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Rapid Responses: Rapid Responses published:
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Credit where credit is due?
- Ellen Goudsmit (9 August 2008)
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'Management' means more than one 'patient'
- Woody Caan (15 August 2008)
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Postnatal depression - don't forget children and fathers
- Ruth V Reed (18 August 2008)
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Postpartum period: When the thyroid might bring the blues
- Shirwan A. Mirza, MD, FACP, FACE (19 August 2008)
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Depression following child birth
- James Paul Pandarakalam (19 August 2008)
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Birth always takes place in a social context
- Sheila Kitzinger (22 August 2008)
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Early recognition of vulnerable women is everyone's responsibility
- Jasia Khan (28 August 2008)
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Ellen Goudsmit, Chartered Health Psychologist Teddington TW11 9QX
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As a specialist in post natal depression, I found the review in the BMJ both informative and authoritative. However, I'm not sure that NICE adopted the Whooley questions. When I assessed the draft guidelines as part of the team at the British Psychological Society, there were only two questions. I (we) suggested the third. Can the authors acknowledge the BPS team for alerting NICE to the need for the third question? I don't think it would have been there without us. Competing interests: None declared |
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Woody Caan, Professor of Public Health, Department of Child and Family Health Anglia Ruskin University, Cambridge CB1 1PT, UK.
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Thank you BMJ for an excellent clinical review of the common problem, postnatal depression. [1] However, 'PND' is rarely a disorder of just one person: the new Mother. The review misses the Family dimension of this treatable condition. The baby whose birth triggers the presentation of PND is likely to be affected for years to come, as are older siblings and even siblings as yet unborn, as the illness can distort the whole pattern of attachments within a household. Family violence is a major antecedent of PND, and increased marital dysharmony AFTER maternal onset of the illness is common: especially in first-time mothers under 20 years, we observed frequent desertion of depressed women by their men. The 'Respect' community research shows that depression and abandonment affecting the mother is a most common feature of anti-social behaviour orders implemented against the household... in the Respect Tsar Louise Casey's language 'out-of- control children' making 'neighbours from Hell'. PND is more common in the poorest families with the least fiscal and social capital. The same young parents may present with co-morbid alcohol problems, amplifying their low self-efficacy and the risk of injury to infants (and partners). First-hand assessment of the home environment, and the family system connected to the new Mother, is essential for adequate management of these problems. 1 Musters C, McDonald E, Jones I. Management of postnatal depression. BMJ 2008; 337: 399-407. Competing interests: Have (in the past) been involved in research on postnatal depression. |
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Ruth V Reed, Specialty Registrar in Psychiatry Berkshire Adolescent Unit, Wokingham Hospital, Barkham Road, Wokingham, Berkshire RG41 2RE
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The review of postnatal depression by Musters et al (1) was very useful but omitted some important aspects which must be borne in mind by the treating clinician. The ‘serious consequences’ that postnatal depression can have for a child were alluded to but not elaborated upon. Recent research has highlighted many concerning transgenerational effects, including reduced cognitive development (2), violence (3), and disturbances in behaviour and patterns of play (4). Cognitive therapies often have prohibitively long waiting lists of months or even a year, and mothers, particularly if breastfeeding, have a difficult decision to make regarding whether to accept psychotropic medication for their depression. Doctors will no doubt remember to warn the mother of the risks of medication passing through breast milk, but also have a duty to give women a balanced view of the long-term risks that untreated depression may potentially pose to their child’s social, intellectual and cognitive development, as well as to the quality of attachment and the later relationship between mother and child. Another neglected area is the existence and consequences of depression in fathers, which has received almost no public or professional attention, despite the commendable recent increase in publicity given to postnatal depression in women. Health professionals need to be aware of this condition and the similarly negative consequences it appears to have upon children (5), and be proactive in their efforts to seek and treat depression in new parents, whether male or female. 1 Musters C, McDonald E, Jones I. Management of postnatal depression. BMJ 2008:337;399-403. 2 Sharp D, Hay DF, Pawlby S, Schmücker G, Allen H, Kumar R. The impact of postnatal depression on boys’ intellectual development. J Child Psychol Psychiatry 1995; 36(8):1315-36. 3 Hay DF, Pawlby S, Angold A, Harold GT, Sharp D. Pathways to violence in the children of mothers who were depressed postpartum. Dev Psychol 2003; 39(6):1083-94. 4 Murray L, Sinclair D, Cooper P, Ducournau P, Turner P, Stein A. The socioemotional development of 5-year-old children of postnatally depressed mothers. J Child Psychol Psychiatry 1999; 40(8): 1259-71. 5 Ramchandani P, Stein A, Evans J, O’Connor TG, the ALSPAC study team. Paternal depression in the postnatal period and child development: a prospective population study. The Lancet 2005; 365:2201-2205. Competing interests: None declared |
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Shirwan A. Mirza, MD, FACP, FACE, Clinical Assistant Professor of Medicine Auburn, New York, NY
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Postpartum thyroiditis is a relatively common form of autoimmune thyroid dysfunction during pregnancy. There is a mysterious link between thyroid autoimmunity and pregnancy outcomes (higher risk of miscarriage)and a higher propensity for postpartum depression. In 30% of patients with post-partum thyroiditis, the thyroid goes through a transient period of hyperthyroidism, which could be confused with a manic episode of bipolar disorder, the thyroid might sometimes evolve into frank hypothyroidism, which could also manifest as depression among other symptoms. If one doesn't think or measure thyroid function in the postpartum period especially in women with goiter and symptoms suggestive of anxiety and or depression, it would be very easy to miss the diagnosis. Based on this association, I recommend thyroid function test (thyroid stimulating hormone and free thyroxine) and thyroid perxidase (TPO) antibodies in all my postpartum patients who are being evaluated for depression. Since vitamin B12 deficiency is common in patients with autoimmune thyroid disease and that this vitamin deficiency could cause depression, I also check vitamin B12 level during this period. Before diagnosing depression or bipolar disease in the postpartum period, one should ascertain that autoimmune thyroid disease is not the culprit. References: 1. Charles Musters, Elizabeth McDonald, and Ian Jones Management of postnatal depression BMJ 2008; 337: a736 3. Amino, N., Mori, H., Iwatani, Y., et al. High prevalence of transient post-partum thyrotoxicosis and hypothyroidism. N. Engl. J. Med. 1982, 306, 849-52. 4. Pedersen CA, Johnson JL, et al. Psychoneuroendocrinology 2007 Apr;32(3):235-45 Antenatal thyroid correlates of postpartum depression. 5. Kuijpens JL, Vader HL, et al. Thyroid peroxidase antibodies during gestation are a marker for subsequent depression postpartum. Eur J Endocrinol. 2001:145(5):579-84. 6. Harris, B, Othman, S, et al Association between postpartum thyroid dysfunction and thyroid antibodies and depression. BMJ 1992; 305:152. 7. Pedersen, CA. Postpartum mood and anxiety disorders: a guide for the nonpsychiatric clinician with an aside on thyroid associations with postpartum mood. Thyroid 1999; 9:691. 8. Kent, GN, Stuckey, BG, Allen, JR, et al. Postpartum thyroid dysfunction: clinical assessment and relationship to psychiatric affective morbidity. Clin Endocrinol (Oxf) 1999; 51:429. Competing interests: On the Speakers' Bureau Abbott Pharmaceutical |
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James Paul Pandarakalam, Consultant Psychiatrist 5 Boroughs Partnership NHS Trust,Pennington Unit, Leigh Infirmary, Leigh, Grater Manchester.
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Sir, Musters et al have given a balanced view of the management of postnatal depression and their treatment regime is based on a multifactorial aetiology of depression.1 There are suggestions that postpartum depression(PPD) is an evolutionary adaptation by way of expressing negative emotions of helplessness in order to get greater level of investment from others.2 Evolutionary psychologists propose that humans and non humans will not invest in their offspring when the cost outweigh benefits. Reduced care, abandonment, and killing of offspring have been documented in a wide range of species. In many bird species, both pre and post hatch abandonment of brood is common. Unlike non-human offspring, human infant demands extraordinary parent care. Postpartum period is a stage show for many of the evolutionary human instincts. In ancient cultures, there is a time-honoured practice of 40 days of “confinement”, and the family and relatives relieve her of household chores so the new mother gets enough rest for revitalising before she resumes her normal activities. As a matter of fact there is less incidence of PPD in traditional cultures. Such a finding probably points towards a prominent psychosocial aetiology in majority of the cases of PPD, and tally with the observation that there is a higher incidence of PPD among single mothers.In general depression is a psycho bio-social condition. In biological depression, there is more noticeable cognitive emptiness and affective blankness and these are indicators where biological causes predominate in PPD: such cases probably warrant more psychopharmacological intervention.PPD is also a testing arena for potential cases of bipolar disorder. 1.Musters Charles, MacDonald Elizabeth, Jones Ian. Management of postnatal depression.BMJ.2008;Vol 337:399-403 2.Trivers R.L. Parental investment and sexual selection. In B Campbell (Ed0 Sexual Selection and The Descent of man.1072; p136- 179.London:Helinemann. Competing interests: None declared |
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Sheila Kitzinger, Author and social anthropologist of birth Standlake, Oxford OX29 7RH
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I agree that the term postnatal depression is often applied indiscriminately. But Musters, Macdonald and Jones (1) go on to state that the main differential diagnoses of distress after childbirth are postpartum blues and postpartum psychosis. They write about birth as if it occurred in a social vacuum and fail to mention any social causes of depression. Yet as long as 40 years ago Brown and Harris published The Social Origins of Depression (2) and a few years later Oakley produced Women Confined (3) which also examined social causes of distress. The authors refer to hormonal and genetic causes and find the most plausible explanation of postnatal depression 'an abnormal sensitivity to the normal physiological changes of childbirth.' Curiously, they ignore poverty, poor housing, being a prisoner or failed asylum seeker who has her baby taken away from her, and, for many women, medical management in which the patient is tethered to machines, surrounded by strangers, treated primarily as a failed reproductive machine, and left feeling that birth was like rape. They explain distress as the outcome of a psycho- pathological process, locating the causes as inside the woman herself and the result of her faulty functioning. Many women who are struggling with post traumatic stress, constantly on red alert and tortured by nightmares, flashbacks and panic attacks, are wrongly diagnosed as depressed. Treatment with anti-depressants makes PTSD more severe and they feel further manipulated, isolated and disempowered. Above all, they need to be listened to, their experience validated, and come to realize that this is a normal reaction to abnormal stress. (4) (5) 1. Musters C, McDonald, Jones I, Management of postnatal depression, BMJ 2008;337:a736 2. Brown G, Harris T. The Social Origins of Depression, Tavistock, London 1978 3. Oakley A. Women Confined: Towards a Sociology of Childbirth, Martin Robertson, Oxford 1980 4. Kitzinger S, Birth Crisis, Routledge, London, 2006 5. Kitzinger C, Kitzinger S. Birth trauma; talking with women and the value of conversation analysis. British Journal of Midwifery 2007; 15; 5; 256 - 264 Competing interests: None declared |
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Jasia Khan, Foundation year one doctor St. George's Hospital SW17
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A very thorough review of postpartum dpression, which emphasises the need to recognise the development of postnatal depression early. I have been lucky enough to shadow a perinatal psychiatry team both in the community and at a formal mother and baby unit. My understanding is that women who are vulnerable to develop postnatal depression and are sought early, are the ones who go on to do well, as the appropriate support network is put into place. My feeling is that recognising women vulnerable to developing postnatal depression is not just a job for doctors. On several occasions, the midwives and health visitors played a pivotal role in both the recognition and management of postanatal depression. Midwives and health visitors also tend to spend more time with expectant mothers/mothers and so are key players in alerting appropriate health care professionals if they feel a woman is at risk. It would be very beneficial if the authors were able to advise the ideal way in which health professionals should communicate if they come across a woman giving them any cause for concern. Competing interests: None declared |
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