Trapped in the shadows
Frine and Joe Madigan, Co Kilkenny had a much longed-for son, Connor. But Catharine suffered severe post-natal depression and was admitted to St Patrick's Hospital, Dublin. She left the hospital sometime on May 14th and was captured on video walking away. She has not been seen since.
Sometimes a joyful event can lead to tragedy. Dr Abbie Lane, consultant psychiatrist at St John of God Hospital, says that while having a baby is ultimately fulfilling for most women, the early weeks can be very difficult: "There is the popular image of motherhood, the picture of the perfect baby smiling up at you, though most of us know it's not like that.
"In reality, being a new mother involves a huge amount of work in the physical care of the baby. All this has to be done along with the other work you do. Motherhood means a significant change in lifestyle; you have a new person there to be totally cared for. You can become very over-tired, exhausted, irritable." A new baby also crucially affects the relationship between partners, and may lead to feelings of confusion and inadequacy. And if the mother also works outside the home, there will be the wrench of leaving the baby at the end of maternity leave: "It's very hard," says Abbie Lane. "Research would show that such separation does not have a long-lasting effect on the baby, particularly if parents have focused time with baby at home. But a mother will miss her baby; in fact, she may often believe she hears him crying and has difficulty detaching from him".
About half of all new mothers tend to become a little low a few days after the baby is born. This brief bout of the baby blues is most likely due to hormone levels dropping after birth. But post-natal depression is different. "One in 10 mothers suffers post-natal depression," says Dr Lane. "Warning signs include feeling very down and miserable - feelings she can't shake off, loss of enjoyment, sleeplessness, anxiety about self and/or baby, and worries about harming herself or the baby. If these symptoms persist for two weeks or more, she should seek some form of help. Those at risk may have had a previous personal or familial history of depression, or may lack social support.
"Symptoms are mixed. They may include elation as well as depression, irritability, over-activity, which is why it can be missed."
A Coombe Women's Hospital study published last year by Dr Abbie Lane, Dr Siobhan Barry and Dr Michael Turner showed that the factors predisposing women to post-natal depression included an unplanned pregnancy, unemployment, being a single mother and social isolation. Other triggering factors could be some crisis or trauma and, of course, the temperament of the baby may play a part. Equally, none of these factors may be obvious and a mother might still suffer postnatal depression.
"Given our research findings, it should be possible to `flag' the atrisk woman, as most of the pointers are documented during routine history-taking at antenatal visits," says Abbie Lane. "We found that you could predict three days after birth which women would go into post-natal depression. If such mothers were monitored before and after delivery and a closer eye kept on them, this would be very helpful and very cost effective. This could involve alerting the GP and the public health nurse. In the UK, community visitors contact vulnerable mothers and keep in touch with them, but we don't have such a service here."
Families may help with practical support if depression is suspected or confirmed. Many women may be treated at out-patient level with psychotherapy and counselling and non-addictive anti-depressants, and most cases can be successfully treated in three to four months.
But a current worrying aspect of the illness is that it can go unrecognised and untreated for years. "In spite of the fact that women are most in touch with the hospital and GP during their pregnancy and in the immediate aftermath, most cases of post-natal depression tend not to come to professional attention," says Abbie Lane.
Non-recognition lengthens the course of the illness. Studies show that one in three mothers will be unwell for one year and one in ten 10 will be unwell for up to four years - with consequent implications for the health and development of the baby and the family.
Overall, Dr Lane believes that the downside to motherhood is massively under-acknowledged. "Rates of depression after childbirth are higher than at any other time in a woman's life and the chances of her being admitted to a psychiatric hospital are increased over 20 times. We need more education on these facts. Many people do have problems, help is there, treatment is effective, but many people still do not come to attention. They are not being picked up as much as we would like."
Last week Anthony McCarthy, consultant psychiatrist at the National Maternity Hospital, Dublin, called for a national strategy to tackle the prevention and treatment of post-natal depression which, he says, can remain undetected and undertreated. And he highlighted the fact that while there are psychiatric services attached to the three Dublin maternity hospitals, no such services exist outside Dublin.
"The recognition that these are special women with special needs is only emerging," he says. "First, a woman is more likely to present in a severe depression during the first three months after the birth and how this is dealt with is crucial. Secondly, the depression is coming at a time of profound spiritual, emotional, psychological time changes in her life." Thirdly, studies show that a significant number of the babies may be affected emotionally, socially and cognitively - though these effects may be reversible.
He explains that a national strategy would ideally include ante-natal screening for vulnerable factors, assessment and treatment during pregnancy and after birth. "Doctors say things like we won't give you anti-depressants because it may harm the baby, or the depression is just your hormones. Both statements are equally untrue. "Post-natal services need to pick up evidence of depression while a woman is still in hospital," adds Dr McCarthy. "We also need mother-and-baby units so the small number of women who need in-patient treatment can bring their babies with them. We do not have one such unit in this country."
Post-natal Distress Association (tel: 01-8727171) offers one-to-one telephone support and holds monthly group meetings.
Coping With Post-natal Depression by Mary Pigot, highlighting Irish women's experiences of post-natal depression, with medical information and practical help, is published by Columba Press, at £4.99.