PND describes the more severe or prolonged symptoms of depression (clinical depression) that last more than a week or two and interferes with the ability to function with normal routines on a daily basis, including caring for a baby.
(Factsheet; Depression during pregnancy and the postnatal period, The Blackdog Institute)

More than 15% of women and 10% of men develop postnatal depression. Many women do not know that postnatal depression can occur after delivery and typically blame themselves, their partners or their baby for the way they feel. Some try hard to "snap out of it" without understanding that women with postnatal depression have little control over the way they are feeling. It is very important for women and their partners to learn to recognise the signs and symptoms of postnatal depression so that they can ask for help as early as possible.
(Factsheet: Postnatal Depression, PANDA)


Postnatal depression is difficult to identify
Society makes it difficult for a woman to acknowledge that she may be experiencing postnatal depression. She is constantly confronted by messages about joy and bliss but not about the challenges that come with motherhood.

The media tends to reinforce the unrealistic expectations of motherhood, for example promoting celebrities who appear to be coping exceptionally well. Added to this is the stigma of depression, with postnatal depression often being portrayed in a negative and sensational way. Women will put on a brave face and go to extraordinary lengths to hide how they feel. A woman who is not coping can feel very alone and can find it hard to come to terms with her feelings.
(Factsheet: Postnatal Depression, PANDA)


Contributing factors for PND
Some parents are more vulnerable to PND than others. Parents experiencing some of the known contributory factors should be encouraged to talk with their doctor and family. It is important to remember that it is the individual meaning and response to these factors that needs to be discussed and assessed.

Biological:

• Genetic predisposition to depression
• Sudden changes in pregnancy hormones following delivery
• Nutritional deficiencies
• Difficult or highly medicalised pregnancy or childbirth experiences
• History of pre-menstrual tension
• Previous experience of PND
• Family/personal history of mental health conditions such as depression, bipolar disorder or schizophrenia
• Sleep deprivation

Psychological:

• Infertility and use of IVF for conception
• Difficult or traumatic birth (perhaps involving unexpected interventions such as an emergency caesarian)
• Traumatic or abusive childhood (particularly sexual abuse)
• Unrealistic expectations of motherhood and of herself
• Certain personality types (perfectionist or controlling)
• Limited social and emotional skills (difficulties in effective communication)
• Past unresolved issues of grief and loss such as previous miscarriage)

Social:

• Lack of family and community support
• Problematic or unresolved relationships
• Difficult couple relationship
• Partner who is removed emotionally, works long hours or travels
• Intrusive or difficult family relationships
• Social isolation
• Financial hardship
• Lack of close friends, particularly families with children
• Moving house
• Lack of access to transport
• Being of younger or older age
• Stressful life events such as a death in the family or a job loss

(Factsheet: Postnatal Depression, PANDA)


Symptoms
Symptoms can begin anywhere from 24 hours to several months after delivery. Where the onset is abrupt and symptoms severe, women are more likely to seek help early. When the symptoms are harder to separate from normal adjustment to changes after having a baby treatment may be delayed, if it is ever sought, and PND can linger beyond the first year.

The following descriptions of PND symptoms come from women who have spoken to PANDA or attended PND support groups and can also apply to a man's experience of postnatal depression.

• Sleep disturbance unrelated to baby's sleep needs. Most women with a young baby fall asleep as soon as they are able to. Women with postnatal depression can lie awake for hours feeling anxious while their baby sleeps, or wake early in the morning. Others want to sleep all the time and have trouble getting up in the morning.
• Appetite disturbance. She may feel totally uninterested in food and say, "I force myself to eat because I am breastfeeding, but I don't taste anything". Some overeat in an attempt to control their anxiety, others feel sick at the thought of food.
• Crying. She may feel sad and cry without apparent reason. Tears come easily day and night. Others say, "I want to cry but can't. I am crying on the inside."
• Unable to cope. Daily chores, caring for the baby or self care may seem insurmountable to women with postnatal depression. Small demands she previously coped with may completely overwhelm her. She may feel like running away, overwhelmingly exhausted and very heavy physically and emotionally, or wish it would all go away.
• Irritability. She may snap at her partner or other children without cause. Partners often say, "I can’t do anything right. If I fold nappies she complains I do it the wrong way. If I don't help, I’m being unsupportive."
• Anxiety. She may feel a 'knot in the tummy' most of the time and panic without cause. Some experience heart palpitations so severe they fear they are having a heart attack. She may be anxious about her own or her baby's health even after being reassured that nothing is wrong. Many women describe anxiety as their most obvious symptom and reject the term postnatal depression. They deny being depressed. The term 'postnatal anxiety' might more accurately describe the way some women feel.
• Negative obsessive thoughts. There can be little peace in the thought processes of women with postnatal depression. Small worries can consume thought processes, interfering with her ability to listen, concentrate or remember. She may experience unrealistic fears, afraid to let her partner go to work in case he has a car accident or fear something bad could happen to her baby. No amount of reassurance or distraction can hold her thinking at bay.
• Fear of being alone. Many women go out a lot or need their partner (or someone) at home with them at all times because they are afraid of being alone at home. The fear of something going wrong with the baby or her own perceived inability to cope with the baby on her own is overwhelming. Some feel incredibly lonely and go out to feel connected with other people - this takes an enormous amount of effort. Others feel they cannot be with other people and withdraw from family and friends, not answering the door or telephone.
• Memory difficulties and loss of concentration. A woman may forget what she wanted to say mid-sentence. She may not be able to concentrate on simple tasks or take in new information. Organising herself and her family can become too difficult. Sometimes she doesn't know where to start or may start everything at once. She may be unable to think creatively about her problems or find solutions - like reaching out to services that will help her.
• Feeling guilty and inadequate. Feeling guilty can be a common feeling for all mothers but more so for the mother with postnatal depression. Her thoughts and feelings constantly reinforce in her own mind that she is inadequate and a bad mother. She may be unable to take encouragement from the good things she has done or to feel affirmed by her relationship with her baby. Reassurance will not dissuade her thinking and can discourage her from talking about how inadequate and guilty she feels.
• Loss of confidence and self-esteem. A woman who enjoyed her job may panic at the thought of returning to it, no longer sure she is able to do it. A woman who enjoyed having family and friends over may panic at the thought of visitors. She may feel unable to prepare a meal which she enjoyed doing before the baby was born. Most women with postnatal depression have very low self esteem regardless of how well they seem. Some describe their experience as a loss of sense of who they are, a loss of sense of self.

(Factsheet: Postnatal Depression, PANDA)



The Edinburgh Postnatal Depression Scale (EPDS)
The EPDS (Cox, Holden and Sagovsky, British Journal of Psychiatry, 1987), used in many antenatal and postnatal clinics, is a set of questions to detect depression and anxiety at this time. It WILL NOT PROVIDE A DIAGNOSIS – only trained health professionals should do this. It will tell you whether you or someone you are close to has symptoms that are common in women with depression and anxiety during pregnancy and in the year following the birth of a child.

To complete this set of questions, the parent should circle the number next to the response which comes closest to how they have felt IN THE PAST SEVEN DAYS.

Please keep in mind that a person who do not score high on the Scale may still have depression. Likewise, a person who score high on the scale does not necessarily have depression. The Scale only gives an indication.

Link here: http://www.testandcalc.com/etc/tests/edin.asp



Effects of postnatal depression
If postnatal depression is not identified or treated the toll it takes on the woman, her baby, partner, family and extended relationships increases. It does not usually resolve itself fully without treatment and she may experience future episodes of depression and mental illness. Many women with postnatal depression are very close to their babies despite how they feel. For others, if postnatal depression is ongoing they may struggle to connect with their baby. This can have an impact on the wellbeing of the baby. With early identification and intervention most women fully recover from postnatal depression and there are no long term effects.
(Factsheet: Postnatal Depression, PANDA)


Effects on the woman

• There can be significant impact on the woman's physical wellbeing - poor diet, lack of sleep, altered activity levels and exhaustion.
• Depression and anxiety may be expressed in physical symptoms such as pain, headaches, chest pain, difficulty breathing or feeling sick.
• Ongoing depression and high anxiety levels reduce the body’s immunity and ability to fight infection.
• Unresolved or future episodes of depression or complicated mental health problems.
• Suicide is a leading cause of maternal mortality in the UK and probably also in northern Europe.

Effects on the mother-infant relationships

• PND can interfere with behavioural and emotional mother and infant interactions.
• A woman with PND may be less sensitive to her infant’s needs and less appropriately responsive to his communications.
• There can be attachment difficulties between the mother and infant that effect her ability to parent.
• Severe PND has been claimed to contribute to child abuse and neglect.

Effects on the infant

• Difficulties in mother-infant interaction may lead to increased fussiness or withdrawal and have an impact on the development of the infant's brain pathways.
• PND can impact on the child’s future cognitive and language development as well as social competence and mental health.
• The child may go into adulthood with behavioural and mental health problems and experience difficulties parenting their own children.

Effects on the partner relationship

• Living with a woman experiencing PND is difficult. Her partner can be the target for much of her frustration and distress, her intense needs within the relationship and her partner's struggles to know how to best provide support can result in conflict.
• Partners often feel confuse, lost and helpless and are at increased risk of developing depression and anxiety. They may manage this with increased use of alcohol, drugs, withdrawal or extended hours at work.
• They benefit from counselling, support from their family and friends and from other people with similar experiences such as men at PND support groups.
• Partners benefit from understanding more about what is happening to the woman. It is important that they are included by the health professionals who are treating women with PND. Partners tend to be more supportive if they understand what the problem is and what they can do to help.

Effects on family relationships

• Parent-child relationships may be damaged due to the woman's withrawal or volatility with her children, parental conflict and inconsistent parenting, often at a time when they need her the most (toddlers and pre-schoolers)
• Extended family relationships may become strained due to a lack of understanding of PND and the family may be unhelpful and provide only conditional support.
• Extended family members may worry about the new mother and become exhausted by providing practical and emotional support.

(Factsheet: Postnatal Depression, and Guide to Postnatal Depression Support Groups, PANDA)


Treatment
All women with postnatal depression need emotional support from family and friends. Some women find psychological treatments helpful especially if they have experienced traumatic events in their childhood or more recently.

Antidepressant medication is a successful part of treatment for many women. There are many misconceptions about antidepressants and women who could benefit from them refuse them because they are afraid the medication is harmful. Antidepressants are not addictive and some can be safely taken while breastfeeding and pregnant.  It can be helpful to seek objective advice from a pharmacist or Drug Information Line.

This type of medication does not "change your personality"; it corrects the chemical imbalances in the brain that are thought to be responsible for symptoms of depression and anxiety.

It is important to understand that women cannot "snap out of" depression any more than they could "snap out of" diabetes.
(Factsheet: Postnatal Depression, PANDA)


Where to go for help
If a woman does not feel the way she expected to feel after having a baby it is very important that she talk to her doctor or maternal and child health nurse. It could simply be that she is having trouble adjusting to the changes in lifestyle or the increased demand that occurs when a baby is born. If she is suffering postnatal depression it is important that she receive appropriate help as soon as possible. Postnatal depression is not something to be ashamed of. It should be seen as one of the many complications of pregnancy and delivery. With appropriate help women with postnatal depression do recover.
(Factsheet: Postnatal Depression, PANDA)


Biopsychosocial postnatal depression and recovery
Postnatal depression should be viewed as a biopsychosocial condition that has an impact on the woman’s biological, psychological (spiritual) and social (cultural) wellbeing. Factors that contribute to postnatal depression come from all these areas and result in a variety of symptoms. A different combination of factors is responsible for each woman's unique experience of postnatal depression. Strategies for managing postnatal depression towards recovery must address all biopsychosocial aspects of the woman's life. This usually requires a combination of interventions.

Postnatal depression exists within family and communities, not with the woman alone. Assessment and intervention need to consider the significant other people in her family.
(Factsheet: Postnatal Depression, PANDA)