Postnatal depression: recognition and diagnosis

Maternal suicide remains the leading cause of death from a direct cause in the postnatal period, accounting for around 22% of maternal deaths reported in the UK between 2014 and 2016^[1]
. With around 10% of women experiencing a mental health problem postpartum or during pregnancy, it is important for all healthcare professionals to understand and recognise the risk factors for perinatal mental health problems and know where to refer patients^[1]
. 

Postnatal depression (PND) can begin at any time within one year after delivery. It is a relatively common condition that reportedly occurs in around 10–15% of women following childbirth and around 10% of new fathers, although it is thought that the true prevalence is higher than this^{[2],[3],[4],[5],[6]}
.

PND can also occur following miscarriage, stillbirth or in parents who adopt a child. In England, it is thought that particular ethnic groups (e.g. Asian women and women from a non-English speaking background) may be affected to a greater extent^[3],[7]
. This is possibly owing to cultural beliefs around depression, lack of integration and language barriers making it difficult to express difficulties in the postnatal period.

Signs and symptoms

Many women will be emotional or experience mild mood changes in the first week after having a baby (referred to as the ‘baby blues’), but these feelings should be self-limiting^[8]
.

In PND, these feelings last longer. Similar to other forms of depression, patients may experience a persistent low mood, lack of interest and enjoyment in usual activities, low self-esteem or lack of energy^[8]
. In addition, they may feel as though they are a bad parent, are unable to cope with their baby or may feel indifferent to their baby.

Pharmacists should be able to recognise red flag signs and refer these patients immediately (see Box).

Risk factors

Previous history of depression or PND is the greatest risk factor for a parent developing PND, but other risk factors include:

• Poor social support;
• Having more than one child;
• Financial instability;
• Having a poor relationship with their partner;
• Recent stressful life events (e.g. break up of a relationship, job loss, family bereavement);
• History of abuse (e.g. physical, sexual or emotional abuse, neglect)^{[9],[10],[11],[12]}
  .

Women also appear to be at an increased risk of developing depression by as much as threefold in the first four to six weeks after birth compared with the remaining postnatal period^[8],[9]
. This is potentially caused by the stressful experience of childbirth and adjustment to the new baby^[13]
.

Experiencing infant loss (e.g. miscarriage, stillbirth or neonatal death), birth trauma, such as an emergency caesarean section, or post-birth complications can also affect a patient’s mental health^{[12],[14],[15],[16],[17]}
.

In men, PND in their partner is a significant risk factor for them also developing PND, as is feeling excluded from the bond between the mother and baby, and a lack of a good male role model in a male parent’s life^[5],[6],[13]
.

Associated mental health issues

Other mental health conditions or mindsets may occur alongside PND or may present similarly:

Suicidal ideation — women known to social services with a history of domestic violence, a previous history of a psychiatric disorder, and those who have experienced the death of an infant are at particular risk of suicide
^[1],[3],[18]
. Evidence has shown that younger women may be at greater risk of PND and at an increased risk of suicide. Those with suicidal thoughts require prompt referral to specialist perinatal mental health services^{[1],[15],[18],[19]}
.

Psychiatric disorder relapse — where parents have a diagnosis of a previous psychiatric disorder, relapses of these conditions after birth are high, particularly for patients with bipolar disorder^{[20],[21],[22]}
. The risk of a first presentation of psychosis, although still low overall, is higher in the first four weeks after birth than at any other point in a woman’s life^[20],[23]
.

Postpartum psychosis — this is a severe illness that shows similarities to bipolar disorder (e.g. an elated or depressed mood that can cycle rapidly, irritability, hallucinations or delusions). It usually presents in the days or weeks after childbirth. Prompt treatment is essential; if left untreated it can put both the mother and baby at risk^{[20],[22],[23]}
.

Anxiety disorders — these conditions include generalised anxiety, panic disorders and obsessive-compulsive disorders are common postnatally. These can occur either alone or alongside depression. 

Anxiety is also particularly common in first-time parents. However, the majority of postnatal care is targeted at mothers and, since men can be more reticent to visit healthcare professionals, it can be difficult to reach fathers who are at risk^[13]
. Providing fathers with written information about anxiety and PND in men can be helpful (e.g. resources available on the PANDAS Foundation website).

It should be noted that hyperthyroidism or hypothyroidism can present alongside mood disorders, with episodes of thyrotoxicosis (excess thyroid hormone) presenting similarly to postpartum psychosiso are at risk^[24]
. Feelings of guilt and fear are also common, and patients may worry about what may happen if they tell someone how they are feeling (e.g. that their baby will be taken away).

Assessment and referral

Mothers should be routinely assessed for signs of PND when interacting with healthcare professionals and should be referred to their GP or mental health team if they demonstrate any red flags (see Box).

Pharmacists will frequently come into contact with parents who seek advice about over-the-counter medicines or advice on using prescribed medicine and, therefore, have an opportunity to help identify and signpost people at risk of PND^[10]
. Seeking help should be seen as a positive step that will enable parents to better care for themselves and their family. They should be reassured about any concerns they may have if they are reluctant to seek help. Parents should be treated sensitively, questioned in private and referred for further assessment as appropriate.

Women who have had a traumatic, complicated or difficult birth are often given a debrief with the midwife team, which can be helpful to go through any unanswered questions and help them understand what happened and why. Where parents express concerns about their obstetric care, pharmacists should suggest that they contact their maternity team to arrange a debrief.

Screening questions and tools

It is important that any screening questions or tools do not override clinical judgement.

There are a range of screening tools available; however, in most cases, the Whooley or Generalised Anxiety Disorder scale questions are sufficient to identify the majority of patients who may have or be at risk of PND or anxiety.

Generalised Anxiety Disorder scale

This tool involves asking two questions about anxiety symptoms:

1. Over the past two weeks, how often have you been bothered by feeling nervous, anxious or on edge?
2. Over the past two weeks, how often have you been bothered by not being able to stop or control worrying^[25]
   ?

This should be followed by asking:

• Do you find yourself avoiding places or activities and does this cause you problems?

If the patient says they have experienced these feelings, they should be referred for further clinical assessment.

Whooley questions or Patient Health Questionnaire-2

This is recommended by the National Institute for Health and Care Excellence, these tools can be used by any healthcare professional. If the questions below identify possible depressive symptoms, it is useful to ask if the patient would like any help with this and make a referral where possible:

1. During the past month, have you often been bothered by feeling down, depressed or hopeless?
2. During the past month, have you often been bothered by having little interest or pleasure in doing things^{[25],[26],[27]}
   ?

Patient Health Questionnaire

A follow on from the Patient Health Questionnaire-2 that is more commonly used to monitor severity of established depression, rather than diagnose it^[28],[29]
.

It is a patient questionnaire that asks nine questions based on the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) criteria for depression, whereby the patient rates how frequently they have experienced symptoms over the past two weeks. While not a specific scale for PND, it has been used effectively in this population
^[29].

Edinburgh Postnatal Depression Scale

This is ten-question scale asks the patient to rate how they feel about the questions asked, based on how frequently they have felt like that over the past week, scoring 0–3 for each question^[30]
. The patient can answer the questions themselves unless they require assistance. The maximum score is 30 and a score of 11 or more is indicative of PND. The scale has also been validated for use in men^[31]
.

The Bromley Postnatal Depression Scale

A specific questionnaire for PND that looks at diagnosing previous episodes of PND, as well as the current one^[32]
. It asks the patient to write down when the previous episodes started, when episodes were worse and how long they lasted. The scale also contains a ten-item questionnaire.

Effective tools not specific to postnatal depression

These include:

• The Mood Disorder Questionnaire: this tool looks at diagnosing bipolar disorder based on the DSM-5 criteria and clinical experience and, therefore, also asks questions about elated mood and symptoms of mania/hypomania^[33],[34]
  ;
• Hospital Anxiety and Depression Scale: this patient questionnaire looks at symptoms of both anxiety and depression by asking seven questions about each.

Summary

PND can negatively affect the developing relationship between the mother/father and child, and their relationship with the mother/father’s partner and family^[35]
. This may affect the child’s short-term and long-term cognitive and emotional development^[35],[36]
. Symptoms of PND can persist for months or years without treatment; therefore, it is important that healthcare professionals are able to recognise the signs and symptoms and refer patients where appropriate.