Depression is usually classified as being postnatal (or puerperal) if it occurs within 12 months of childbirth. Feeling low or depressed after the birth of a new baby is very common among new parents, and depression may affect as many as one in six new mothers. However, depressive states cover a broad spectrum between normal sadness at one end and severe illness at the other. True postnatal depression must be differentiated from post-partum blues and puerperal psychosis.

Some useful websites providing information and guidance about postnatal depression are listed below.

Post-partum blues (also called baby blues or maternity blues) is a mild and transient disturbance in mood occurring between the third and sixth day after delivery. Usual features include crying, fatigue, sensitivity to criticism, anxiety, irritability, helplessness and lability of mood. Symptoms last from a few hours to a few days. Estimates of incidence vary between 50 and 70%, and it is more common in first time mothers. In fact, the symptoms are so common that they are almost regarded as a normal result of childbirth.

Causes may include:

• physical discomfort
• the emotional drain of the delivery
• lack of sleep
• anxiety about the ability to cope in the future
• the fear of diminished attractiveness to the partner
• poor relationship with the father
• an unwanted baby.

This is a short-lived syndrome which requires support rather than pharmacological treatment.

True postnatal depression is more severe than post-partum blues and symptoms tend to appear later. The peak incidence appears to be at three months but a significant number of cases still appear at six months or more following the birth. Postnatal depression occurs after 10 to 15% of pregnancies, but many women suffer in silence and the condition may go unnoticed by health professionals. The usual features are similar to non-psychotic depression appearing in women at any other time of life.

Possible causal factors include:

• previous psychiatric history
• poor marital relationship, lack of support from partner, little contact and help from family and friends
• lack of social support
• negative birth experience
• stressful life events (e.g. death of a close relative or friend)
• severe postnatal blues.

Postnatal depression can be an extremely distressing condition and has many symptoms. These can include:

• feeling low, not enjoying things as much as usual
• crying – anything from being a little tearful to uncontrollable sadness
• poor sleep, irritability, tiredness
• feeling anxious and unable to cope, possible panic attacks
• not enjoying the baby or having little interest in the baby
• difficulty concentrating and even memory loss
• feelings of guilt, feelings of hopelessness
• changed appetite
• low sex drive
• aches and pains or feeling unwell
• possible suicidal thoughts
• possible thoughts about harming the baby.

As some of these symptoms are easily mistaken for normal changes after having a baby, mothers often do not realise that they have postnatal depression. Even health visitors, midwives and GPs may find it hard to spot postnatal depression in a new mother. A simple questionnaire, the Edinburgh Postnatal Depression Scale (EPDS), can help to check for some key symptoms.

In most cases, the symptoms will gradually improve after 3 to 6 months, but they can last much longer. Management options include counselling, psychotherapy and drug therapy.

Puerperal psychosis is a rare complication of childbirth, with an incidence of about 1 to 2 per 1000 births. The onset is usually 2 to 4 days after delivery and it is often characterised by clouding of consciousness, perplexity, delusions and hallucinations.

Paranoid delusions often centre on the child, for example a belief that the child is the devil, or that the world is too evil for the child to live in. Consequently there may be a risk of infanticide or injury to the child. In addition to this specific risk, the baby is also at risk of general neglect or inappropriate treatment.

Hospital in-patient management is usually required. Treatment may include stabilising drugs such as lithium, antipsychotics such as haloperidol, antidepressants and electroconvulsive therapy. The mother usually makes a complete recovery, although this may take a few weeks or months.

The Department of Health Birth to five guide for parents has information about postnatal depression in ‘the first weeks’ chapter.
www.dh.gov.uk/PublicationsAndStatistics

The DirectGov website provides advice for parents of new babies. It includes information and advice about postnatal depression.
www.direct.gov.uk/Audiences/Parents

Scotland NHS Ready Steady Baby website offers information and advice about postnatal depression.
www.readysteadybaby.org/youandyourbaby

The Royal College of Psychiatrists is the professional and educational body for psychiatrists in the United Kingdom and the Republic of Ireland. Information on postnatal depression for healthcare professionals and for patients is available on the website.
www.rcpsych.ac.uk

The NHS Direct encyclopaedia has a section on postnatal depression.
www.nhsdirect.nhs.uk

The BBC Parenting website offers practical advice on postnatal depression.
www.bbc.co.uk/parenting

The NHS Health Scotland website has a section on postnatal depression.
www.hebs.com/services/pubs

The National Childbirth Trust offers support in pregnancy, childbirth and early parenthood. Information about postnatal depression is available on the website.
www.nctpregnancyandbabycare.com

The WellBeing of Women charity’s website offers a useful leaflet for patients on postnatal depression.
www.wellbeingofwomen.org.uk

The Association for Post-Natal Illness is a charity offering support, education, information and research about the condition.
www.apni.org

MIND is the leading mental health charity in England and Wales. The website provides information about postnatal depression including an on-line booklet called Understanding postnatal depression.
www.mind.org.uk

The Mental Health Foundation is a UK charity working in mental health. The website offers various resources on postnatal depression.
www.mentalhealth.org.uk

SANE is a national mental health charity offering information, research and a mental health helpline.
www.sane.org.uk

The Meet a Mum Association aims to provide friendship and support to all mothers especially those feeling depressed and isolated. The website offers information about postnatal depression.
www.mama.co.uk

The 2004 Prodigy Depression Guidelines provide detailed recommendations for the management of postnatal depression.
www.prodigy.nhs.uk

The Scottish Intercollegiate Guidelines Network (SIGN) published Postnatal Depression and Puerperal Psychosis Guidelines in 2002.
www.sign.ac.uk/guidelines

The British Medical Journal Publishing Group’s Clinical Evidence website is a source of the best available evidence for effective healthcare during pregnancy and childbirth. It has evaluated treatments for postnatal depression.
www.clinicalevidence.com/ceweb

The Community Practitioners and Health Visitors Association (CPHVA) website provides information about the organisation and its work. It also provides a gateway to many other sites that provide information on community nursing, public health and primary healthcare.
www.amicus-cphva.org

The Women's Health specialist library is a virtual library providing access to a growing collection of quality evaluated resources and links for health professionals working in the fields of obstetrics and gynaecology, and also for patients and others interested in the topics. Provided by the National Library for Health (NLH), this on-line library provides access to information on a wide variety of topics concerning women's health issues.
www.library.nhs.uk/womenshealth

GP notebook is a system designed to provide a concise synopsis of the entire field of clinical medicine with material organised systematically to ensure rapid retrieval of information. There is a detailed section on postnatal depression.
www.gpnotebook.co.uk

NMAP offers free access to a searchable catalogue of hand-selected and evaluated, quality internet resources for nursing, midwifery and allied health professions.
http://nmap.ac.uk

The eMedicine.com on-line US textbook has a chapter covering post-partum depression.
www.emedicine.com/med