Why perinatal depression is both normal and temporary

It doesn’t seem like a question you’d expect on your first visit to the maternity hospital: “How’s your mental health?” At that early stage, it’s more likely you’re preoccupied with your pregnancy than focusing on your own emotions. But it’s a vital question.

Depression, anxiety and stress in pregnancy can have negative effects on everything from obstetric outcomes in the mother to neurodevelopmental disadvantages in the infant. Research shows that one-third to a half of those who experience ante-natal depression, go on to suffer post-natal depression (PND).

It’s a distressing condition on its own – but it brings a whole new set of problems when an exhausted mother is trying to deal with the constant needs of a small baby. The importance of identifying emotional disorders in mothers-to-be is a key aim of the Government’s National Maternity Strategy, which will run for the next 10 years.

As part of the strategy, every woman in Ireland will soon be asked about their mental health at their initial booking appointment, which is normally around eight to 10 weeks into their pregnancy. Current mental health status and details of a person's past history and medication will go on their electronic patient health record.

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Standard practice

It’s already happening in Cork and Kerry, and by early next year, it will be standard practice in all the main maternity hospitals across the State. All 19 of the Republic’s maternity hospitals will have the system in place by 2020.

For many years, patients attending in Dublin's Rotunda Hospital have been asked about their mental state as the hospital team uses the "Edinburgh test" to establish levels of depression in mothers.

Prof John Sheehan has been the consultant psychiatrist there since 1995, responsible for the psychological care of 10,000 pregnant women a year. Under his guidance, maternity care is now focused on perinatal depression, instead of just post-natal. The perinatal period is the time just before and after birth.

“Everyone talks about PND, as if it doesn’t happen in pregnancy. But it is just as common in pregnancy, as after. If we can identify those women early, we can monitor them, and ensure they have the support they need,” he said.

The most recent study into perinatal depression in Ireland was carried out last year by a research team from Trinity College Dublin, who interviewed 5,000 women of all ages during all stages of pregnancy in five maternity hospitals.

It found that the rate of depression in pregnancy was 16 per cent, which is on par with international studies. This is about the same as the percentage level of PND.

A high score on the Edinburgh test is a red flag – of those who score highly, 75 per cent will become clinically depressed.

Prof Sheehan explained why depression in the post-natal period is of particular concern. “Depression in itself is very difficult. When you add to that the needs of a newborn baby – for example, the mother isn’t going to get two night’s sleep for six to 12 weeks, if they’re lucky – and we’ve got a problem. Being a mother is challenging. A woman who is depressed as well will have less energy, drive and motivation. She is just dragging herself around.

“When we check in on their mental health before we let them go home, we can identify women at risk and link in with the services, like the public health nurses and the GPs. If a woman scores high, that’s a big indicator and we raise the alert. It’s all about early detection, raising awareness.”

The team look out for a pervasively low mood over a period of two weeks. Post-natally, it manifests itself in either over-anxiety about the baby, or a loss of interest. Everything seems like a huge mountain to climb.

“Typically, she will feel really tired. Yet when the baby goes asleep, she can’t. She has anxious thoughts worries about the baby, or in some cases, intrusive thoughts about harming the baby. The likelihood is very remote, but it causes enormous distress.

“These are often mothers who are super, but sees themselves as inadequate. She has a total loss of confidence and puts herself down as being no good, beating herself up over things of no consequence.

“If this kind of thinking progresses, it moves onto thoughts of: this baby would be better off without me. A passive death wish of ‘I wish I was gone’ or ‘I want to run away from this, to just disappear’ . . . suicidal thoughts.”

Sleeplessness reduces clarity and can lead to panic attacks and anxious thoughts

He said these mothers are, in fact, usually very committed to their babies, who are well-cared for and not at all neglected.

Those with a previous episode of depression – and particularly those with bi-polar disorder (BPD) – are more at risk. BPD patients have a high risk of the more serious form of it, post-partum psychosis, a severe mental illness which comes with the horrific increased chance of the mother harming herself of her baby. Tragically, suicide is now recognised as a common cause of maternal deaths, with figures showing that five women in Ireland died by suicide while either pregnant or within 42 days of delivery.

Medication is essential in these cases, and preventing exhaustion is also a major factor, says Sheehan, who explains that sleeplessness reduces clarity and can lead to panic attacks and anxious thoughts. The Rotunda promotes active management of exhaustion – for example, giving a burned-out mother a sleeping pill and minding her baby for the night – which he believes prevents many cases of psychosis in at-risk mothers.

But for many women, post-natal depression is a side effect of the huge change that motherhood brings.

Sheehan says, “The psychological change with motherhood is profound. It changes a woman’s view of the world, of themselves. Her identity changes, her values change, there is an adjustment to being responsible for a little human. Literally, overnight, all they have known before is challenged.”

Modern society

He says modern society – which can expect women to be successful workers as well as wonderful mothers – can add to the pressure.

“PND is multi-factorial and complex. So, I don’t know if this has added to the prevalence rates. But I do think the modern world makes things more difficult: the supermum syndrome. Expectations are different. Women think having a baby is going to be a certain way and the reality of it is quite different. They see pictures in magazines and everyone is happy and laughing and they are thinking: why isn’t that me?

“And they find it hard to say: ‘Actually, I’m not enjoying this, I’m finding it difficult.’ Because the stigma is still there.”

It was something the singer Adele referred to when she spoke honestly of her experience of PND after having son Angelo. She said: “One day I said to a friend: ‘I f**king hate this. And she said: ‘I f**king hate this too.’ And it was done. It was lifted.”

However, Sheehan believes that the trauma of PND can ultimately be character-building.

“There is a role of depression in an evolutionary sense. It forces a woman to re-evaluate, make necessary changes in her life. Sometimes it can be a matter of thinking: ‘I can’t do this (full-time job), and mind a baby and be a good mother. I’m not going to try and be supermum.’ The pressure that women are under is intense.”

Peof Sheehan says often it can be a weight off a woman’s shoulders just to know that what she is experiencing is “normal” – a recognised, treatable medical condition – and that there is help, in the form of therapy as a first approach, and medication in case it is needed.

“There is hope, and it will get better. Medically, it is important to tell the woman – this is temporary.”