mother, infant, partner, children and to the whole community. It is imperative that all nurses continue to update their mental health knowledge to assess and implement practices in order to provide wholistic care and best practice

REFERENCES

Allen S. (1993) Early detection of postnatal depression. Nursing Standard, 8: 25–38.

American Psychiatric Association (1994) Diagnosis and Statistical Manual of Mental Disorders DSMIV. American Psychiatric Association, Washington.

American Psychiatric Association (2000) Diagnosis and Statistical Manual of Mental Disorders DSMIV TR. American Psychiatric Association, Washington.

Austin MP. (2003) Psychosocial assessment and management of depression and anxiety in pregnancy. Australian Family Physician, 32: 1-2.

Barnett B & Parker G. (1998) The parentified child, early competence or childhood deprivation. Child Psychology and Psychiatry Review, 3:

Beardslee W, Versage E & Gladstone T. (1998) Children of affectively ill parents: a review of the past ten years. Child and Adolescent Psychiatry, 37: 1134-1141.

Bewley C. (1999) Postnatal depression. Nursing Standard, 13: 49–56.

Bowman B. (2003) Electroconvulsive Therapy Manual. Central Sydney Area Mental Health Service, Rozelle.

Chandra P, Venkatasubramanian G & Thomas T. (2002) Infanticidal ideas and infanticidal behaviour in Indian women with severe postpartum psychiatric disorders. Journal of Nervous and Mental Disorders, 190: 457–461.

Commonwealth Department of Health and Aged Care (2000) Life, a framework for prevention of suicide and self harm in Australia. Australian Government Publishing Service, Canberra ACT.

Creedy D & Shochet I. (1996) Caring for women suffering from depression in the postnatal period. Australian and New Zealand Journal of Mental Health Nursing, 5: 13–19.

Dalton K. (1996) Depression after childbirth. Oxford United Press, Oxford UK.

Dunnewold A & Sanford D. (1994) Postpartum survival guide. New Harbinger Publications, Oakland.

Hiscock H & Wake M. (2001) Infant sleep problems and postnatal depression – a community based study. Paediatrics, 107: 1317–1322.

Holden (1991) Postnatal depression, its nature, effects and identification using the Edinburgh Postnatal depression scale. Birth, 18: 211–223.

Jebali C. (1993) A feminist perspective on postnatal depression. Health Visitor, 66: 59–60.

Kowalenko N, Barnett B, Fowler C & Matthey S. (2000) The perinatal period – Early interventions for mental health. Clinical approaches to early intervention in Child & Adolescent Mental Health. The Australian Early Intervention Network for Mental Health in Young People, Adelaide.

Kruckman l & Smith S. undated. An introduction to postpartum illness. Accessed on the internet 27th July 2002 http://www.postpartum.net/

Mauthner NS. (1997) Postnatal depression, how can midwives help? Midwifery, 13: 163–171.

Miller J. (2002) Postpartum depression. JAMA, 287: 762–765.

Murray L & Cooper PJ. (1997) Effects of postnatal depression on infant development. Archives of Disease in Childhood, 77: 99–101.

National Health and Medical Research Council (2000) Postnatal depression – a systematic review of publicised Literature to 1999. NHMRC, Canberra.

NSW Department of Health (1994) Postnatal depression services review. NSW Health: Sydney.

NSW Department of Health (2001) Resources for assessment and management of postnatal depression. NSW Health: Sydney.

NSW Department of Health (2001) Introductory kit - postnatal depression. NSW Health: Sydney.

Nicholson P. (1998) Postnatal depression. Routledge: London.

Oates M. (1997) Patients as parents – the risk to children. The British Journal of Psychiatry, 170 Supp 32: 2- 27.

PaNDa (1998) Postnatal depression. Post and Ante Natal Depression Association, Richmond.

PaNDa (2001) Information package. Post and Ante Natal Depression Association, Richmond.

Perry B. ( 2001) Bonding and attachment in maltreated children, consequences of emotional neglect in childhood. 1 accessed on the internet 9th March 2002.

Rahman A, Harrington R, & Bunn J. (2002) Can maternal depression increase infant risk of illness and growth in developing countries. Child Health Care and Development, 28: 51–56.

Royal Australian and New Zealand College of Psychiatrists (undated), College statement, new public information statement, electroconvulsive therapy explained. Accessed on the internet 9th April 2003, www.ranzcp.org

Sands I. undated Post natal depression information for men, accessed on the internet 4/5/01

St John of God, Raphael Centre (undated) Fact sheets on fathers, accessed on the internet 24/2/04 www.sjog.com.au

Western Sydney Area Health Service (1995) Post natal depression. Early Childhood Procedures Manual. WSAHS: Parramatta.

Wisner K, Parry B, & Piontek C. (2002) Postpartum depression. The New England Journal of Medicine, 347: 194–199.

Women’s Consultative Committee (1994) If motherhood is so bliss, why do I feel so awful? NSW Ministry for the Status and Advancement of Women: Wolloomoolloo.

World Health Organization (1997) Management of mental disorders Vol 11, 2nd ed. Collaborating Centre for Mental Health and Substance Abuse: Darlinghurst.

Wyld B. (2003) Dark thoughts common in post natal dads, in The Sydney Morning Herald. Accessed on the internet 24/2/04 www.smh.com.au

Sydney South West Area Mental Health Service