Engaging

Women are often reluctant to admit how they are feeling and, in
some cases, particularly to doctors, who they fear will give them
an antidepressant. Women who present frequently to their child
health nurse or general practitioner, and do not appear to be
their usual selves should be asked again and again about their
own health. Talking about normal 'stress' rather than depression,
and engineering a view that to get help in fact makes them a
good mother, might help break down the barriers over time.

Management

Many women with postnatal depression can be managed, at
least initially, without medication. Unless the woman has very
significant or long-standing symptoms, it is worth starting with
psychosocial management. Antidepressants can be mentioned
as one possibility if things do not improve. Although trials have
been limited in postnatal depression, evidence suggests that
antidepressants do have a role in treatment.2
The key to deciding about medication lies largely in diagnosis
– is this an adjustment disorder or a major depression?
Management must also take into account the woman's
particular circumstances (see Box 2). The decision to prescribe
is made in conjunction with the woman, and ideally her partner.
Some partners are not supportive and may have strong views
about the effect of drugs when the woman is pregnant or
breastfeeding.

Psychosocial interventions

While postpartum psychosis (a probable variant of bipolar
disorders) may have a clear biological aetiology, perinatal
depression appears to begin at least as a stress response, in
someone predisposed through personality or genetics. While
the end result may be biological changes that will respond to
medication, unless the stress is dealt with, recovery is likely
to be delayed or prevented. In many cases, stress reduces as
the baby ages, becomes more predictable, and life develops
a routine. Women can be helped as they adapt to their new
lifestyle. They need an opportunity to talk about their feelings
and experiences. Although there are common themes, they will
vary among women. For some a traumatic birth may be
an issue, for others not being 'in control' or loss of lifestyle
may be crucial to their feelings.
Therapeutic groups can be effective3, but new mother groups
can be counterproductive with depressed women feeling they
are failures compared to the 'normal' mothers around them.
A specific group can target the common anxieties of these
depressed mothers, such as needing to be perfect and always
there for their child, as well as focusing on the relationship with
their infant. Many groups also include the partner for at least
some sessions as the advent of parenthood and coping with a
depressed woman can have a significant effect on the partner's
mental health, as well as on the relationship.
It is important to look at the available supports and try to
enhance these. Childcare to give the woman a break to have
time for herself is often something women desperately need,
but feel guilty about. If her main support is her mother or
partner and there is conflict in the relationship, it is important
to deal with this. Extra stress does not constitute support even
if the intention is there.
Specific cognitive behavioural or interpersonal strategies in
an individual setting can be helpful, although more research
is needed.4 Referral to a psychologist is worth considering.
Relaxation, yoga and meditation can all have benefits, but
are difficult for many women to implement. Website-based
interventions can be useful such as those provided by the
Centre for Clinical Interventions (www.cci.health.wa.gov.au).

Antidepressants in pregnancy

There are risks with antidepressants in pregnancy5,6, but it
is important to balance these largely unknown and seeming
relatively low risks with the risks of not treating depression.
Anxiety and depression in pregnancy can affect the fetus,
for example a higher cortisol concentration at birth can be
maintained for 10 years.7 Depressed women are also more likely
to smoke, and have poor nutrition and a risk of suicide.