Depression after childbirth – What can help?

It is very similar to the kind of depression that can affect people in any phase of life. Except for one major difference: Mothers often feel very guilty and worry about not being able to care properly for their baby. Often, they can't respond sensitively to their child. Many mothers feel too ashamed to speak with others about how they are feeling. They are afraid of not living up to the idea of a “good mother” and might become more and more withdrawn. Some women say that they no longer recognize themselves.

Or they may feel so bad that they aren’t able to reach out for the help they need. So it might be a doctor, midwife, partner, friend or family member who realizes what is happening, and helps to get more support.

In postnatal depression, these negative feelings are much stronger than the “usual” baby blues. The following are signs of postnatal depression:

• Long-lasting sadness (deep sadness, frequent crying)
• Not enjoying things that you usually enjoy
• Anxiety
• Insomnia
• Loss of appetite
• Poor concentration
• Low self-esteem
• Brooding
• Thoughts of harming yourself or your baby

If these symptoms continue for at least two weeks, it is considered to be depression.

Up to 15 out of 100 women will get depressed in the first three months after giving birth. About half of these women (8 out of 100) will have mild or moderate depression, and around 7 out of 100 will have more severe depression.

Postnatal depression typically lasts four to six months without treatment. Some symptoms may still persist over one year later. Women who do not have treatment are more likely to develop chronic depression.

Postnatal depression is usually not dangerous. But it is very distressing for the mother and can also affect the relationship to her child, especially if it is difficult for her to respond to the child's needs.

It is not that unusual for a new mother to develop obsessive thoughts. Some mothers think about harming their child, for instance – even though the vast majority of them would never act on these thoughts. But even the idea itself can be frightening, and could make some mothers reluctant to bathe their child when alone, for example. Knowing that these kinds of thoughts are usually never acted upon can be a relief.

Anyone who has severe depression is at risk of being depressed for a long time, though. In rare cases this may lead to an attempt to take your own life (suicide). This is the exception, especially when breastfeeding, but anyone who is seriously considering suicide needs urgent medical support.

There is also another serious condition that can occur after childbirth, known as postpartum psychosis or puerperal psychosis. This mental illness is rare; it occurs in about 1 out of 1,000 women. But the risk is higher for women who have previously had manic depression (bipolar disorder).

People who develop psychosis become delusional. They lose touch with reality and hallucinate. Some become paranoid, while others show inappropriate behavior, make bizarre statements or experience extreme mood swings. If you suspect that someone has psychosis, it’s important to get psychiatric help fast.

Motherhood can also be difficult and challenging at times, both physically and mentally. So it isn’t surprising that some women react to the struggles and difficulties they are having by developing depression after a while.

Women are more likely to develop postnatal depression if they have

• already had anxiety disorders or depression in the past.
• experienced stress and stressful situations during pregnancy and after childbirth.
• been in a bad relationship or don’t live with their partner, as well as those who have experienced domestic abuse and who generally have less social support.

It is still not clear what sort of an influence the hormonal changes resulting from pregnancy have.

Research shows that social and psychological support can help to prevent postnatal depression from developing in the first place. Frequent visits from a midwife or a specially trained nurse can help. Psychotherapeutic treatments can play a role in keeping someone from sinking into depression too. Studies involving women who were at higher risk of developing depression showed the following:

• An average of 3 to 4 out of 100 women who had completed a support program were diagnosed with depression.
• An average of 7 out of 100 women who had not participated in a support program were diagnosed with depression.

In other words, support programs prevented depression in an average of 3 to 4 out of 100 women. But these numbers also show that support programs don’t always prevent depression. Research has suggested that it might be a good idea to only offer these programs to women who are considered to be at greater risk of depression, such as women who have had depression before or who experienced a difficult pregnancy.

In Germany, a program called "Frühe Hilfen" (Early Assistance) helps parents who have difficulties after childbirth. That includes mothers who receive little support from others and couples who don't feel confident about caring for their child. The program offers support in the form of arranging a family midwife, helping parents meet up, or providing information on raising children, for instance. The statutory health insurers may also cover help for the household.

In mild depression, getting more emotional support and practical help in everyday life is often enough to help a woman through things. Here it's very important that the person offering support doesn’t judge or criticize her. It might help to talk with other women who have gone through the same thing – either people you know or women in a support group.

But it's still important to get medical or psychological help, particularly for moderate or severe depression. Researchers have found that many women feel at least somewhat better after getting help from trained psychotherapists and counselors.

Cognitive behavioral therapy (CBT) has also been proven to help. CBT involves working with a trained CBT psychotherapist to change the thoughts, beliefs and behaviors that make your life more difficult.

Interpersonal psychotherapy has been shown to help too. Here the woman has weekly sessions with a psychotherapist to try to find out what might be making it harder for her to adjust to the changes in her life, and to develop a strategy to help her in everyday life. Interpersonal psychotherapy is not covered by statutory health insurers in Germany, though.

Antidepressants can help relieve depression after childbirth. But they are usually only considered if the symptoms are so severe that support from the social environment or psychotherapy are not effective enough on their own. The choice of medication may be determined by what the main symptoms are – whether the biggest problems are exhaustion and lack of motivation or restlessness and difficulty sleeping.

It is not a good idea for women who were taking antidepressants before getting pregnant to stop using them abruptly. They may be able to continue taking them at a lower dose instead, for instance. Your doctor can help you make this decision. It is important that women tell their doctors, midwife and people close to them if they decide to stop taking medication during pregnancy and while breastfeeding. Then they can all keep an eye on how she is doing and coping in everyday life.

There is a lack of good research on whether St John's wort (hypericum) is effective in the treatment of postnatal depression. Products containing St John’s wort have been shown to help in some people with milder forms of depression. But there is not much research on their use during pregnancy or when breastfeeding, and little is known about the potential side effects. Interactions with other medicines are possible too.

There is no evidence that hormone products containing estrogen or progestin can help to treat or prevent postnatal depression.

Women who take antidepressants while breastfeeding should talk with their doctor about what they ought to bear in mind. Most antidepressants are not dangerous for the child while breastfeeding. The dose is kept as low as possible at the start of treatment, though. Small amounts of medication may be passed on to the baby in breast milk, and this could cause side effects in the baby. There have been some individual reports of children who were restless or drowsy after their mothers had taken certain kinds of antidepressants. These symptoms disappeared when they started drinking infant formula milk from a bottle. It is also possible to lower the dose or switch the medication.

There are a number of other treatments and strategies that women who have postnatal depression try out. Sports and exercise can reduce the symptoms of depression, Studies have shown that omega-3 fatty acids are not effective. There is too little research on things like massages, acupuncture and bright light therapy to be able to say whether they help or not. Bright light therapy involves spending a certain amount of time near a special lamp or light box with your eyes open, so that the light shines on the retina of your eyes.

Although it can be hard to reach out to other people if you’re depressed and ashamed of how you’re feeling, most women find someone they know or a professional who doesn’t judge them, and instead helps them to cope with the difficult situation.

If you have symptoms of depression, it is important to seek medical assistance immediately. You can go to your family doctor, or a gynecologist or psychotherapist. It is possible to see a psychotherapist for a first consultation without a referral from your doctor or needing to apply to your health insurer. At this initial consultation you can get advice on your problems and see whether continuing with psychotherapy would be helpful.

Many women who have had postnatal depression before are afraid of developing it again if they have another baby. Then it's a good idea to prepare for the time after the child's birth well in advance. With help from your doctor and support from those around you, it's possible to prevent postnatal depression from coming back another time.