Managing postnatal depression in primary care
Depression is more prevalent among women than men.1 Given women’s central role in the family, postnatal depression must be addressed accordingly. Audrey Abella speaks with Dr Chua Tze-Ern, Head and Senior consultant, Women’s Mental Wellness Service at the Department of Psychological Medicine at KK Women’s and Children’s Hospital, Singapore, to discuss the importance of tackling postnatal depression in primary care.
The stress and physical demands following childbirth can be enormous and may precipitate episodes of postnatal depression. Postnatal depression, which can be mild or severe, affects about one in 14 women in Singapore.
Physical, emotional changes
Apart from the hormonal changes and the recovery process following childbirth, a new mother must adapt to her new role, which can be a round-the-clock task. Breastfeeding can be similarly tiring and may present unexpected challenges (ie, latching issues, low milk supply, breast infections).
Postnatal depression may render the nurturing care experience more difficult and less pleasant for mothers. Over time, their relationship with their infant may be affected. Mothers with postnatal depression may experience more parenting problems, owing to increasing irritability/impatience, or feelings of being withdrawn. Consequently, this may negatively impact their children’s emotional and behavioural development.
Personal, interpersonal effects
Aside from the mother-infant relationship, the mother’s bond with other family members may be compromised; she may not be able to connect as well as usual with her partner, parents, and in-laws.
The drive to assimilate into the new role as parents, coupled with coping with parenting advice from parents and in-laws, require a tremendous amount of time, understanding, and energy. Emotions may run high upon the arrival of the newborn, which might precipitate misunderstanding and frustration. Left unresolved, domestic relationships may sour in the long run.
Another factor that may be contributory is work. The financial load that comes with the birth of a child may compel new mothers to split their time between being career women and mothers.
These factors may collectively contribute to the development of postnatal depression. Not all patients will have the same situation, hence the need for a tailored and unique management approach.
An individual with depression may experience most of these nine cardinal symptoms persistently in the previous 2 weeks, to the extent of not being able to function normally:
1. Feeling low and tearful
2. Inability to enjoy usual activities
3. Sleeping either more or less than usual
4. Appetite and weight are either more or less than usual
5. Feeling restless or slowing down
7. Impaired concentration, memory, and decisiveness
8. Feeling worthless; excessive self-blame
9. Suicidal thoughts
As with depression in other patient groups, postnatal depression is diagnosed according to the above-mentioned symptom criteria. Five or more of these symptoms indicate a major depressive disorder.
Postnatal anxiety may commonly present as a comorbidity. It may manifest as excessive worrying about the baby’s well-being, intrusive thoughts about the baby being harmed, or pre-occupation with cleaning and checking.
Another possible comorbidity is poor mother-infant bonding. Mothers tend to struggle to have positive emotions about their babies which, in turn, increases their own feelings of guilt and distress.
While there are no physical tests that can confirm a diagnosis of postnatal depression, trained healthcare professionals may use the Structured Clinical Interview for DSM-5 to systematically evaluate symptoms. However, clinicians still need to independently probe for subjective experiences.
Some depressive symptoms overlap with the normal experience of having a baby. For instance, a person who is depressed may often have trouble sleeping, or feel fatigued. A new mother recovering from childbirth may have interrupted sleep patterns due to the erratic waking hours needed when feeding her baby, which may not necessarily equate to depression.
Hence, questions about physical symptoms need to be structured carefully to confirm if these are depression-related. For instance, instead of merely asking a new mother if she has trouble sleeping, the clinician may tailor it to ask if she has trouble sleeping due to feelings of unhappiness. Another example would be instead of asking if she has lost weight, the clinician may paraphrase her question and ask if she is losing her pregnancy weight more quickly than expected.
New mothers may feel pressured to appear happy and on top of things, making it hard for them to be open about their emotional struggles. Instead of saying that they feel depressed, they may remark obliquely that ‘I shouldn’t have become a mother’ or ‘My baby deserves better’. These lines should signal clinicians to encourage their patients to elaborate on their feelings to facilitate a proper and accurate assessment.
This manner of questioning may indirectly encourage mothers with postnatal depression to develop insight and accept help. A clinician who speaks and listens with empathy can make patients feel that they are not being reprimanded for their emotions, but rather, supported towards getting better.
Locally, the 2014 Ministry of Health Clinical Practice Guidelines for depression offer advice on the management of pregnant and postnatal women, including a simple screening for depression, risk factors, and broad concepts of treatment. For a more detailed guideline, clinicians may refer to the UK National Institute for Health and Care Excellence.
Even when the clinician is familiar with the guidelines, it may be hard to act on them if the patient does not see postnatal depression as an illness, or if she is worried that it reflects poorly on her parenting capacity.
If so, it often helps to take a step back and focus on support and psycho-education. Clinicians may explore what the patient’s experiences mean to them, and empathize about how their symptoms might be affecting them (eg, how tiring it can be to care for a baby especially if they are not sleeping and eating well). Clinicians may then provide perspective by sharing with the patient that postnatal depression is relatively common and responds well to treatment. While this requires time, it is reassuring to the patient and gives her some understanding and autonomy about her condition.
Mild cases of postnatal depression often respond to support and psycho-education. More than one session may be required to ensure that symptoms resolve over time.
Psychological therapy may be beneficial for women who exhibit an ability to reflect meaningfully on their own and others’ feelings and experiences. Cognitive behavioural therapy, mindfulness-based therapy, or acceptance and commitment therapy may help them cope with their symptoms, while psychodynamic psychotherapy may be appropriate for those with interpersonal issues stemming from childhood.
Patients with moderate-to-severe major depression may benefit from antidepressants. Breastfeeding mothers may be started on a low-dose antidepressant such as sertraline (25 mg daily).2 Non-breastfeeding mothers may be prescribed antidepressants similar to those prescribed for the general population.
A referral to specialist psychiatric care, preferably at a centre with expertise in perinatal psychiatry, may be warranted for more worrisome symptoms that might not be addressed through primary care management protocols.
Severe postnatal depression may result in psychotic symptoms (eg, hearing voices, making derogatory remarks) or active suicidality (ie, intention to commit suicide). In rare cases where symptoms cause risk of harm to self or others, urgent admission to a secure inpatient psychiatric facility is clearly warranted.
Unless such risk exists, postnatal depression can and should be managed in the outpatient setting. Outpatient care gives mothers the chance to bond with their babies and learn how to care for them which, in turn, contributes to building positivity, curiosity, and confidence.
Psychiatric case management is a helpful strategy to enable safe and effective outpatient care for postnatal depression.3 In between psychiatric appointments, patients continue receiving support, psycho-education, and symptom monitoring by trained case managers, as well as individual counselling sessions, if required. With this level of care, patients can be managed in an individualized and responsive manner even as they remain in the community.
Disease management tools
The Edinburgh Postnatal Depression Scale (EPDS), a 10-item self-administered questionnaire available in the public domain, is a quick and effective screening tool for postnatal depression. This should be considered in conjunction with clinical factors. Patients with suicidal thoughts or psychotic symptoms, or those with history of severe mental illness, should be offered psychiatric referral even if their EPDS scores are not high.
Although fairly common, postnatal depression in Singapore may be underdiagnosed. Primary care physicians are in a good position to help with this problem as they are the first port of call for postnatal mothers seeking medical care. When primary care physicians discuss with mothers about postnatal depression in an open and empathic manner, it helps to reframe postnatal depression as a medical condition that is treatable.
Clinical guidelines and screening tools have been developed to enable GPs to provide effective care. However, not every mother with postnatal depression will accept help. There are still many barriers to treatment (eg, lack of awareness, busyness, cost, stigma). Nonetheless, each positive conversation about mental health will bring a measure of relief and open access to care.