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Postnatal depression (PND) is a common problem, affecting around one in 10 new mothers in the year following the birth of a child. Yet despite its potentially lifelong consequences for the child, it frequently goes undetected and untreated.

Some mothers suffering postnatal depression have very good relationships with their babies. But the agitation and distress the mother experiences tend to make her less sensitively tuned to her baby’s experience and more preoccupied with her own. And it seems that it is the mother’s reduced sensitivity to the baby, and in some instances a tendency to be more critical and less affectionate than non-depressed mothers, which affects the baby’s development.

Heather Welford, writer for the National Childbirth Trust on PND, says: "Babies need human contact and socialisation to learn and develop. Postnatal depression interferes with mothers’ ability to communicate with their baby. They find it much more difficult to look at their babies, talk to them and give them space to come back to them."

For some families, the onset of postnatal depression can be the trigger for a chain of adverse events. The depressive episode affects the child’s early development and the mother’s relationship with the child, which in turn puts pressure on the whole family. Even a short episode of depression can cause lasting harm.

Research carried out in Cambridge by Professor Lynne Murray from Reading University¹ shows that children, especially boys, of mothers who have been depressed in their first year, perform less well in cognitive tests at 19 months, and are more likely to be rated by teachers in their first year at school to have behavioural problems.

However, Murray points out that children living in favourable circumstances often recover from their initial disadvantage. She says: "Cambridge was quite a low risk population. It doesn’t have the social problems of inner London where another study found lasting cognitive effects in boys. It is poverty and social problems and factors in the child - prematurity or illness after birth - coupled with postnatal depression that pose the risk."

Murray goes on: "What seems to happen is that the mother finds it difficult to respond positively to the child. Even when she stops being depressed she sustains a negative attitude." But she stresses there is nothing inevitable about PND leading to lasting problems in the child, because so much can be done. "It doesn’t mean that you can’t break out of the negative cycle. Even in the most at-risk groups only a minority of children develop problems."

Alarmingly, a high proportion of postnatal depression goes undetected. As many as two in five cases are not picked up by health visitors, unless they have been specifically trained. Particularly in areas where there are high vacancy rates, women may have little or no contact with a health visitor beyond the first few weeks after the birth. At the baby’s six-week and nine-month developmental checks a mother may be asked just a single question about how she is feeling.

A depressed woman may not realise she is ill or may be reluctant to disclose it because of the stigma associated with mental illness.

However, PND can be reliably detected with the aid of the Edinburgh postnatal depression scale (EPDS) when used by staff with specialist training. Kath Broscombe, a health visitor working in Barkerend Sure Start in Bradford finds the questionnaire helpful. She says: "It’s only an indicator and needs to be used by someone trained to look for other signs of depression. But it’s a useful way of introducing a discussion with a woman to find out how she is feeling."

Once the illness has been diagnosed, there are several interventions which can be effective. Murray has published a book1 containing stills from videos of mothers interacting with their babies which can be used to help women communicate with their babies. The effectiveness of individual counselling by a specially trained health visitor over a period of a couple of months is also well validated by research. Group therapy can also be very beneficial for women who are socially isolated.

Many women find antidepressants helpful, particularly if their depression is moderate to severe. According to Welford, some GPs incorrectly tell mothers they should stop breastfeeding when taking medication. "There’s a lot of poor practice," she says. "Women can be treated with antidepressants while they are breastfeeding. For some women, breastfeeding is one thing that they feel they are doing well."

The Barkerend programme runs a variety of interventions, including support groups and one-to-one visiting, and encourages women to take part in activities like postnatal massage. Broscombe says: "Baby massage is very useful. It’s a five-week programme of contact with the mother and baby. It helps with bonding as well as giving you time to develop a one-to-one relationship with a woman."

Despite examples of good practice, many women with PND still receive no professional support. Breige Coyle, lead professional officer at the Community Practitioners and Health Visitors Association (CPHVA) for PND acknowledges that services are patchy. She says that since the publication of the National Service Framework for Mental Health three years ago requiring health authorities to develop protocols for early identification and treatment of PND there has been a "flurry of activity to get something in place". However, it is difficult to tell how far this is leading to better services.

Coyle adds: "Postnatal depression is being given more priority than in the past. But an awful lot more needs to be done. There needs to be more training and more multidisciplinary working. In many parts of the country services aren’t adequate because of a lack of staff."

¹ L Murray, The Social Baby, Understanding Babies’ Communication, The Children’s Project, 2000

‘In Punjabi there is no word for depression’

At the moment there is no diagnostic tool for women with little knowledge of English. Barkerend Sure Start, Bradford, is working with Sheffield University to validate a questionnaire in Punjabi based on the EPDS developed by Razia Bhatti-Ali for detecting depression in Asian women. Bradford health visitor Kath Broscombe is optimistic that it will help women who find it particularly difficult to talk about their experience. She explains: "There are women in any community who are reluctant to express how they are feeling. Having a baby is supposed to be a joyous time. In Punjabi there is no word for depression. Women who have arrived recently find it odd that someone should ask them how they are feeling. But we find they are grateful that people are asking them these questions."

What does postnatal depression feel like?

"For the first few weeks I was doing really well, feeding the baby, looking after my older children, running the home. Then, when he was about seven weeks old, I started to feel that I wasn’t coping. I’d start crying when I was changing or dressing him. I was convinced that I was unfit to be his mother and that I was going to harm him. I felt that I couldn’t cope with the older ones. They seemed completely out of control.

"I was sleeping badly - sometimes I’d just get off to sleep and then wake up almost immediately and stay awake all night with my heart pounding and my mind racing. I had this awful feeling of agitation and couldn’t concentrate properly. I went to see my GP who prescribed anti-depressants. I didn’t take them because I was worried about them getting into the milk. He referred me for some counselling but the waiting list was for over a year.

"I couldn’t talk about it to my friends - one said it was a shame I wasn’t enjoying my children, and that made me feel even more of a failure. My nerves were raw and I couldn’t stand the older ones quarrelling. Then I’d end up shouting at everyone myself, or just crying. Sometimes I thought it would be better for them if I put them all into care. I felt like I was in hell."

A mother of four in her mid-thirties