Post Natal Depression
11 October 2016
Postnatal depression (PND) is a serious and common disorder that occurs some weeks after delivery and may last for many months or one or two years. This is not the ‘baby blues’ for two or three days but a delayed depression sometimes with psychotic features. It occurs in at least 15% of women and frequently goes unrecognised because women regard this degree of depression and exhaustion as the normal consequence of looking after a new baby and certainly the exhaustion following night calls and breast feeding would be enough to make the strongest woman somewhat depressed.
Surprisingly postnatal depression does not seem to be associated with obstetric factors such as the length of labour, caesarean section, difficult labour or even separation of the mother and baby in the special care baby unit. It does not occur in one social class more than any other, and in fact the only environmental factor seems to be that the perceived level of support given by the partner to the woman.
Traditionally PND was treated by orthodox psychotherapy with antidepressants, discussions groups together with mother and baby units. This has hardly changed in spite of the strong evidence from randomised trials published in the last twenty five years that estrogens are effective in the treatment of these women even in those who had failed to respond to antidepressants. This has also been supported by the highly critical Cochrane database supporting the use of oestrogens, which improve depression and clearly stating that the alternative progesterone or progestogen makes depression worse.
It is very likely that the essential cause of postnatal depression is a sudden decrease of hormones particularly oestradiol that occurs after delivery. This is a huge; a hundred-fold sometimes even a thousand-fold decrease in oestradiol levels.
In this way it is a similar to the depression of premenstrual syndrome and the menopause which is also related to decreases of ovarian hormones particularly oestrogen. Only it is worse. In fact, later in life it is clear that women who had the most severe menopausal depression around the age of forty five years are those women who had a history of postnatal depression and premenstrual depression and incidentally felt very well during pregnancy when the hormone levels were high.
There was an interesting experiment from Bloch in the USA who mimicked the pregnancy hormonal changes in a group of women. Half of these women had a past history of postnatal depression and the other half had no history of postnatal depression. They were given high levels of oestrogen to mimic the pregnancy hormonal changes for three months and then the oestrogen was withdrawn. Of the eight patients with a history of postnatal depression, five developed depression again with this experiment and none of the patients with no previous history developed depression. At last there is clear experimental and therapeutic evidence that oestrogens help postnatal depression as well as logically being the obvious treatment.
Moderately high doses of transdermal oestrogens, such as 200micrograms of Oestradiol patches twice weekly, have been shown to be effective in postnatal depression, even in patients where prolonged antidepressants therapy has failed. Patches do leave marks on the skin so the current treatment would be to use transdermal gels about four measures daily as an effective treatment of postnatal depression. When we consider the three components of Reproductive Depression, premenstrual, postnatal and perimenopausal depression in the history of the forty five-ish year old woman, who by this time has suffered twenty years of varied but ineffective antidepressant therapy it becomes quite clear that the postnatal depression incident was the tipping point when it has to be effectively treated.
The 40 to 50 year old patient with long term depression who has not been improved by antidepressants over the years will often say that she were last well without depression during her last pregnancy then postnatal depression occurred followed by cyclical depression lasting for years. Many psychiatric drugs did not work and antipsychotic drugs for a misdiagnosis of bipolar disorder was a ghastly experience for her. This commonplace sad history is a result of the doctor failing to link the depression with the hormonal turmoil of PMS and the postnatal state.
Recently it has been recognised by psychiatrists that women with Bipolar disorder have an 8 fold increase in postnatal depression. That makes sense of the BPD is in reality PMS because psychiatrists are unable to recognise PMS . More recent studies show that 60% of women with pre pregnancy PMS develop PND.Transdermal estrogens should be first line therapy for PND as it will spare the woman 10-20 years of poorly treated Reproductive Depression