Bringing postnatal depression out of the shadows.

Last week, it fell to a judge in a UK court to decide the fate of a woman who had killed both her children, while suff ering from postnatal depression. The court heard from three psychiatrists who gave evidence that Felicia Boots, who suff ocated her 14-month-old and 10-week-old children, had postnatal depression. She had stopped her prescribed antidepressants because she was convinced that the drugs would harm her baby through her breast milk and feared that her children would be taken away from her. Justice Fulford said: “A prison sentence would be wholly inappropriate in this case...I unreservedly accept that what she did to the two children, that she and her husband loved and nurtured, were the results of physical and biological factors beyond her control.” The verdict was manslaughter due to diminished responsibility (murder charges were dropped), and the outcome is inpatient psychiatric treatment. Postnatal depression and, more broadly, perinatal mental health disorders, are among the least discussed, and most stigmatising, mental health illnesses today. Despite being common (the prevalence of depression during or after pregnancy is about 12%), women are reluctant to seek help or to talk about how they feel to friends and family. One or two in every 1000 women who give birth develop puerperal psychosis, which is characterised by depression with psychotic features, mania, or atypical psychosis, and is associated with an increased risk of self-harm or harming the baby. Treatments for perinatal mental health disorders are eff ective and largely available, but misinformation, or lack of information, abounds, especially about the risks of drug treatment to the baby, unborn or born. According to Louise Howard (King’s College London, UK), as with any clinical decision, the decision to treat with drugs should be determined by the severity of the illness. “Severe illness needs treatment”, and the risk of not treating is usually greater than the risk of treatment. Mothers killing their babies, or themselves, because of an illness that can be successfully treated is a preventable tragedy. Stopping antidepressant treatment, against medical advice, is all too common. Some treatments have adverse eff ects, for the mother or the baby, but the risk of not treating might be substantial. Women need access to the best available evidence on the effi cacy and safety of treatments, provided locally by their primary care health team. Prompt referral to specialist perinatal psychiatric care is needed for those with a history of severe mental ill health, or with symptoms or signs of current severe perinatal mental disorder. Inpatient treatment where indicated should not be baulked at. A study to investigate the outcomes of mothers and babies admitted to psychiatric mother and baby units is currently awaiting a decision on funding from the UK National Institute for Health Research; such research is urgently needed. Updated guidance on prescribing antidepressants perinatally, and revised NICE guidance on antenatal and postnatal mental health, are under development. Health professionals can do more to provide accurate, up-to-date information to women and their partners on perinatal mental health disorders. But women themselves need to speak out and not fear telling doctors, health visitors, midwives, and their families and friends how they feel. A society in which women know that they will receive empathy, understanding, and help might be one in which women seek advice more readily, and accept appropriate treatments. Family members and friends, too, might feel able to help guide women to make the best choices, or, when choice becomes inappropriate, to seek professional help for outpatient or inpatient treatment. The day in which women can talk to other new mothers at mother-baby groups, or to others antenatally, honestly and frankly about how they feel is still some way off . The pressure to be the perfect mother, needing no help, is immense. The leader of the UK’s Labour Party, Ed Miliband, speaking to the Royal College of Psychiatrists last week, called mental health “the biggest unaddressed health challenge of our age”. “People pretend they are OK, family and friends turn a blind eye, nothing happens until it is often too late.” Miliband spoke of the need to change the status of mental health in the NHS and within society, and for “more mental health specialists working in teams with GPs, nurses and carers”. In conclusion, he said “We can’t prevent all mental ill health. There are not cures for all conditions. But we can help change the culture in our country. We can insist that everyone counts. That everyone matters. And that no-one dealing with any form of illness should ever feel ashamed.” Wise words indeed. The Lancet For the summary of the court case see www.thelawpages.com/ court-cases/print_sentence. php?id=9461