WebChat With Postnatal Depression Counsellor Liz Wise.
Postnatal depression counsellor Liz Wise hosted a webchat in April. She answered your questions on PND, including treatments, recognising the symptoms and talking to your GP.
Liz is a specialist postnatal depression counsellor who has been supporting mothers with PND for the past 25 years. Having had severe PND after both her children, she has a great deal of personal and professional experience. Liz also sits on the commitee for The Association for Postnatal Illness and has also produced the popular DVD, Understanding Postnatal Depression.
Preventing Postnatal Depression
Q. My relationship broke down while I was pregnant, and shortly before this I moved to a new city with my husband. I am now due to give birth alone and feel fairly isolated in my new city. I have no family support and I feel concerned that I am at risk of PND once the baby is born, although I have not had depression in the past. Is there anything I can do to minimise the risk of being hit by PND once the baby is born?
Liz Wise: I'm sorry to hear that you're feeling very isolated in a new city and don't have family support around you. I think it would be a really good idea for you to talk to your doctor about your feelings, so they can try and get you some ongoing support. I wonder if there's any practical support that a charity such as HomeStart could offer you? Again, your GP or health visitor should know about this. It would be a good idea to talk to someone that you totally trust about your fear of getting PND.
Q. Do you think the use of positive psychology (resilience training, human givens therapy, mindfulness, teaching of relaxation techniques etc) could prevent postnatal depression in at-risk women? Do you think there should be more critical assessment to see what types of counselling/medication works for each individual?
Liz Wise: I definitely think the use of positive psychology and cognitive behavioural therapy (CBT) could help prevent PND in some women. However, it would be important to learn this before, as getting a grip on it when you are depressed is very hard. Yes, I think it is important to assess individual mothers to know what type of treatment and/or support is needed.
Recognising the symptoms
Q. I suffered from severe postnatal depression after the birth of my daughter. My husband realised this pretty quickly and encouraged me to seek help but I was convinced that it was just sleep deprivation. How do you differentiate between a woman 'just' being sleep deprived and it being PND?
Liz Wise: Sleep deprivation definitely contributes to PND and tiredness certainly makes it worse, however there are mums (most, in fact) who are sleep deprived but are not depressed. Sleep deprivation would not usually be a factor on its own to cause PND.
Q. Where does 'normal' life after a baby end and PND begin? Is there any link regarding prenatal depression/anxiety and postnatal illness? Is it a case of one or the other or is it mix and match? And how do you think diagnosing PND years after the birth fits into all of this? Are prenatal and postnatal depression just a way of saying a woman with children is depressed.
Liz Wise: Around 10% of women have some symptoms of depression/anxiety whilst pregnant and two-thirds of mums with PND have had some symptoms prenatally. However, it does not necessarily mean that if you have antenatal depression you will have PND. PND is depression after childbirth, not ongoing depression
Q. If untreated, can PND, and even prenatal depression, just stay with a woman for the rest of her life? Is it possible that a mother can still be suffering from this 10 years or more after the birth of a child? Or, over time, does it sort of go away of its own accord?
Liz Wise: That really depends on the individual and their own circumstances. I have met women in their 50s and 60s who say they had PND which was not treated, and they have gone on to have depressive episodes. However, I have also met women who have not had any treatment or support who have made total recoveries. In my experience, mums who have it recognised and treated recover quicker and more fully.
Q.To me, the whole area is a muddle of psychological, physical and social issues. It has sometimes struck me that there's "acceptable" PND (hormonally related in a woman with no history of mental health problems and treatable with antidepressants) and the altogether more "messy" sort. Are they two separate disorders?
Liz Wise: I would agree that there's a real muddle of disorders and there are many women who have PND who have no history of mental health problems. I myself was one of them. It would depend on the mental health issue as to whether you would see them as two separate disorders. Someone with bipolar or schizophrenia may well be treated with different medication and support than a mother who does not have an existing mental health issue.
Q. I had PND, and it frustrates me so much that people still always assume that this means you don't bond with your baby. Why is there is misconception and what can be done to challenge it?
Liz Wise: It is a myth that if you have PND you don't bond or love your baby. Many mums I work with have no problems with bonding, even though they have PND. Unfortunately, for some mums the severity of their depression doesn't allow them to feel the bonding or feelings of love for their baby. However, as the depression lifts the feelings will start to emerge.
Q. I developed severe PND after the birth of my third baby. I had periods of psychosis and ended up in hospital. Two years and seven months later, I still suffer very badly at times and I am currently on five different types of medication. How long can PND continue? I feel ridiculous that I am still struggling after all this time.
Liz Wise: PND is different to postnatal psychosis and I'm sorry to hear that you are still suffering badly at times. Usually, PND is a temporary episode of depression that doesn't reoccur once it has totally lifted.
Q. I have had very broken nights for seven months now and my mood is often very low. My GP thinks I'm "just tired". How can I tell the difference?
Liz Wise: I think only you will be able to tell the difference by asking yourself if you are able to enjoy things when you're not so tired, if you have other symptoms of PND and feelings of feeling very different to before you had the baby.
"I ask two questions when supporting mums with PND: are you able to look forward to anything and are you enjoying anything? If these are both answered with a no then discussion around other feelings and thoughts needs to take place."
Q. Where does normal reaction to becoming a parent end, and PND begin?
Liz Wise: I think the line between normal reactions to becoming a parent and PND is in how the mum is feeling herself. Most of us have anxieties adjusting to becoming a parent but not all of us have symptoms of depression, eg low mood, inability to sleep, obsessive thoughts, panic attacks.
"I ask two questions when supporting mums with PND: are you able to look forward to anything and are you enjoying anything? If these are both answered with a 'no' then discussion around other feelings and thoughts needs to take place."
There are mums who have similar thoughts and feelings as mums with PND but they are not causing problems for them and they are able to look forward to and enjoy things.
Q. Do you think there's a complete spectrum of experience from content and happy through to seriously depressed? As in, can you really say when so/meone has PND and when they don't? Aren't some people (speaking from personal experience) just either undiagnosed or slightly sub-clinical/sub-threshold?
"I do think there's a complete spectrum of experience from content and happy to seriously depressed. There are various degress of having postnatal depression."
Liz Wise: I think in the majority of cases, you can really say when someone has PND, by assessing them from how they tell you they are feeling. I do think there's a complete spectrum of experience from content and happy to seriously depressed. There are various degrees of having postnatal depression. I think some people are slightly sub-threshold, however it is important to offer them the same level of treatment and support as you would with a woman who has been diagnosed with PND.
Q. I am interested in the lesser known postnatal illnesses, like postnatal obsessive-compulsive disorders and postnatal anxiety. Why are they always bundled up with PND (as lists of PND symptoms always seem to list 'anxiety, obsessions, intrusive thoughts, repetitive behaviours, etc.')?
This seems to mean that mothers with non-depression-based mental health problems get overlooked, and aren't dealt with properly. I have a friend who has had depression in the past but now feels she is having OCD behaviours - her GP just keeps telling her it's PND and trying to treat her 'depression', which of course isn't working.
Non-mothers with OCD/anxiety don't get treatment for depression, they get OCD specific treatment so why do mothers with PND-OCD and PNA get treated for depression?
Liz Wise: PND has many different symptoms, including OCD and anxiety. Sometimes it may be difficult to separate OCD from PND, however it would be treated in the same way in a person who had OCD but no depression.
When OCD is part of PND it tends to get better as the depression lifts. OCD in PND has a lot to do with gaining some control, as when one has PND there seems to be very little control felt.
Q. I am certain I had PND but did not go to my GP. My son is now four, but is it still possible to have PND? How is it differentiated from "depression"?
Liz Wise: It may be that you are still experiencing some depression left over from your PND, if it was never totally resolved. The difference between PND and depression is the timing of it; PND is a depressive episode after childbirth, which usually is isolated and temporary. Usually after a couple of years, if having being treated and supported, the depression will be better. It may be a good idea for you to talk this through with your GP if you haven't done already, so you can get some support.
Q. I was wondering what the difference is between a diagnosis of depression and PND? I have had two episodes of depression, each lasting one to two years, and two months ago was diagnosed with PND. But I don't feel any different now than I did previously, other than it has worsened my OCD tendencies.
"The difference between a diagnosis of depression and PND is timing. PND is a depressive episode after childbirth, whereas depression can occur at any time."
Liz Wise: The difference between a diagnosis of depression and PND is timing. PND is a depressive episode after childbirth, whereas depression can occur at any time. As you have had previous depression, it did put you at a slight increased risk of having PND. The symptoms and feelings of depression and PND are very similar, however having a baby to look after can make the depression feel worse.
Q. I wonder if the things that make you prone to anxiety and depression are likely to be triggered by becoming a parent? Issues relating to control, perfectionism, black-and-white thinking, added to by sleep deprivation, and by societal expectations.
Liz Wise: Yes, I do think some of those issues may make you prone to PND along with other factors. However, I have known women who would class themselves as liking to be in control and perfectionists who haven't have PND.
Q. Someone close to me has suffered long-term PND following a traumatic birth. Her own mother had a traumatic time in giving birth to her as well. I wonder if there is a connection? I don't mean genetically, but in terms of early birth trauma possibly leading to anxious parenting, leading to an anxious child, growing up to be an anxious mum etc?
Liz Wise: Yes, I think there is probably a connection, as birth trauma is a possible risk factor of PND. However, if this is dealt with when the woman is feeling strong enough to address it, it should not lead to anxious parenting and an anxious child etc. This brings me to traumas in our life that are not resolved; if we suppress them, they can raise their ugly head years down the line.
Q. I wonder if "maternal depression" would be a better term for PND? Just to give more emphasis to the tremendous social and personal changes a woman experiences as she becomes responsible for caring for a young baby?
Liz Wise: I think maternal depression may be different to PND, as 'post-natal' is a short period after the birth. However 'maternal' implies that the depression is ongoing.
Q. I think it's a miracle that mothers avoid PND! I meet so many pregnant women who tell me that they've never even held a baby, but they're preparing with books that have rigid schedules (ie advising you, "At 11 weeks your baby needs 16 hours and 45 minutes sleep a day" and a routine which requires you to start expressing breastmilk at 6:40am). Is it any surprise that babies don't do as the books say and mothers feel like failures?
Liz Wise: Yes, I totally agree with you. I think there is far too much pressure on pregnant women to become 'supermums'. We all parent differently according to how it feels for us. There is no right or wrong in how you deal with your own baby, within reason.
Q. It sometimes baffles me how people don't get PND. I think it is made worse by society painting motherhood as this amazing experience - you bond straightaway, it all comes so naturally and it's all lovely. But so many people I speak to don't have that experience and feel like massive failures if they don't.
"There is a big difference between someone with PND, and someone who is finding it hard adjusting to motherhood. Many new mums have feelings of inadequacy, are tired, a bit anxious, but with PND these feelings are very exaggerated and cause day to day problems for the mother."
Liz Wise: I totally agree with you that there is too much pressure on mums to bond straight away. Not all mums take to it naturally, and often feel guilty if they don't. However, for a mum with PND these feelings are exaggerated and make her feel negative and have an effect on her day-to-day life.
Q. Do you ever wonder if the term 'PND' downplays the social reality women face upon having children? I think it detracts attention from what it is about having a baby that causes depression and, instead, plants the idea that it is just something 'wrong' with each of those individual women and not a pattern at all?
Liz Wise: That is a really good question. However, there is a big difference between someone with PND, and someone who is finding it hard adjusting to motherhood. Many new mums have feelings of inadequacy, are tired, a bit anxious, but with PND these feelings are very exaggerated and cause day to day problems for the mother.
Talking to your GP
Q. How do you think GPs and health professionals can be encouraged to take PND seriously, but also appropriately? When I was pregnant with my third daughter I was concerned about PND after having had it twice before. My GP was supportive, but the midwife and consultant dismissed it as unlikely.
Liz Wise: I think it varies greatly for health professionals, as with all professions, some take it more seriously than others. I'm surprised that as you had had PND twice before that it wasn't taken more seriously by your midwife and consultant and the only support you were offered was a group, not any one-to-one counselling.
I think PND should be part of every health professional's training and that it needs to be spoken about more to get rid of the stigma attached to it.
Q. I had PND following a traumatic birth of my first daughter, but although symptoms were there from very early on, things didn't escalate until I stopped breastfeeding when my daughter was five months old. Despite showing the full range of symptoms (including obsessive behaviour, suicidal thoughts, hysteria, despair and anxiety), I was told by my GP that he didn't think I was depressed, because my daughter was five months old and not a newborn.
Are GPs routinely given training on how to diagnose PND? If a patient or health visitor can't get help through this avenue, where else can they turn? Are there NHS/funded services that can be accessed without having to go through a GP referral? If so, are health visitors aware of them? Mine was brilliant, visited me every other day and called me daily to check I was OK, and even she seemed to draw a bit of a blank when the GP failed to diagnose me.
Liz Wise: I'm sorry to hear that you had such a dreadful lack of support for your PND. As with any other profession, GPs and health visitors do vary and I think I would have been tempted to ask to see another GP. However, I know when you're depressed, trying to be assertive can be virtually impossible. To be told that because your daughter was five months old it couldn't be PND is outrageous. PND can manifest itself months after delivery. I am aware that GPs are routinely given training on postnatal depression. However, if there are no answers from the health visitor or GP, I would be tempted to change my GP practice and go somewhere else. It is quite unusual for a health visitor and GP not to offer any support.
Q. I had PND with my daughter (now three and a half years old) and again with my son (who is now one). With my daughter, 150mg of sertraline worked; with my son I caught it early (six weeks) and tried both sertraline (200mg) and mirtazapine (30mg) at different stages and although they helped some symptoms, I was left feeling like I had PMT all the time; black moods, snapping, feeling rage.
I went on the mini-pill five months ago and there was an overnight transformation. I am now on the mini-pill and 150mg sertraline and am much better. Will I have to remain on the mini-pill indefinitely and is there an underlying cause of this hormonal imbalance?
Liz Wise: For some women the mini-pill can help their PND, for others it makes it worse. I would suggest talking to your GP about a possible hormonal imbalance. I wouldn't have thought you would have to stay on the mini-pill indefinitely, as I would think the sertraline is probably making you better rather than the mini-pill.
Q. I have been receiving treatment for PND for about six months now, although I think I should have requested help a few years earlier. Do you think PND is ever 'cured'? My GP has recommended I remain on antidepressants for around two years. I have experienced a massive positive change in the last six months and have no problem with being on medication if they work, but am also scared of becoming overly dependent.
Liz Wise: I think the very fact that as your PND wasn't recognised or diagnosed for a few years, it would be a good idea for you to remain on medication for a couple of years. I think that is very sensible advice from your GP. There should be no reason for you to become dependent on them, as if they are working, you in turn will be getting better. As long as you don't come off them too early or too quickly, there should be no reason for you to have a relapse.
Q. How can we untangle the fact that having PND makes you lose your grip on reality, so that it is hard to tell whether your fears about admitting how you feel are in proportion, or if they are actually part of the problem?
Liz Wise: When you have PND it is sometimes difficult to untangle what are usual fears – everything seems blown out of proportion with PND and you can feel quite irrational. The best way of dealing with this is to be able to talk openly to someone you trust and someone who understands about PND, be it your GP, health visitor, a counsellor, friend etc.
Q. In a conversation with some friends about how childhood memories come flooding back when one is linked closely to a child, my friends and I wondered if PND research backs up the idea of a boost of childhood memories when a child is born? Could PND affects this boost of childhood memories, which then goes on to affect the relationship a sufferer would have with their parents? Would an abusive childhood cause negative childhood memories to surface after childbirth and cause PND?
Liz Wise: For some parents, their memories of childhood will come back when they have their own children and these memories may be negative. This may bring on feelings about their own parents and yes, women who have been abused may be at high risk of having PND.
Q. My mother is pretty sure she had undiagnosed PND after the birth of my younger sister, but the local health visitor did nothing to help. How can my mum begin to get over this, when it was not her fault, but rather a medical condition? She still beats herself up for the effects it had on me and my sister. And how can I avoid the same thing happening to me when I have my second child in a few weeks' time?
Liz Wise: How awful for your mother – perhaps it would help her to have some counselling to talk through her feelings about this and to relieve her guilt? She could contact her GP for a referral. It sounds as if you are very aware of the signs and symptoms, which is excellent. The fact that you were fine after your first child is very encouraging. Talking about your feelings, getting as much rest as possible, eating well and exercise can all be helpful.
Q. Is there a link between PND and a traumatic birth? Is PND actually a form of PTSD, or are they related? I definitely had PTSD after my first birth, due to terrible staff, and an occiput posterior baby. I often wonder if I would have suffered as badly and for so long in silence if the birth had gone smoothly. I didn't even have the baby blues after the second (dream birth at home). I often think about how the harsh reality of a labour/delivery ward is often shrouded in mystery - stirrups, scissors and shouting are all that spring to mind when I think of our local one, based on my own experience. What can be done to assist women overcome the gap between their expectations and the reality?
Liz Wise: A traumatic birth is a risk factor for PND, combined with other factors. There is a very fine line between PND and PTSD, and I do believe that PTSD can lead to PND. I wish I could answer what could be done, however we all have our own expectations about how motherhood is going to be, whether or not we are aware of the reality of it. I think it's quite difficult to prepare anyone for adjustment to parenthood.
Q. Do you think there's a link between PND and PMT? My doctor diagnosed PND after the birth of both my children and, subsequently, my PMT significantly worsened. I saw a nutritionist with a track record of helping women with PMT and since the birth of my youngest, five years ago, I have not experienced PMT.
During this time I have been taking supplements and have followed a diet and exercise routine prescribed by my nutritionist. The nutritionist thought that there was a dietary, and consequently hormonal, link between the PMT and PMD, as my PMT used to be exactly the same as my PMD but only around the time of my period. I think it's a shame that more diet and exercise help isn't given to women diagnosed with PMD. Do you agree this could help the situation for some cases?
Liz Wise: There is certainly a connection between PND and PMT. It seems to be that as a mum is recovering from PND, she may find her symptoms heighten before or during her period. There is a definite connection between diet, exercise and PMT and these may help it. PMT may be a positive sign that a mum is recovering – if she's feeling well most of the month then drops before her period, it shows that her PND is becoming PMT. It can be a good idea to keep a diary of symptoms to see a pattern.
Q. Are you more likely to get PND after a c-section as it's harder to bond with the baby (due to a lack of oxytocin)? Breastfeeding also might be more difficult along with a feeling a failure for not able to do it naturally?
Liz Wise: Having a c-section or a traumatic birth may be a risk factor that contributes to PND, especially if it is unexpected and the mother feels that she is not in control of her birthing experience. I wouldn't necessarily say that it is harder to bond with the baby after a c-section due to a lack of oxytocin, and breastfeeding can be difficult for women who have had natural deliveries too. However, it still is a risk factor for some women.
Q. I am 32 weeks pregnant with my second child and am slowly coming to terms with the fact that I have mental health issues related to pregnancy and the postpartum period. What do you have to say about the medicalisation of PND and how it lays the causes for maternal distress in chemical/hormonal imbalances in the mother, with little apparent public recognition of the role of past experience and current social support?
"I would really like to see antenatal screening for every woman to assess their risk of PND, as we know that past experiences and current social circumstances can certainly be risk factors."
Liz Wise: I don't think there is a huge amount of preventative support around. However, if you have had PND before, you should be given some extra support by your GP or midwife, and possibly a referral to a counsellor or the community mental health team if necessary.
I would really like to see antenatal screening for every woman to assess their risk of PND, as we do know that past experiences and their current social circumstances can certainly be risk factors. Sometimes there is nothing you can do to prevent a reoccurrence, however as mentioned before putting support in place may well help. In your case, I feel that you and your husband should have some prenatal counselling. However, I have known many women have severe PND after their first child but none with subsequent babies.
Q. I attended an NHS postnatal depression group when my son was a year old and it was a disaster for me. I found that the stories of the other women increased my own levels of emotional arousal and also made my OCD worse. I have been reading about human givens and it says that long-term counselling can cause the same effect. The excessive cortisol in the blood makes the chemical imbalance of depression worse.
According to the human givens theory, depressed people have too much rapid eye movement sleep which is why someone with depression is so tired. People dream as a way of the brain processing stress/anxiety/unresolved anger. The problem with too much dreaming is that people do not get restorative sleep.
With my daughter, I went to a couple of skills-based sessions run by a woman from the Herts Mind network. I found that learning how to relax or looking for a balance between work life and home life more useful than the opportunity to 'talk'.
Liz Wise: For many women, attending a PND support group really can help, as it normalises the feelings for them and reduces that dreadful sense of isolation you can have with PND. However, it's not for all. Everyone is unique in their own experience of PND, as they will be in what will help them recover. I'm glad that you found the sessions that you had useful.
Q. Do you have any advice on how to support friends who are new mums and encourage them to recognise if they have crossed the line from the usual challenges of a baby to becoming ill with depression?
Liz Wise: Don't alarm them, but point out how common it is, that there is treatment and support for them and that it does go away.
Q. How do you get over it when the guilt won't go away? The way I see it, it's always going to be there because of how it started. And if I'd not had that one particular thought, then none of it would've happened. And that thought isn't going to disappear. Even if one day I don't believe it anymore, there was a day when I did.
Liz Wise: I never thought that I would ever get over the dreadful guilt I felt about not being able to feel love for my first daughter. However, the further away you get from your PND, the easier the guilt feelings will get. The depression sometimes hooks itself on to "if I hadn't thought that, then it wouldn't have happened", however it is the depression that makes you feel that. It may also be that having some cognitive behavioural therapy may help with these thoughts.
Q. I had PND with my eldest quite severely, and as a result my husband was my son's main caregiver. I did not spend extended periods alone with him until he was 14 or 15 months old. I have a terrible feeling of needing to make up for lost time with him now that I am healthy, trying to reassure him that I am 100% committed to meeting his needs even though I didn't when he was a baby. How can I get past this feeling and do I need to be worried about 'loving him too much' and pushing him away?
Liz Wise: You certainly don't need to be worried about loving him too much. I don't think you can ever give a child too much love. He won't remember that time when you weren't caring for him, although you will. Those feelings of guilt will fade. Remember, you were ill and these feelings weren't your fault. They will not do him any harm.
Q. How do you cope, having had a traumatic time yourself, with being so immersed in making things better for other women? Do you ever feel like you would rather not be so close to something that was a source of such heartache in your own life? Or have you managed to work through your own issues in such a way that you use them to inform what you do, but you're distanced from the feelings you had at the time? If so, how did you go about that process?
Liz Wise: I think the fact that I had such a traumatic time with my postnatal depression has been very useful in giving me greater understanding and empathy towards others going through it. No, I never feel that I don't want to be close to something that brought me such heartache.
As far as I'm concerned, it's given me the best job that I could possibly have - that is one where I help other women. My PND was over 20 years ago, so I'm very far removed from it. Although I do remember it well, it doesn't have any negative impact on me now at all. I worked through my issues when I was strong enough after my depression and also when I trained as a counsellor.