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Post-natal Depression Post-natal depression is a serious and common disorder that occurs some weeks after delivery and may last for many months. It occurs in at least 15% of women and frequently goes unrecognised because women frequently regard this degree of depression and exhaustion as the normal consequence of looking after a new baby. Surprisingly it does not seem to be influenced by obstetric factors such as length of labour, Caesarean section or even separation of the mother from the baby in the Special Care Baby Unit. It does not occur in one social class more than another and in fact the only environmental factor seems to be the perceived level of support given by the partner to the women. Traditionally this has been treated by orthodox psychotherapy with antidepressants, discussion groups together with Mother and Baby Units. It is very likely that the essential cause of post-natal depression is the sudden decrease in hormones, particularly oestradiol that occurs after delivery. In this way it is similar to the depression of pre-menstrual syndrome and the menopause which is also related to decreases in ovarian hormones, particularly oestrogen. In fact later on in life it is clear that women who have the most severe "menopausal" depression around the age of 45 are the women who also had post-natal depression, pre-menstrual depression and significantly felt very well during pregnancy when the hormone levels were high. Moderately high doses of transdermal oestrogens (200 mcgs twice weekly) have been shown to be effective in post-natal depression even in patients where prolonged anti-depressants have failed. We have a Psychoendocrine Unit at the Chelsea & Westminster Hospital, London dealing with this problem and believe this treatment, shown to be effective, by a scientific study published in the Lancet (1) should be used more often. Reference
There is a syndrome of Reproductive Depression related to sudden changes of gonadal hormones. Postnatal depression is perhaps the most obvious and dramatic example of this but it also occurs with cyclical premenstrual depression and peri-menopausal depression. These often occur in the same vulnerable patient who responds abnormally to normal fluctuations of oestrogen and perhaps also progesterone (1). Although there are randomised studies to show that each component of this triad of hormone responsive mood disorders respond to transdermal oestrogens usually in a dose of 100-200 micrograms of oestradiol patch, such therapy is virtually never used by psychiatrists. We are all products of our training and no doubt psychiatrists are not familiar with the simple problems of hormone therapy such as breast discomfort and uterine bleeding, which could be dealt with by any competent general practitioner (2). In the case of postnatal depression it is much easier for them to use a whole gamut of treatments ranging from mother and child units, SSRI antidepressants and even ECT rather than prescribe oestrogens which are the logical and proven treatment producing a rapid improvement in symptoms (3). It is a predictable that the recent paper from Chile does not mention oestrogens in the wide range of treatments reported (4). There is experimental evidence that women with a past history of postnatal depression develop more depression on hormonal manipulation that mimics the increase of oestrogen and progesterone with pregnancy and the fall, which occurs post-partum (5). The tragedy is that the efficacy of oestrogens in the treatment of postnatal depression is as proven as it is logical but still the world of psychiatrists would not consider using oestrogens for this severe disorder nor for premenstrual depression nor for the perinatal depression in the woman who is still having regular or irregular periods. It is not even the WHI data which deters them as this neglect antedated these data. But we should take the reassurance that even the much criticised WHI study showed that women who start oestrogen therapy below the age of 60 have fewer heart attacks, less breast cancer and fewer deaths than in the placebo group (6). Also oestrogens given in the transdermal rather than oral route do not elicit abnormal coagulation patterns. There is no reason why oestrogens should not be used for postnatal depression but for reasons of ignorance and prejudice.Reference 1. Studd J , Panay N. Hormones and Depression in Women. Climacteric 2004. 7: 338-346 2. Studd J, Why are estrogens rarely used for the treatment of depression in women Gynecol. Endocrinol 2007; 23: 63-64 3. Gregoire AJ, Kumar R, Studd J W, Transdermal Oestrogen for the Treatment of Severe Postnatal Depression, Lancet 1996; 347: 930-933 4. Rojas G, Fritsch R, Solis J. Treatment of postnatal depression in low income mothers in primary care clinics in San Diego, Chile, Lancet 2007; 370: 1593-1595 5. Bloch H, Schmidt PJ, Rubinow DR, Effects of Gonadal Steroids in Women with a history of post-partum depression. Am. J. Psychiatry 2000; 157: 924-930 6. Anderson G. L, Limacher, Assaf AR et al. The Women’s Health Initiative Steering Committee, Effects of Conjugated Equine Oestrogen in Postmenopausal women with hysterectomy. Journal Am Med Asoc 2004; 291: 1701-1712 |
