The SIGN guideline on postnatal depression and puerperal psychosis should be required reading, says Dr Chris Barclay
Some 10-15% of pregnancies are followed by postnatal depression (PND) yet GPs remain unaware of most cases. PND causes lasting damage to the mother, sets the scene for future mental health problems, and compromises the child?s social and emotional development. Do new mothers deserve better? Is improvement feasible? The answer to both questions, according to the new SIGN guideline, is yes.1
PND is defined as a non-psychotic depressive illness developing in the first postnatal year. It should not be confused with the ??baby blues? nor used as a catch-all diagnosis for any mental health problem after childbirth. It may originate antenatally and indeed differs little from depression at other times in life; previous depression is predictive of postnatal relapse.
SIGN concludes that taking a mother?s mental health history should form part of the antenatal assessment. Although routine antenatal screening is ineffective, postnatal screening is useful. The guideline suggests that health visitors are ideally placed to carry this out. The Edinburgh Postnatal Depression Scale is a useful tool but should not be used in isolation.2
While there is no point screening for conditions that cannot be treated, a variety of therapies are known to be effective in PND. These include social support, counselling, cognitive behavioural therapy and, of course, antidepressant medication. Progesterone therapy, however, is ineffective. With very few exceptions antidepressants are safe and effective during pregnancy and lactation.
Many different health professionals may be involved in the initiation and monitoring of care. GPs and health visitors can spot cases and provide continuity of care. Community psychiatric nurses, psychiatrists, midwives and obstetricians also have roles.
Puerperal psychosis is much less common than PND, following just 1 in 500-1000 births, and requires urgent psychiatric review. SIGN states that there is no place for admission of mothers with babies to general psychiatric wards; dedicated mother and baby units are best.
Women with a previous episode of puerperal psychosis have a high risk of relapse in future pregnancy. The risk of a future puerperal episode is 25-57%, and the risk of non-puerperal relapse even higher, according to the guideline.
As a GP I took away several messages:
- Taking a mental health history antenatally is essential.
- Almost all antidepressant drugs are safe in pregnancy and lactation.
- Taking medication before a breast-fed baby?s longest sleep minimises transfer to milk.
- Screening all new mothers for PND 6-8 weeks after delivery is effective. Health visitors are well placed to undertake this.
- Both psychosocial and drug therapies make a difference not only to the mother but also to her baby and her partner.
- Banagement of PND requires strategic planning and implementation.
- The resource implications (apart from building and staffing mother and baby units) are not large.
The first few months of life are precious. PND blights them and can cast a shadow over the mother?s future mental wellbeing and the child?s psychosocial development. Detecting and treating PND and puerperal psychosis is valuable work. The SIGN guideline is a worthy contribution to the subject and should be required reading within every primary care organisation.
- Scottish Intercollegiate Guidelines Network. SIGN 60: Postnatal depression and puerperal psychosis: a national clinical guideline. Edinburgh: SIGN, June 2002. The guideline can be downloaded from the SIGN website: www.sign.ac.uk
- Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987; 150: 782-6.