Letters

Postnatal depression

Postnatal depression is not being missed in primary care

Biology mustn't be excluded

Postnatal depression is not being missed in primary care

EDITORIn their review of postnatal depression Cooper and Murray comment that depression is often missed by primary care teams.¹ There are several reasons why this might be the case, even though a reliable tool (the Edinburgh postnatal depression scale) has been available for detecting its presence for over 10 years.²

When the Edinburgh postnatal depression scale has been used to detect postnatal depression, health visitors have used various strategies to help women, with varying degrees of success. ^{2 3} Factors that influence the process of screening and caring for women with postnatal depression include health visitors' workload and their willingness to use the Edinburgh postnatal depression scale³ and the readiness of women to be labelled as patients with depression, to accept an intervention by a health visitor,^2-4 or to be referred for further care. ^{2 3} There is still uncertainty about when to use the Edinburgh postnatal depression scale, where to set the threshold for the purposes of screening, ^{2 3} and how to prioritise patients and determine which intervention is likely to be the most appropriate and effective.^2-4

Watson et al showed that women with postnatal depression could be classified into as many as six categories.⁵ Cooper and Murray's comments on the aetiology of postnatal depression confirm their findings. McIntosh has recommended that a personalised women-centred approach is the most appropriate and more likely to be successful than reliance on just drug treatment or counselling.⁴

Cooper and Murray highlight the impact of postnatal depression on child development and behaviour and comment that this can be a consequence of communication problems. The impact of postnatal depression on a mother's ability to cope, which is a difficult concept to measure and evaluate, may be the most important factor affecting infant development and behaviour. In my general practice there are women who are not depressed according to a rating scale such as the Edinburgh postnatal depression scale but are not coping; others, with depression, seem to the general practitioners and health visitors to be coping. I wonder whether an approach to new mothers that focuses on their ability to cope and the resources available to help them will be more fruitful than the recommendation to diagnose depression. Clinicians in primary care teams need not feel guilty about comments from the secondary sector that they are missing patients.

J P Richards, Professor of primary care.  .
School of Nursing and Midwifery, University of Glamorgan, Pontypridd, Cardiff CF37 1DL

1. Cooper PJ, Murray L. Postnatal depression. BMJ 1998; 316: 1884-1886[Free Full Text]. (20 June.)
2. Richards JP. Postnatal depression: a review of recent literature. Br J Gen Pract 1990; 40: 472-476[Medline].
3. Gerrard J, Holden J, Elliott SA, McKenzie P, McKenzie J, Cox JL. A trainer's perspective of an innovative teaching programme teaching health visitors about the detection, treatment and prevention of postnatal depression. J Adv Nurs 1993; 18: 1825-1832[Medline].
4. McIntosh J. Postpartum depression: women's help-seeking behaviour and perceptions of cause. J Adv Nurs 1993; 18: 178-184[Medline].
5. Watson JP, Elliott SA, Rugg AJ, Brough DI. Psychiatric disorder in pregnancy and the first postnatal year. Br J Psychiatry 1984; 144: 453-462[Abstract/Free Full Text].

Biology mustn't be excluded

EDITORBy stating that "there is little evidence to support a biological basis to postpartum depression," Cooper and Murray as psychologists risk the accusation of taking just as partisan an approach to the subject as biological psychiatrists sometimes do.¹ We are a species of supremely socialised primates who have evolved awareness of our inner drives and thoughts, so all human behaviour and illness, including mental illness, shares biological, psychological, and social factors that are so tightly overlapped and interwoven that to divide them in order to exclude some becomes futile. Would Cooper and Murray say, for instance, that there was no biological basis to the attachment behaviour of Harlow's rhesus monkeys or that there was no biology at the root of Bowlby's observations of human infant attachment?

Childbirth and early parenthood are profound psychosocial stressors, and these aspects must be prominent in any aetiological formulation of postpartum depression. But to see postpartum depression as arising only from these aspects would run counter to the impression of many psychiatrists. They believe that, rather than being a discrete homogeneous disorder, it lies in the middle of a spectrum of severity that culminates in postpartum psychosis, which clearly includes a biological factor in its aetiology.

The biopsychosocial approach to treatment of postpartum depression should use any therapeutic tool available, including pharmacological and other biological treatments, precisely because all current treatments are inadequate. The article states that drug treatment is no better than, and perhaps less welcome than, psychological treatment, but the fact that it is effective at all should be promoted rather than minimised. The alternative in clinical practice in many areas is a wait of several months for anything more than the most basic psychological treatments.

The detrimental effect of maternal depression on infant development was admirably described in the article and deserves the widest possible readership. This knowledge should spur us to our best multidisciplinary efforts for the many women and children who suffer from the adverse mental and physical consequences of childbirth.

Peter Talbot, Research fellow in mental health. 
Holywell Hospital, Antrim, Northern Ireland

^a peter.talbot{at}dial.pipex.com

1. Cooper PJ, Murray L. Postnatal depression. BMJ 1998; 316: 1884-1886. (20 June.)