By Prof. Raveen Hanwella Caroline Beale was arrested in September 1994 as she was about to board a plane in New York to return to the UK. Inside her shoulder bag was her dead baby. The baby had died of neglect, probably soon after delivery, in a New York hotel room where Caroline was staying. [...]

The Sunday Times Sri Lanka

When maternal blues turn to postpartum depression


By Prof. Raveen Hanwella
Caroline Beale was arrested in September 1994 as she was about to board a plane in New York to return to the UK. Inside her shoulder bag was her dead baby. The baby had died of neglect, probably soon after delivery, in a New York hotel room where Caroline was staying. She was charged with murder and spent eight months in jail. Being a UK citizen her parents requested a world authority on psychiatric problems during pregnancy, Professor Channi Kumar, to fly to New York and give evidence on her behalf.

Channi Kumar was the first professor of perinatal psychiatry in Britain and a pioneer in the field. He set up a special unit for perinatal psychiatry in the Maudsley Hospital in London and was its first head. His two-volume textbook titled Motherhood and Mental Illness is a classic. Partly on his evidence Caroline Beale was released. After coming back to the UK she was successfully treated by Prof. Kumar for her mental illness.

There is a difference in law, between the US and UK, as regards the killing of an infant. The UK recognises the potential for mental illness up to 12 months after childbirth. If found guilty of the crime of infanticide, women are generally managed on probation orders, and given medical treatment.

The law is similar in Sri Lanka. In the US the law gives no such exception. Pregnancy and its aftermath is a time of joy for the mother and family. It is also a time when there are huge changes in the body of a woman. These include large fluctuations in hormone levels. Combined with the stress of having to cope with a new-born, this increases the risk of psychiatric illness. The risk is highest immediately before and after delivery of the baby. It is important to recognise the signs of impending mental illness during this period and seek help early. Otherwise there is potential for tragedy as in the case of Caroline Beale.

Pregnancy has traditionally been considered a time of emotional wellbeing for women, conferring protection from psychiatric disorders. However newer studies show that this is not correct. They show that around 15 percent of pregnant women experience symptoms of depression characterised by reduction in sleep, appetite, energy and low mood. Depression is most likely in the first and third trimester and may be difficult to detect as the somatic symptoms could be a normal part of pregnancy. Depression is the most common psychiatric disorder during pregnancy. Several factors increase the risk of depression during pregnancy. They include a history of depression, and a family history of depression. Some social factors such as a negative attitude towards the pregnancy, lack of social support and a partner who is unhappy with the pregnancy also increase the risk.

It is rare for women to develop psychoses for the first time during this period but the risk of relapse of a previous psychiatric illness is high. Women on psychiatric drugs are also likely to stop their medication fearing for the wellbeing of their baby. They often do so without consulting their psychiatrist. This is unwise as a serious relapse would need treatment with much higher doses of medication and the psychiatric disorder itself increases the risk of harm to the unborn baby. Please do consult your psychiatrist if you happen to become pregnant while on psychiatric medication. The psychiatrist will be able to change or adjust the medicines to prevent any harm to your baby.

The risk of a psychiatric illness rises sharply after delivery of the baby. Classically three types of mental illness are recognised in the period after child birth. The first type is called maternal blues. Also called ‘Baby blues’, or ‘postnatal blues’, it is experienced by 50-85% of women following the birth. It is usually transient and occurs three to five days after birth of the baby. The symptoms are tearfulness, mood swings, irritability, poor sleep and feeling unbonded with the baby. Most women recover spontaneously and without specific treatment. But it is important to recognise it and give reassurance. Rarely it can progress to a depression.

Postpartum depression occurs later, sometimes even six months later, than maternal blues. Initially it may resemble maternal blues but the symptoms are more intense and last longer. In addition, there is reduced pleasure and interest in activities previously enjoyed. There is more irritability and anger, feelings of worthlessness, shame or guilt. Sometimes there are thoughts of harming the baby or even ideas of suicide. Untreated postpartum depression lasts for many months and seriously affects the health of the mother and baby.

Postpartum psychosis is less common than depression and occurs a few weeks after child birth. The symptoms are even more severe than in depression. They include disorientation, confusion, hallucinations (hearing voices when there is nobody around) and delusions (false beliefs without evidence, about people and events). The most serious are, attempts by the mother to harm or kill herself or the baby.

If you are a new mother and feeling depressed, you may be embarrassed or reluctant to seek help especially from a psychiatrist. But it is important to do so as delay will make symptoms worse, treatment more difficult and affect your bonding with the baby. Sometimes it is difficult for persons to recognise the symptoms of depression in themselves. If you suspect that a relative or friend is having postpartum depression or is developing a postpartum psychosis please request them to seek medical help immediately. Don’t wait and hope that things will improve.

A major problem with treating a serious mental illness in a new mother is that if admission to hospital is necessary she is separated from her baby. Understandably a mother will not readily agree to such a separation. Even if the mother agrees, a prolonged admission would serious impact mother-baby bonding and feeding.

Understanding this problem, in 1981, Prof Channi Kumar started one of the first mother baby units in Europe at the Bethlem Royal Hospital in London. This innovative step enabled mothers with mental illness to be admitted with their babies. Sri Lanka too now has one such unit in the National Institute of Mental Health.

The good, they say, die early. Channi Kumar died of leukemia in 2000. He was 62 years old and at the peak of his career. The unit he began was renamed recently as the Channi Kumar Mother and Baby Unit. His pioneering work in perinatal psychiatry has greatly improved the care of mothers with psychiatric illness, around the world. They are in his debt.

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