Guideline No 60: Postnatal Depression and Puerperal Psychosis

Postnatal depression and puerperal psychosis
Section 3: Management

Untreated postnatal depression may be prolonged and may have a deleterious effect on the relationship between mother and baby and on the child's cognitive and emotional development.^4,91 However, the response to both pharmacological and psychosocial interventions is good.¹⁴ Evidence level 1+,2+

Postnatal depression and puerperal psychosis should be treated.

Many women are reluctant to consider the use of psychotropic medicine during pregnancy and the postnatal period. The choice of treatment for postnatal depression should be governed by efficacy, incidence of side effects, likely compliance, patient preference and, in the case of pharmacological therapies, safety of use when pregnant or breast feeding (see section 4).

There are instances where the mother and infant may be at risk because of the mother's mental illness. Although rare, infanticide and suicide do occur. Multidisciplinary risk assessment and risk management protocols and, if necessary, local child protection procedures should always be followed when there is the potential for serious harm to the mother and/or baby.⁹² These should provide a protective framework by ensuring good communication between the family and professionals.

3.1 Pharmacological and physical management

3.1.1 POSTNATAL DEPRESSION

Hormonal therapies

Hormonal therapies have been the subject of considerable debate, however little reliable evidence is available. No evidence could be identified for the effectiveness of natural progesterone or synthetic progestogens in the treatment of postnatal depression.⁹³

One double blind randomised controlled trial indicates that transdermal oestrogen (with cyclical progestogen) is more effective than placebo in moderate to severe postnatal depression.^93,94 However, concern about side effects, particularly endometrial hyperplasia and thrombosis, may limit its use. Evidence level 1-

Antidepressants

A randomised controlled trial of the use of antidepressant therapy in postnatal depression carried out in a community setting in Manchester demonstrated a beneficial effect from fluoxetine combined with at least one session of modified cognitive behavioural therapy (CBT) in women with mild postnatal depression.¹⁴Evidence level 1+

Evidence from a case control study carried out in the United States suggests that both SSRIs and tricyclic antidepressants (TCAs) are effective in postnatal depression.⁹⁵ A small case series suggests that SSRIs are no less effective in patients with postnatal depression than in other patient groups.⁹⁶Evidence level 2-,3

Physical therapies

No evidence was identified relating to the use of electroconvulsive (ECT) therapy in postnatal depression.

St John's Wort (hypericum perforatum)

No evidence was identified relating specifically to the treatment of postnatal depression by St John's Wort or other alternative medicines. The potential for interactions with other prescription medicines and the lack of pharmacoregulation of these products means that caution should always be exercised before recommending their use in pregnancy and lactation.⁹⁷

Physical exercise There is good evidence to support the role of exercise in reducing levels of depression in the general population⁹⁸ but little research has been conducted into its role in postnatal depression.⁹⁹

Postnatal depression should be managed in the same way as depression at any other time, but with the additional considerations regarding the use of antidepressants when breast feeding and in pregnancy (see section 4).

St John's Wort and other alternative medicines should not be used during pregnancy and lactation until further evidence as to their safety in these situations is available.

The use of hormonal therapies in the routine management of patients with PND is not advised.

3.1.2 PUERPERAL PSYCHOSIS

There is limited evidence for the effectiveness of treatment specifically for puerperal psychosis. As the nature of puerperal psychosis is essentially affective, treatments used for affective psychoses in general are also appropriate for puerperal psychosis. Such treatments would typically involve one or more drugs from the antidepressant, mood stabilising or neuroleptic groups and /or occasionally ECT.

Puerperal psychosis should be managed in the same way as psychotic disorders at any other time, but with the additional considerations regarding the use of drug treatments when breast feeding and in pregnancy (see section 4).

3.2 Psychosocial management

The evidence relating to the role of psychosocial interventions in the treatment of postnatal depression focuses mainly on the "talking" therapies, including counselling, psychotherapy, and approaches based upon these techniques. A number of studies have investigated the role of complementary therapies, including massage, infant massage and relaxation therapies in postnatal depression; and a few studies have reviewed the interaction between the depressed mother and her infant. The majority of published studies are descriptive and observational in nature. Methodological weaknesses and small sample sizes limit the conclusions that can be drawn from the few randomised controlled trials identified.

3.2.1 COUNSELLING AND PSYCHOTHERAPY

A number of studies indicate that this type of intervention, when provided by trained practitioners, can significantly reduce depressive symptoms in women diagnosed with postnatal depression.

Counselling

Counselling is a systematic process which gives individuals an opportunity to explore, discover and clarify ways of living more resourcefully and with a greater sense of wellbeing. It may be concerned with addressing and resolving specific problems, making decisions, coping with crises, working through conflict, or improving relationships with others.¹⁰⁰

Evidence consistently demonstrates that a systematic intervention based on non-directive counselling (supportive listening without giving opinions or advice) of around six to eight sessions, delivered by trained primary health care workers (e.g. health visitors), is effective in reducing mothers' depression in the postnatal period compared with routine care.^7,101,102 Although there are some difficulties in defining "routine care" and one of the studies is now over 15 years old, the size of the effects described outweighs the problems of completely controlling confounding variables. Evidence level 1+

Cognitive behavioural approaches

Cognitive behaviour therapy (CBT) is a structured therapy combining concepts and techniques from cognitive and behaviour therapies. It seeks to solve problems and reduce symptoms by changing unhelpful thoughts, beliefs and behaviours.¹⁰⁰

Brief interventions using cognitive behavioural and problem-solving approaches are effective in reducing depressive symptoms in women during the postnatal period.^7,14 Such interventions, which are based around a minimum number of sessions, can be as effective as antidepressants in alleviating the symptoms of mild to moderate depression in new mothers.¹⁴Theuse of these techniques can be transferred to telephone counselling with good effect.¹⁰³Evidence level 1+

Interpersonal therapy

The interpersonal therapy approach focuses on the mother's past and present relationships, including the relationship with her own mother, and helps her to relate problematical aspects of these relationships to her current depression.

Interpersonal therapy has been shown to significantly reduce depressive symptoms in postnatally depressed women.¹⁰⁴Evidence level 1+

3.2.2 SOCIAL SUPPORT

The relationship between postnatal depression and adverse social circumstances is similar to that for depression generally. Both cultural and environmental factors are important when considering social support and little work has been done specifically in Scotland.

There are various local initiatives and responsive services in Scotland offering support to the mother, the baby and family. Many of these have been established by practitioners with an interest in the field of postnatal depression and, like much of current practice, have not been subjected to rigorous evaluation.

Systematic review of a small body of evidence indicates that social support may be helpful in reducing depressive symptoms in the mother.¹⁰⁵ Help must be carefully matched to the mother and family's particular needs to avoid undermining the mother's confidence and place in the family.^106,107 Evidence level 1+

It is clear from a number of studies that a mother's perception of lack of support can be a risk factor in predisposing her to depression. A mother's ability to use social support (e.g. home help and childcare) may be affected by her depression. A confiding relationship and secure adult attachment are protective factors.¹⁰⁸Evidence level 2+

3.2.3 FAMILY FOCUSED INTERVENTIONS

Several studies focusing on interventions involving the mother and partner and mother with baby have described various benefits.^{109,110,111,112}

Couple interventions

One study suggests that couples involved in an individual or group intervention focused on parenting and their reactions to it experience a reduction in their depressive symptoms and a benefit to their general health.¹⁰⁹Evidence level 1+

Interaction focused interventions

The quality of relationship between a mother and her child may be adversely affected by the mother's depressive condition. Several early intervention studies suggest that working with depressed mothers in order to teach different response patterns to their children can positively affect the mother-infant bond.^110,111 Evidence level 4

Infant massage

A small randomised controlled study demonstrated that attending infant massage classes had a significant and positive effect on both mother-infant interaction and depressive symptoms in the mother.^112,113Evidence level 1-

Psychosocial interventions should be considered when deciding on treatment options for a mother diagnosed as suffering from postnatal depression.

Interventions that work with more than one family member at a time should be considered when assessing the treatment options available.

The effects of a mother's postnatal depression on other family members and their subsequent needs should be considered and support offered as appropriate.

The psychosocial treatment option chosen should reflect both clinical judgement and the mother's and family's preferences where possible.

3.3 Mother and baby units

In severe cases of postnatal depression and puerperal psychosis, there is frequently a difficult question: whether admission to hospital would hasten the recovery of the mother. If the answer is yes, there is an important follow-up question: whether to admit the baby as well. This applies equally to mothers with severe postnatal depression or puerperal psychosis and to mothers with a schizophrenic illness exacerbated by the impact of a new baby.

Several studies have examined whether mother and baby admissions are an effective approach. The papers are descriptive, largely written by the clinicians running the units. The authors have generally found advantages in avoiding separation of mother and infant: establishing positive attachment, enhancing the mother's confidence in her maternal role, and providing support to the husband and family.^114,115,116 A study of a specialist day hospital has also shown benefits for mother and baby.⁶⁸Evidence level 2+

There are concerns, however, that admission of mothers with their babies to general psychiatric wards may not adequately ensure the safety and security of the baby. Guidelines published by the Royal College of Psychiatrists discourage such ad hoc arrangements and recommend the provision of mother and baby units.⁶⁸ In England, the Mental Health Act Code of Practice and other national guidance states that infants should not be admitted to general psychiatric wards.^117,118 The SIGN guideline development group endorses these recommendations. Evidence level 4

The option to admit mother and baby together to a specialist unit should be available.
Mothers and babies should not routinely be admitted to general psychiatric wards.

A multiprofessional assessment, including social work, and involving family members, should take place to review the decision to admit mother and baby to a specialist unit either before or shortly after admission.

Clinical responsibility for the baby whilst the mother is an inpatient needs to be clearly determined.