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CLINICAL REVIEW: Peter J Cooper and Lynne Murray Fortnightly review: Postnatal depression BMJ 1998; 316: 1884-1886 [Full text]

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What about Breastfeeding?

Jack Newman   (22 June 1998)

Don't exclude biology.

Peter Talbot   (22 June 1998)

Is postnatal depression really missed in primary care?

J P Richards   (17 July 1998)

What about Breastfeeding? 22 June 1998
Jack Newman, Asst. Professor, University of Toronto Toronto Hospital, Toronto Send response to journal: Re: What about Breastfeeding?	The review article on postpartum depression was interesting and relevant, but I was disappointed that the authors did not mention the importance and the need to preserve the breastfeeding relationship. Indeed, I don't think the word "breastfeeding" was mentioned at all. Breastfeeding is jeapordized by depression because physicians will treat with oestrogens, which decrease the milk supply considerably, or feel that usual antidepressants are contraindicated during breastfeeding or mothers are hospitalized and thus separated from their babies. Breastfeeding is particularly important to maintain for some of the that is, that children of depressed mothers often will have later behavioural and cognitive problems because of a disturbed mother-child relationship. Oestrogen therapy should be avoided in the nursing mother. Some antidepressants, such as sertraline (Zoloft) are almost certainly safe for mothers to take while breastfeeding. And even if mothers occasionally require hospitalization, it is possible, in many situations to maintain breastfeeding, even keep the mother and baby together, in hospital. The problem of breastfeeding in western societies is that nobody thinks about it, despite ample evidence of its importance to the mother and the baby's psychologic and physical health.
Don't exclude biology. 22 June 1998
Peter Talbot, Research Fellow in Mental Health Holywell Hospital, Antrim Send response to journal: Re: Don't exclude biology.	By their bald statement that 'there is little evidence to support a biological basis to postpartum depression' Professors Cooper and Murray as psychologists risk the accusation of taking just as partisan an approach to the subject as can biological psychiatrists. As we are a species of supremely socialised primates who have evolved awareness of our inner drives and thoughts, 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 Professors 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? Of course childbirth and early parenthood are profound psychosocial stressors and these aspects must be prominant in any aetiological formulation of postpartum depression. But to see it as only arising from these aspects would run counter to the impression of many psychiatrists that postpartum depression, rather than being a discrete homogeneous disorder, lies along the middle of a spectrum of severity culminating 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. While the article states that drug treatment is no better, and perhaps less welcome, than psychological treatment 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. That said, the clear detrimental effect of maternal depression on infant development was admirably well put 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.
Is postnatal depression really missed in primary care? 17 July 1998
J P Richards, Professor of Primary Care School of Nursing and Midwifery, University of Glamorgan, Pontypridd, CF37 1DL Send response to journal: Re: Is postnatal depression really missed in primary care?	Cooper and Murray comment in their review of postnatal depression that ‘depression is often missed by primary care teams’ (1). There are a number of 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 ten years (2). When the Edinburgh Postnatal Depression Scale (EPDS) has been used to detect postnatal depression, health visitors have employed a variety of strategies to help women with varying degrees of success (2,3). Factors that have been reported to influence the process of screening and caring for women with postnatal depression include: health visitor workload and willingness to use the EPDS (3), the readiness of women to be labelled as patients with depression or to accept a health visitor intervention (2,3,4) or to be referred for further care (2,3). There is still uncertainty about the timing of the EPDS and about where to set the threshold for the purposes of screening (2,3) and about how to prioritise patients and determine which intervention is likely to be the most appropriate and effective (2,3,4). Not all women experiencing postnatal depression are the same. Watson and colleagues showed that women experiencing postnatal depression could be differentiated 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-centered approach is the most appropriate and more likely to be successful than reliance upon just medication or counselling (4). Cooper and Murray highlighted the impact of postnatal depression upon child development and behaviour in their review and comment that this can be a consequence of communication problems. The impact of postnatal depression upon a mother’s ability to cope, which is a difficult concept to measure and evaluate, may be the most significant 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 EPDS but who are not coping whilst others with depression seem to the general practitioners and health visitors to be coping. I wonder whether an approach to new mothers that focuses upon their ability to cope and the resources available to help them will be more fruitful than the recommendation to make a diagnosis of depression. Clinicians in Primary Care Teams need not feel guilty about comments from the secondary sector that they are ‘missing patients’. References 1. Cooper PJ, Murray L Postnatal depression BMJ 1998;316:1884-6 2. Richards JP Postnatal depression: A review of recent literature. Br J Gen Pract. 1990; 40: 472-476 3. Gerrard J, Holden J, Elliott SA et al 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 4. McIntosh J Postpartum depression: women’s help-seeking behaviour and perceptions of cause. J Adv. Nurs 1993; 18: 178-184 5. Watson JP, Elliott SA, Rugg AJ, Brough DI Psychiatric disorder in pregnancy and the first postnatal year. BR J Psych. 1984; 144: 453-462