New motherhood is a challenging time for many women. More than 1 in 10 women experience a clinically significant depression in the first year postpartum and a similar incidence has been reported during pregnancy. This has been consistently found both in Australia and around the world, with higher rates in low-income countries. For up to 40 per cent of women identified with postnatal depression, symptoms begin during their pregnancy (Austin, 2004; Eberhard-Gran, Eskild, Tambs, Samuelsen, & Opjords, 2002; Gavin et al., 2005; Mann, Gilbody, & Adamson, 2010; O'Hara & Swain, 1996; Rubertsson, Wickberg, Gustavsson, & Radestad, 2005).
The impact on the woman, her partner and her child is profound and at odds with societal perceptions of an easy and joyful transition to motherhood. Not only do many women feel devastated by their mood symptoms, but ongoing depression may result in a wide range of negative and lasting consequences on the infant across a range of domains (e.g., social, emotional and cognitive) as well as having a negative impact on the partner relationship (Murray & Cooper, 2003; Paulson & Bazemore, 2010; Talge, Neal, & Glover, 2007).
Diagnosing depression and related disorders
Perinatal depression is a term used to refer to depression occurring in pregnancy (also called antenatal depression) or in the first year postpartum (postnatal depression). While the symptoms of depression in the perinatal period are the same as those at any other time of life, some of the physical changes associated with motherhood overlap with the symptoms of depression (e.g., changes in sleep patterns, appetite and weight) and so may confound the identification of depression in this period (Born, Zinga, & Steiner, 2004). Careful assessment is needed to differentiate these overlapping symptoms from other mental health disorders when making a diagnosis of depression (American Psychiatric Association, 2013).
Depression can be further complicated by:
- anxiety which frequently coexists with depression during the perinatal period
- other mental health conditions (e.g., eating disorder, borderline personality disorder, post-traumatic stress disorder)
- physical conditions (e.g., diabetes, physical disability)
- psychosocial factors such as substance abuse (Chapman & Wu, 2013) and domestic violence (Howard, Oram, Galley, Trevillion, & Feder, 2013).
The beyondblue Clinical Practice Guidelines (2011) outline the importance of a comprehensive assessment in the perinatal period. Working with special populations may also require adapting approaches to assessment and treatment. For instance, adolescent mothers may need support, not only with the demands of motherhood, depressive thoughts and feelings, but also with the loss of their adolescence and the need to take on responsibilities earlier than would otherwise have occurred. Similarly, when working with other cultural groups, an awareness of cultural values and practices is important. A number of women may have given birth away from their families and communities, which can lead to extra financial costs, lack of practical and emotional support, isolation and separations. At times traumatic experiences due to a refugee background, lack of secure housing or poverty increase the complexity of issues requiring management.
Risk factors for perinatal depression
For each woman, a combination of biopsychosocial factors may combine to trigger depression. Current research consistently identifies six major factors that predict postnatal depression:
- a past history of depression and/or anxiety
- antenatal depression and/or anxiety
- lack of support from partner or the presence of marital problems
- a family history of depression and/or other mental health difficulties
- a lack of practical, financial, social and/or emotional support
- major life events and stresses (e.g., death of a relative, relationship break-up, unemployment, moving house, miscarriage, illness (Milgrom, Ericksen, Negri, & Gemmill, 2005; Robertson, Grace, Wallington, & Steward, 2004).
More recently, domestic violence and child abuse have been implicated (Howard et al., 2013). Many of these same factors also make antenatal depression more likely (Bilszta et al., 2008; Bunevicius et al., 2009; Leigh & Milgrom, 2008). In addition, risk factors commonly described for depression in general play a role (e.g., low self-esteem) and there is evidence for biological and genetic factors (Saveanu & Nemeroff, 2012).
The need to identify perinatal depression
Few women seek help for depression during the perinatal period, with an estimated 40 per cent of women being identified and only 10 per cent receiving adequate treatment (Milgrom & Gemmill, 2015). In Australia, universal screening for all perinatal women is recommended. The beyondblue Clinical Practice Guidelines (2011) recommend that screening tools such as Cox, Holden and Sagovsky’s (1987) Edinburgh Postnatal Depression Scale (EPDS) can be used (Buist & Bilszta, 2006; Leigh & Milgrom, 2007).
High scores on screening instruments do not necessarily mean that a woman is depressed, so further assessment is required. Of particular note is the importance of assessing suicidal risk. The EPDS is particularly helpful in this regard as Question 10 asks about thoughts of self-harm.
Once women are identified as depressed, a more comprehensive assessment is likely to include assessment of anxiety and other psychosocial risk factors.
Treatment of perinatal depression
Perinatal depression, like depression at other times in life, is very responsive to treatment. Women are often relieved when they realise that their symptoms have a ‘name’, are common and treatable. Both psychosocial and psychological treatments are superior to routine care and are effective in reducing depressive symptoms in perinatal women (Cuijpers, Brannmark, & van Straten, 2008; Dennis & Hodnett 2007).
Cognitive behaviour therapy (CBT) for depression
CBT currently has the most robust evidence-base for use in the postnatal period (Appleby, Warner, Whitton, & Farager, 1997; Milgrom et al., 2005; Morrell et al., 2009; Murray & Cooper, 2003; Prendergast & Austin, 2001).
A detailed manualised CBT treatment program (Getting Ahead of Postnatal Depression) which has been adapted specifically for the postnatal period by Milgrom, Martin, and Negri (1999) has been shown to be effective in numerous trials (Milgrom et al., 2005; Milgrom & Holt, 2014) and includes couples/partner sessions.
CBT is continually evolving, and third-wave CBT therapies such as mindfulness based cognitive therapy (MBCT), acceptance and commitment therapy (ACT), dialectical behaviour therapy (DBT), and schema therapy are increasingly being used (Hoffman, Sawyer, & Fang, 2010), however evidence regarding their effectiveness is limited within the perinatal period.
In addition, e-treatment as a new mode of delivery is proving successful in reaching women who find it difficult to leave the house. Recent trials of MumMoodBooster designed for perinatal women have shown a fourfold improvement compared to routine care (Danaher et al., 2013).
Interpersonal psychotherapy (IPT) for depression
IPT has also been investigated in clinical trials with effectiveness demonstrated for treatment of perinatal depression. Couples therapy may also be useful as difficulties within the marital/partner relationship are common during this time.
Non-directive therapies
While evidence on non-directive counselling is limited in the perinatal population, in the context of home visits it can be considered as part of the management of mild to moderate depression for women in the postnatal period, given that there is good evidence for its effectiveness in the general population (Cooper, Murray, Wilson, & Romaniuk, 2003).
Treating partners and relationship problems
Depression and anxiety in the perinatal period can also be experienced by partners who may also require support. Engaging partners is important and can be incorporated in routine work (Fletcher et al., 2014). In addition, a woman’s depression can impact on her partner and symptoms such as being withdrawn or irritable, may result in poor communication and interactions. Living with a depressed partner can be a risk factor for depression in itself. In the perinatal period specifically, there is evidence that approximately five per cent of expectant and new fathers will experience depression, anxiety and other forms of emotional distress (Condon, Boyce, & Corkindale, 2004). Given the reciprocal relationship between maternal and partner’s mental health, couple therapy may be beneficial (Paulson & Bazemore, 2010).
Medication
Most women prefer psychotherapy to medication during pregnancy and whilst breastfeeding, due to concerns for potential side-effects on their infants (Boath, Bradley, & Henshaw, 2004; Turner, Sharp, Folkes, & Chew-Graham, 2008). Despite this, medication might need to be considered, particularly in cases where symptoms of depression are severe or where there is a lack of psychological mindedness. It is essential that all health professionals associated with the woman’s care work in a collaborative manner (e.g., GPs, psychiatrists, psychologists, maternal child and health nurses).
Mother-infant psychotherapy
Depression and anxiety in pregnancy may have a direct impact on the developing fetus, and postnatal depression has been found to be associated with long-term effects on infants’ emotional and cognitive development, persisting into later childhood (Paulson & Bazemore, 2010; Talge, Neal, & Glover, 2007; Williams, 2007).
Infants are very sensitive to the quality of care they receive early in life and thus the symptoms of depression make it difficult to engage in joyful mother-infant interactions (see article on the psychological factors associated with the transition to motherhood p. 18). A depressed woman may be more withdrawn, less available or more irritable, and may not provide consistent responses or consistent care to her infant. In turn, sub-optimal interactions influence the attachment relationship. Growing evidence suggests that treating the maternal mood disorder is insufficient to address the negative impact on the mother-infant relationship which has long-term effects on the developing child (Forman et al., 2007; Milgrom, Ericksen, McCarthy, & Gemmill, 2006). When there is a significant disconnect between the mother and infant, specialist assessment and treatment may be needed.
The following programs focus on enhancing the mother-baby relationship and are designed to enhance secure attachment between parents and children:
- Baby & Community HUGS (Ericksen, Milgrom, & Loughlin, 2007; Milgrom et al., 2006)
- Circle of Security (Marvin, Cooper, Hoffman, & Powell, 2002)
- Watch, Wait and Wonder (Muir, 1992).
Conclusion
Given the impact of depression and anxiety in the perinatal period, early identification, comprehensive assessment and management with consideration of the woman, her partner and infant is indicated.