Women's views of antidepressants in the treatment of postnatal depression

Women’s views ofantidepressants in the treatmentof postnatal depression

E. Boath, E. Bradley and C. Henshaw

Little research has been carried out on the treatment of postnatal depression and

clinicians must currently rely on general recommendations for the use of

antidepressants. Antidepressant medication as the main treatment for depression

in general practice has been shown to be effective when used as prescribed.

However, research has shown that depressed patients consistently receive either

no medication or consistently low doses of medication. This study will investigate

women’s experiences of taking antidepressant medication for postnatal

depression.

Thirty-five women with a clinical diagnosis of postnatal depression who had

been prescribed antidepressant medication completed a questionnaire detailing

their experiences of taking medication. Four open-ended questions and responses

were discussed with the women.

Of the 35 women who were prescribed medication, 4 chose not to take it

because they were breast-feeding. Twenty of the women described finding

medication helpful. Although only 4 women directly reported not taking

antidepressants as prescribed, the comments made by a further 9 women suggest

that compliance may have been poor.

This study suggests a need to improve information about medication for

postnatal depression. If this information is not provided, women are likely to

continue to self-manage medication at a dosage that may be clinically ineffective.

Key words: postnatal depression, treatment, antidepressants, self-regulation

INTRODUCTION

Postnatal depression (PND) is a serious and

debilitating psychiatric disorder that is

equivalent to a diagnosis of major or minor

depressive disorder1. With a prevalence rate

of around 13% one can make a conservative

estimate of 75,000 cases of PND per annum

in the United Kingdom2,3.

Although depression accounts for up to

40% of GP consultations4,5, GPs have little

specialist training in mental health6. It is

therefore not surprising that some studies

show that depressive disorders are not treated

adequately by GPs7. The picture for PND is

equally bleak. Despite a common perception

of the wide use of the Edinburgh Postnatal

Depression Scale (EPDS)8 primary care profes-

sionals often fail to identify PND and research

has shown that over half of the cases of PND

go undetected and subsequently untreated8,9.

Even when depression is recognised it is

unsuccessfully treated10,11,12 and research

has shown that depressed patients consis-

tently receive either no medication or

consistently low doses of medication13.

Although much work has been carried

out on the treatment of depression in

primary care14,15 remarkably little research

has been carried out on the treatment of

PND16. There is a proposal for a systematic

review of antidepressant treatment of PND17,

E. Boath, Reader in Mental

Health, Faculty of Health

and Sciences, Staffordshire

University, UK, *E. Bradley,

Centre for Health Policy and

Practice, Faculty of Health

and Sciences, Staffordshire

University, Blackheath Lane,

Stafford, ST18 0AD, UK,

and C. Henshaw, Senior

Lecturer in Psychiatry,

School of Medicine,

Academic Unit, Harplands

Hospital. Stoke-on-Trent,

ST4 6TH, UK

*Correspondence to: E. Bradley, Centre for Health Policy and Practice, School of Health, Staffordshire University,Blackheath Lane, Stafford, ST18 0AD, UK. Email: [email protected]

J Psychosom Obstet Gynecol 2004;25:221–233 September/December 2004

ª 2004 Parthenon Publishing. A member of the Taylor & Francis Group 221DOI: 10.1080/01674820400017889

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but to date, there is only one published

comprehensive review of the treatment of

PND18. This comprehensive literature review

identified 26 published articles, however

only four of these studies addressed anti-

depressant treatment19,20,21,16, and all

exhibited methodological flaws.. Roy et al.19

successfully treated 4 women with fluoxe-

tine, however this study was limited by a

small sample size. Stowe et al.20 carried out

an open-label trial of 26 women with DSM-

IV postpartum major depression that oc-

curred within 6 months of childbirth and

treated the women with Sertraline. At the 8-

week follow-up, they found that of the 21

women who completed the study, 14 recov-

ered fully and so the authors concluded that

Sertraline is a ‘highly efficacious and well-

tolerated treatment’ for postnatal depression.

As Stowe et al. outline, definitive conclu-

sions are limited by the open-label design of

the study, the stringent inclusion and exclu-

sion criteria, the limited socio-economic

variability of the women and the lack of a

structured diagnostic interview. Although

side-effects were either transient, or were

resolved by dose reduction, two of the five

women who did not complete the trial,

terminated due to severe side-effects.

Furthermore, the women were given con-

current supportive psychotherapy, which

addressed issues of medication, side-effects

and compliance, and were also given educa-

tion about postnatal depression, infant care

and the physical sequelae of childbirth.

Thus, it is impossible to say whether the

findings are due to the medication, the

psychotherapy, or a combination of both.

Cerruti et al.21 carried out a two phase trial

treating ‘postpartum psychological distress’

with 1600 mg oral S-adenosylmethionine

(SAMe) daily from day 2 to day 30 postpar-

tum. Phase one was a double-blind RCT in

which 60 women whose scores on the Italian

version of Kellner’s Symptom Questionnaire

(KSQ; Fava et al., 1983) indicated that they

were psychologically distressed, were ran-

domly allocated to treatment with SAMe or

placebo. Thewomenwere assessed at2,10 and

30 days postpartum using the KSQ. There was

no evidence of a significant difference be-

tween the two groups at day 2, however there

was evidenceof a significant decrease inmean

scores for the treatment group at day 10 and

day 30. Phase two was an open trial in which

SAMe was given to 40 women who matched

190 control women in terms of age, parity,

education, type of delivery andmarital status.

They found that there was no difference in

mean scores between the two groups at base-

line, no significant change in scores in the

control group at day 10, however those in the

SAMe group showed a significant improve-

ment. By day 30 both groups showed

significant improvement.

It is important to treat these results with

caution as the inclusion criteria of ‘postpar-

tum psychological distress’ included women

with maternity blues and postnatal depres-

sion. Blues are characterised by a transient

change in mood that occurs in the first few

days postpartum. The authors note an

improvement in scores over the 30 days

follow-up, which is of no surprise as one

would expect that up to 80% of the women

in their sample would have blues and

anticipate considerable spontaneous im-

provement over this time period. Thus,

their follow-up period of 30 days postpartum

is too short to pick up postnatal depressions

that may have a later onset.

Appleby et al.16 carried out a randomised

controlled trial, double-blind in relation to

drug treatment, of fluoxetine and a form of

cognitive-behavioural counselling derived

from cognitive-behavioural therapy. A com-

munity sample of 87 women who satisfied

RDC for major (n=51) and minor (n=36)

depressive disorder 6–8 weeks after delivery

were randomised to receive a combination of

either fluoxetine or placebo, plus either one

session or six sessions of counselling. The

duration of treatment was 3 months and

psychiatric morbidity was assessed at 1, 4

and 12 weeks. Women were assessed at entry

to the trial and at 12 weeks using the

Hamilton Depression Scale23.

The findings revealed a highly significant

improvement in all four treatment groups.

The improvement in psychiatric morbidity

was significantly greater following six ses-

sions of counselling, as opposed to one

session, and women who received fluoxetine

showed significantly greater improvement

than those receiving placebo. The differ-

ences outlined above were apparent at 1

week and improvement in all groups was

complete by 4 weeks. However, the generali-

sability of these results is limited by the fact

that out of 188 cases, 101 women refused to

take part and a further 9 women dropped out

during the study due to adverse drug effects.

Some of the characteristics of the women

who dropped-out were different to those

who completed the trial, for example drop

outs were younger, more likely to have an

Boath et al. Antidepressants in the treatment of postnatal depression

222 JOURNAL OF PSYCHOSOMATIC OBSTETRICS & GYNECOLOGY

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unemployed partner and to have planned

the pregnancy. Appleby et al. also used the

Hamilton Depression Scale, which is recog-

nised as a standard assessment instrument in

antidepressant trials, but has not been

validated for use with puerperal women.

The Scottish IntercollegiateGuidelineNet-

work (SIGN) has only recently published

treatment guidelines for PND24. Prior to the

SIGNguidelines, clinicianshavehadtorelyon

general recommendations for the use of

antidepressants and assume the pharmacolo-

gical treatment of PND to be the same as for

depression occurring at other times25. The

general guidelines do not take account of

treating women who have to care for infants

and therefore cannot take sedative medica-

tion at night, most psychotropic drugs are

excreted into breast milk and although only

very small amounts of psychotropic drugs

have been detected in infant serum and both

TCAs and SSRIs appear to be relatively safe for

the infant26, the long-term effects on the

infant are not known and so antidepressants

need to be used with care for breast feeding

mothers27,28,29. Some mothers may refuse

medication if it requires the cessation of

breast-feeding9 and there is a need to avoid

over sedation in the mothers of young chil-

dren30.Thegeneral guidelinesdonot take into

account the limited evidence for the use of

antidepressants for the treatment of PND16

and a number of factors combine tomake the

treatment of PND with antidepressants diffi-

cult16. Antidepressant medication has been

shown to be an effective treatment for depres-

sionwhenused as prescribed31, however there

may be important differences in symptoms

and responses for postnatal and non-postna-

tal depression32. The SIGN guidelines22

recommend that a clear indication for drug

treatment should be established, including

the absence of an acceptable alternative. It is

thought that the risk to breast feedingmay be

over-estimatedalthoughbreast-feeding isbest

done immediately before administering the

dose and should be avoided for 1–2 hrs after

any dose of medication (the time of highest

plasma concentration). There is no clinical

indication for women treated with tricyclic

antidepressantsorSSRIs tostopbreast feeding.

It is clear that the decision to prescribe

antidepressants shouldbediscussed fullywith

the woman and any fears about treatment

shouldbealleviated.However, antidepressant

medication should not represent the only

treatment option and counselling should be

recommended where available.

The symptoms of PND require effective

treatment as they have a far-reaching nega-

tive impact on both the mother and

her infant. The children of depressed

mothers are more likely to have lower

weight percentiles, lower cognitive and

emotional development, to suffer from de-

pression in childhood and have a higher

likelihood of problems in later child-

hood33,34. It has been suggested that the

cognitive and emotional impact of PND on

the infant is due to the negative effects that

PND symptoms can have on mother-infant

interaction35,36,37,38,39,40,41,42. The impact of

PND on the infant is not a straightforward

causal relationship and there are a number

of elements to PND symptoms that can

impact on the infant including interaction

and attachment difficulties. In the case of

teenage mothers with PND, there is a strong

link between depressive symptoms and so-

cio-economic status43 and in these cases the

social situation itself may have conse-

quences for infant development. However,

with older mothers there is less of a relation-

ship between PND and low SES but the

negative impact of PND on the infant is still

evident. As such, it is important that all cases

of PND are treated as effectively as possible.

Despite the difficulties with the prescrip-

tion of antidepressants to women with PND,

antidepressants remain the treatment of

choice for primary care practitioners and

do represent an effective treatment for

PND when used as prescribed. As such,

the perceptions that women hold about

antidepressants, and their subsequent com-

pliance with the antidepressant schedule, are

a crucial factor for consideration. The aware-

ness of alternative treatments for depression

within general practice is increasing and

most general practices in the UK have

counsellors in post44 and this awareness

may also have an impact on women’s

reaction to the prescription of antidepres-

sants. However, it should be acknowledged

that the treatment of PND, and the care

received by women with PND varies widely

between countries. Although general prac-

tices in the UK commonly have counsellors

in post, this is not the case in many other

countries. The health visitor plays a large

role in the treatment of PND in the UK but

does not in other countries. As such, women

in the UK are likely to have knowledge of the

availability of alternative treatments for PND

such as counselling appointments or ‘listen-

ing visits’. This knowledge is likely to have

Antidepressants in the treatment of postnatal depression Boath et al.

JOURNAL OF PSYCHOSOMATIC OBSTETRICS & GYNECOLOGY 223

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an impact on their perception of medication

as a treatment for PND.

The aim of this paper is to assess and

discuss the experiences that postnatally

depressed women have of taking antidepres-

sant medication whilst considering the

previously unexplored assumption that

PND would be treated with therapeutic doses

of antidepressants.

METHODS

The women were participating in a wider

study of the cost-effectiveness of services for

PND45 and as part of this wider study

participants were asked to evaluate the

treatment they had received for postnatal

depression. Women who had a baby aged

between 6 weeks and 1 year and who scored

above the threshold of 12 on the EPDS, had

the study explained briefly to them by their

health visitor or member of their healthcare

team and were asked if the lead author (EHB)

could contact them to tell them more about

the study. A patient information leaflet was

developed to facilitate this stage of the

recruitment. Since a score above the thresh-

old of 12 on the EPDS does not confirm a

diagnosis of depressive disorder, a second

recruitment phase using a standardised psy-

chiatric interview was necessary to ensure

that a clinical depression was present. These

interviews were carried out in the women’s

homes. The women were interviewed by

EHB using the Standardised Psychiatric In-

terview (SPI)46 which was used to give them a

diagnosis according to according to Research

Diagnostic Criteria (RDC)47. Scores on the

SPI and diagnosis were independently ver-

ified by a psychiatrist, Gail Critchlow (GC),

who was blind to the SPI score and diagnosis

made by EHB. The study was assessed by

both North and South East Staffordshire

Research Ethics Committees. For more de-

tails about the methodology, please refer to

Boath et al (1999)48, Boath (1999)49 and

Boath et al (2003)45.

With the women’s consent, their case

notes were reviewed in order to assess the

medication and dosage prescribed. The notes

were reviewed by EHB and the medication

prescribed and the dosage were noted. The

medication prescribed was then reviewed by

EHB and independently by a psychiatrist,

John Cox (JLC). Medication was defined as

therapeutic if after gradual titration a con-

sistent therapeutic dose was prescribed. A

therapeutic dose was based on information

provided in the British National Formulary

and clinical experience. Those who were

consistently under dosed, or did not achieve

a therapeutic dose long enough to be clinic-

ally effective, were defined as subtherapeutic.

The women were all asked to complete a

questionnaire designed specifically for the

study on their experiences of taking medica-

tion. The questionnaire consisted of Likert-

type questions as well as four open-ended

questions to allow subjects to express freely

their opinions and written statements were

treated as quotational evidence. The ques-

tionnaire was administered at the same time

as the SPI and EHB was present whilst the

questionnaires were being completed. It was

possible for the women to discuss their

answers to the four open-ended questions

with EHB whilst they were completing the

questionnaire. The open questions can be

seen in Appendix 1. It was decided preferable

to use open-ended questions and discussion

rather than interviews as these took less time

for the women who were caring for an infant

and suffering depressive symptoms at the

time. Also, the women were receiving on-

going care from health professionals and

unlikely to want to express negative feelings

about any service in a detailed interview. The

written comments allowed the women to

express these feelings in a more confidential

manner. The comments written by the

women were collated into themes and

analysed using content analytic techni-

ques50. Thematic analysis was appropriate

as it was possible to analyse the material

during the data collection process, and guide

any discussion using the results of this initial

analysis. The identification of early themes

allowed EHB to quickly categorise any

important comments made by women dur-

ing discussion of the written open-questions.

The quotes were read in order to become

familiar with the depth and diversity of the

responses and to gain an overview of the

emergent concepts and issues. As concepts

were identified they were labelled and

compared. Any concepts that shared com-

monalities were grouped as themes. This

method of comparing concepts, and group-

ing themes was an effective method for

selecting and organising the written re-

sponses. To increase the validity of the

study, quotes were used to illustrate key

points. Quotes were selected if they were

judged by the authors to describe the essence

of a theme well and capture aspects of

women’s experiences.



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RESULTS

A total of 82 women were approached and of

these, 5 women did not want to be contacted

by EHB. Two women who agreed to be

contacted subsequently refused to partici-

pate in the study, as the research did not

offer them any further treatment. Three

women were already participating in a study

and did not want to take part in another

study. Two women could not speak English

and refused translation, and a further 10

women did not fulfil the inclusion criteria. A

total of 60 women fulfilled the recruitment

criteria and of them, 35 were prescribed

antidepressant medication.

The socio-demographic details, parity,

method of delivery, method of contracep-

tion, factors relating to the baby, or

psychiatric history were all recorded and

are shown in Table 1. All the women in the

study were white.

Difference in total SPI scores between

EHB and GC were analysed using a paired

samples t-test. This revealed that there was

no significant difference between the scores

[p=0.28]. Although slight differences oc-

curred in overall scores [k=0.84] there was

perfect agree-ment on diagnosis between

EHB and GC.

Of the 35 women who were prescribed

medication, 4 of the 13 (31%) women who

were breast feeding did not want to take it

for that reason. The quotes below are there-

fore presented for the 31 women who took

medication. As this was a naturalistic cohort

study, the women were prescribed a range of

psychotropic medication: 5 were prescribed

Selective Serotonin Re-uptake Inhibitors

(SSRIs), 25 were prescribed tricyclic antide-

pressants (TCAs), 2 of these were

subsequently prescribed SSRIs and 3 were

subsequently prescribed flupenthixol. One

woman was prescribed flupenthixol alone.

Table 1 Comparison of socio-demographic details, gynaecologic, obstetric factors and personal and familypsychopathology of the women

Variable (n = 35)

[Numerical] Range Mean (SD)

Age of woman (years) 20–38 27.29 (4.71)Age of Baby (weeks) 7–48 22.91 (11.66)

[Categorical] Frequency (%)

Marital statusMarried/cohabiting 30 (86)Single 5 (14)

Social Class*II 9 (26)III 19 (56)IV 6 (18)

ParityPrimiparous 15 (43)Multiparous 20 (57)

ContraceptionYes 26 (74)No 9 (26)

Gender of BabyMale 16 (46)Female 19 (54)

Feeding**Breast 13 (37)Bottle 22 (63)

Method of DeliveryVaginal 31 (89)Caesarean 4 (11)

Psychiatric HistoryPrevious Psychiatric History 12 (34)Previous Postnatal Depression 7 (20)Pre-pregnancy PMS*** 28 (80)Baby Blues*** 22 (63)

*There were no women in social class V or I. One woman was inadequately described**The feeding figures represent the predominent mode of feeding for women***Pre-pregnancy PMS and baby blues were assessed retrospectively



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Of the 31 women 21 (68%) were prescribed a

therapeutic dose according to the definition

outlined above. There was 100% agreement

between EHB and JLC.

The initial themes that were identified

from reading and re-reading the written

comments included ‘Helpfulness of Treat-

ment’, ‘Alternatives to Medication’, ‘Self-

regulatory Behaviours’, ‘Information for

Health Professionals’, and ‘Suggestions for

Improvement’. It was then possible to group

these themes into the groups that are

illustrated below.

Women’s views of medication

Twenty of the women found medication

helpful in terms of alleviating their symp-

toms of depression:

‘medication were very helpful and I trust they

would be the answer to any future problem’

[W17]

‘I do find the medication helpful. It seems to

help you sleep and cope a little better’ [W1]

‘. . .medication has helped me to overcome my

depression.’ [W20]

Some women did find the medication help-

ful in terms of their symptoms, but this did

not necessarily prevent them from main-

taining a negative view about having to take

medication:

‘Even though I hate medication it helped me

through a tough time.’ [W16]

Other women described finding the medica-

tion helpful, but they felt that this was not

enough and described an awareness of, and

desire for, other treatment possibilities:

‘Yes, medication helped me feel ‘in control’,

but would also appreciate ‘relaxation’,

assertiveness or similar training/help. Yes,

medication is beneficial.’ [W4]

‘Group therapy, yoga and individual

counselling would have been nice to be

offered and this could well of speeded a

recovery being able to talk and be with others

with similar problems.’ [W10]

‘I would like to receive more counselling,

possibly from a community psychiatric

nurse.’ [W2]

‘Somewhere to go with other women. Meeting

place or clinic locally that you can take kids to,

creche facilities. Talk to someone who under-

stands. Individual and group therapy. . .Need

something more. Doctor did what he could.

Someone outside to talk to partners - men are

kept in the dark. Services all for women. They

could then help wives.’ [W11]

In her search for ‘something more’, one

woman attended a group run by MIND, but

found it:

‘rather unhelpful. . .a bit difficult at times, as

everyone has different problems from me. I

need to talk to other mothers not alcoholics

and junkies’. [W5]

Eleven women did not find medication

helpful and comments like the ones below

were typical:

‘Medication tended to remove all emotions

and left me feeling empty and uncaring and

totally abnormal - and if I hadn’t stopped

medication myself these problems would

have become long term and just as bad as

postnatal depression’. [W3]

‘Personally, I don’t think tablets are the

answer; talking to someone who understands

helps more’. [W18]

Self-regulation of antidepressants

Compliance is an important issue for anti-

depressants if women are to start and

continue taking their medication at a ther-

apeutic dose for 6 to 12 months. Women

were asked if they had taken the medication

exactly as it said on the label. Although only

4 women directly reported not taking anti-

depressants as prescribed, the comments

made by a further 9 women suggest that

compliance may have been poor. Some

women stopped taking their medication

shortly after the course began as they felt

the antidepressants were not having an

effect:

‘I took it for a few days, but it didn’t work, so

I stopped’. [W2]

Self-regulation of dosage has been observed

in a number of areas of drug therapy51,52.

Four women in this study reported that they

tried to miss doses or reported taking tablets

on an ad hoc basis:



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‘I take them only when I need them’ [W1]

‘I do without when I can’; [W13].

This type of self-regulation may help women

to manage their fears about becoming de-

pendent on the antidepressant medication.

The presence of side-effects encourages

the self-regulation of antidepressant dosage

and women may fail to increase their dose

to a therapeutic level, even when instructed

to do so, as they do not want to exacerbate

side-effects. Two women did not reach a

therapeutic level for this reason and one

commented:

‘They gave me a terrible dry mouth. The

doctor wanted me to take two, but I just

couldn’t’. [W9].

Patients may interpret the dosage of medica-

tion prescribed for them as an estimation of

the severity of their illness51. The lowering of

a dosage whether independently, or by their

doctor, could be perceived as an indication

that their condition is improving:

‘I must be getting better as my GP has cut my

medication down now’. [W1]

This has important implications for any

changes to the dosage prescribed, and is of

particular importance when doctors gradu-

ally decrease the dosage to prevent any

withdrawal syndrome.

The stigma of antidepressant medication

remains an important consideration for

these women and appears to impact on

how women decide to take their medication.

There is still a stigma attached to depression

and taking psychotropic mediation, and

although some women reported that they

did follow the prescribed regimen

‘I couldn’t do without them’ [W22] they still

expressed their desire to be ‘off the

antidepressants soon’. [W22]

‘I’m not a tablet taker. You don’t know what

they are doing to you’. [W19]

This aversion to taking medicines, and being

seen as a ‘tablet taker’ has been found with

other general practice populations who seek

to reduce or eliminate the use of medication

where possible53.

Patients are often concerned about the

possible harmful effects of the long term use

of medication54. In this study, three women

expressed their concern about the possible

long-term effects of taking antidepressants:

‘I don’t like taking tablets. They are bound to

do you some harm in the long run [W21]

These perceptions about the possible harm-

ful effects of the long term use of medication

have been found to be based on medication

in general rather than personal experience55.

Discontinuation of Antidepressants

Sedation and drowsiness were a problem

with some antidepressants, and 2 women

decided to stop taking medication as a result

of this:

‘It knocks me out - I’m scared I won’t not hear

the baby at night’. [W11];

‘Taking medication was a very slow process

and very impersonal. After having my

medication increased I began to feel totally

like a zombie and decided to stop taking them

and I have struggled back to recovery on my

own without tablets.’ [W10]

This problem could be avoided by prescrib-

ing medication with fewer sedative side

effects and by giving women simple strate-

gies to avoid these problems, such as

splitting the dose throughout the day. Also

reviewing women and their medication on a

regular basis would be useful.

A consensus statement suggests that to

avoid relapse, patients should continue to

take antidepressants for a further 4–6months

after full remission56. As some of the women

in the study had been treated with antide-

pressant medication during the antenatal

period, the women were taking antidepres-

sants for between 2 weeks and 2 years. The

majority of women failed to stay on anti-

depressants after remission. This is probably

due to the fact that in the absence of

symptoms, the women perceived that they

no longer needed to take their medication:

’I felt fine, so I stopped taking the tablets’

[W24]

‘I stopped taking them after a few weeks as I

felt a lot better’. [W6]

Other research studies have found that pa-

tients stop taking their treatment once their



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symptoms disappear, despite medical recom-

mendations to the contrary57,58. Patients self-

regulate their behaviour in accordance with

beliefs about symptoms and their illness. It is

important that health professionals attempt

to elicit understanding about their illness

prior to explaining medication schedules,

otherwise these ‘lay’ understandings will

undermine health advice.

The majority of the general public believe

that antidepressants are addictive and this

may a contributory factor in overall treat-

ment discontinuation rates of over 30%59.

Concerns about addiction were common in

our study and some of the women appeared

to be extrapolating what they had heard

about benzodiazapines to antidepressants

and were concerned about becoming ad-

dicted to antidepressants:

‘My mother was addicted to Valium1, I

didn’t want to be addicted too’. [W7]

The idea that antidepressants are addictive

was also expressed by the women’s perceived

need to wean themselves off them:

‘I stopped taking the two tablets after a while

so I could wean myself off them’. [W23]

This again highlights the need to counsel/

support women to continue with their

medication schedules.

Communication and concordance

Good communication between doctor and

patient is an essential part of care. When the

quality of communication is rated highly,

patients are more likely to be satisfied60 and

this can in turn lead to a greater likelihood of

appropriate medicine taking61. Some women

felt ‘very informed’ about PND:

‘Everything was explained with plenty of time

and listening’ [W14];

‘They made me feel better about my

postnatal depression because of them I fully

understood what it was’. [W15].

Accurate information about PND and treat-

ment is important to enable women to take

an active part in developing their treatment

plan and ultimately, their recovery. One

woman expressed her desire that all staff

should be given detailed information about

PND and its treatment:

‘All of the medical staff and the office staff

should be fully informed of what postnatal

depression is and the services and treatments

available’. [W2]

Seven women suggested that they would like

better follow-up care from health profes-

sionals, with a particular focus on fulfilling

their communication needs:

‘More care and better follow-up care from GP,

midwife and health visitor. These people need

to actually ask ‘‘How are you’’ rather than

just assuming . . . I would like better follow-up

care [W8]

‘I have struggled back to recovery on my own.

Without tablets and without the help of my

husband and family willing me on I don’t

know where I would be. There has been no

follow-up from my doctor to see if I am fully

over my postnatal depression, or if there was

any more he, or anyone else could do’. [W10]

DISCUSSION

This study has attempted to elicit and

understand the experiences of women taking

antidepressant medication for PND. It is

important to bear in mind, prior to discuss-

ing these experiences, that the authors are

not recommending antidepressant treat-

ment for all women with PND. There are

other treatments for PND (such as cognitive

behaviour therapies) that have been found

to be successful, and these should be avail-

able as alternatives where possible. Issues

about dosage and length of treatment are

also important considerations for GPs and

women and should be discussed fully prior

to prescription. This paper focuses on the

experiences of 35 women who had been

prescribed antidepressant medication, and

so the discussion focuses on whether women

have received appropriate information be-

fore prescription, and the impact that

individual perceptions of antidepressant

medication can have on the effectiveness of

this treatment for PND.

Four out of 13 women in this study who

were breast-feeding did not want to take

medication, and breast-feeding poses a clin-

ical dilemma. The guidelines for the

treatment of depression in pregnant and

lactating women suggest that these women

should be referred62. A literature review

revealed that both TCAs and SSRIs appear

to be relatively safe for the infant26 but



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before a decision is made, the risk-benefit

ratio must be clearly outlined and discussed

with the mother and her partner.

The recent move from compliance to

concordance, aims to encourage collabora-

tive decision-making between the doctor and

the patient, and to ensure that the patient

fully understands the importance of taking

medication as prescribed63. However, there

was little evidence of partnership inmedicine

taking or communication about medicine

taking in this study. Indeed, the majority of

women in this study did not take their

antidepressants as prescribed, and were self-

regulating or discontinuing theirmedication.

The women also showed evidence of mis-

understanding about their medication. This

misunderstanding was particularly evident

when women decided to stop taking their

medication because there was no immediate

impact on symptoms. The response to anti-

depressant treatment may take between 10

and 14 days, depending on the drug’s phar-

macokinetic profile, and the physiological

changes occurring in the women during the

postpartum period59. If women are to have an

active role in decision-making about their

medication they need to be fully informed

about it. There was evidence that women had

received information about PND, and had a

good level of understanding about their

illness, however more information about

the treatment of PND is needed to encourage

concordance so that women can make an

informed choice about their medication

schedules. There needs to be further empha-

sis on an alliance between the health

professional and patient to guide the deci-

sion-making process for medication

prescription63. Women are unlikely to com-

ply with amedication schedule if they do not

feel that medication is the appropriate treat-

ment for PND. With an increasing awareness

of alternative treatments for PND, this is a

growing area of importance. In the present

study, women were asked if they had taken

their medication exactly as it said on the

packet and if they had missed doses. In the

cases of women who had chosen not to take

their medication as prescribed, feelings about

taking medication were fully explored. Fu-

ture work is needed to develop partnerships

between doctors and patients, to move the

prescription of antidepressants from compli-

ance to concordance.

If it is decided appropriate to treat PND

with antidepressant medication, it is impor-

tant that women are aware of the need to

take their medication as prescribed, for the

period prescribed. Women may be main-

tained on their medication for 6 to 12

months and women who interrupt their

treatment have a significant risk of relapse

and therefore to consume more health and

social service resources in the long-term.

This risk of relapse can be reduced by almost

half if treatment with antidepressant drugs

is maintained for 4 to 6 months after

recovery64. This study suggests that commu-

nication and information about medication

was sub-optimal, and that without the

necessary information, many women regu-

lated or discontinued their medication in

line with their beliefs about its effects,

stigma and fears of dependence.

Women have a particular fear of their

antidepressant medication being addictive.

There is a need for GPs to spend time with

women prior to prescribing antidepressant

medication to ensure that any fears or

concerns about taking such medication are

elicited. In particular, there is little evidence

of physical dependence caused by antide-

pressants and Priest et al59 advocate

educating patients that stopping antidepres-

sants will not be a problem. However, clinical

experience suggests that it can be difficult to

withdraw treatment with antidepressants for

a variety of reasons. Furthermore, there are

emerging reports that the abrupt withdrawal

of antidepressants, can lead to a ‘disconti-

nuation syndrome’ in up to 1 in 5 patients,

which is characterised by transient flu-like

symptoms including dizziness, nausea, para-

esthesia, headache, tremor, palpitations,

vertigo and anxiety64,65,66. There was no

evidence of any withdrawal effect for the

women in our study, however this may be

because they failed to take their medication

as prescribed and were either taking sub-

therapeutic doses, or by tapering off their

medication were avoiding withdrawal ef-

fects. Strategies for withdrawal need to be

addressed with women alongside the issue of

psychological dependence.

It is clearly vital that women are regularly

provided with the information, support and

reassurance needed about antidepressant

treatment for PND. It is evident from our

study that this support was rarely provided.

It should be considered, however, that this

study was carried out prior to the publication

of the SIGN guidelines and it may be that

these guidelines could play a role in improv-

ing discussion with women about the

treatment of PND. Health visitors are in



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regular contact with postpartum women and

could be trained to reinforce information

about antidepressant medication. In the

absence of this support, women are likely

to self-manage their medication in line with

their fears and perceptions of their depres-

sive illness.

Women in this study showed clear

evidence of self-management in their medi-

cation regimes. This demonstrates the

importance of adopting an approach similar

to that of the ‘Expert Patient’67. Women have

already shown that they are prepared to

make decisions about their treatment, but

they are currently undertaking this in an

uninformed manner. This further suggests

the need for improved information about

PND and medication. Although some wo-

men in this study felt informed about PND in

general, they would have liked more detailed

information. There was also a desire for more

time to be spent in consultations discussing

such information and it would appear that

the provision of this time is perceived to be a

supportive resource. An evaluation of the

role of such counselling provided by GPs

alongside the prescription of medication

needs to be conducted. The role of the GP,

however, should not cease after prescription

of medication as revealed in the quotes.

Women need ongoing support and monitor-

ing from their GP if medication is to be taken

effectively and this will also allow a discus-

sion of the possibility of discontinuation of

the medication. Reasons for stopping medi-

cation could be explored and alternative

treatments suggested. The formation of a

partnership betweenwomen and their health

care providers have been found to reduce the

severity of symptoms, improve confidence

and self-efficacy67 and it would be helpful to

see if this is also the case with PND.

Counselling is perceived as more accep-

table to women as a treatment for depression

than antidepressants and the popularity of

counselling increases when women believe

antidepressants to be addictive, and when

women have previously been treated with

antidepressants68. In the future, there may

be a need to shift the treatment of PND from

a reliance on medication to brief counselling

interventions provided by health visitors, or

counsellors already based within general

practice for which some evidence of success

exists69,70. Until this happens, it is essential

that practitioners spend time with women

prior to, and after, the prescription of

antidepressant medication. It is also impor-

tant that practitioners remain aware of the

particular difficulties with prescribing anti-

depressant medication for women with PND

and consider alternative treatment options

where available.

This study illustrates that womens’ beliefs

about antidepressant medication can have a

direct impact on their medicine taking.

There needs to be the formation of an

alliance between women and their health

professional so that women can make an

informed decision about whether medica-

tion is the most appropriate treatment for

PND. If women are treated with antidepres-

sant medication they need to be fully

informed about side effects and withdrawal

to alleviate fears of dependency. This infor-

mation needs to be provided in a supportive

environment that allows some time for

explanation and the formation of a partner-

ship between women and their health

professionals. In the absence of this, women

are likely to continue to self-manage their

medication at a dosage that may be clinically

ineffective, and it would be more appropri-

ate to recommend an alternative treatment

for PND.

ACKNOWLEDGEMENTS

We wish to thank Dr. Gail Critchlow for

independently verifying scores on the SPI.

The health professionals who assisted in

recruitment and the women who partici-

pated in this study. This work was funded by

West Midlands Regional Health Authority.

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APPENDIX

1. How could services for PND be improved?

2. What changes would you like to see?

3. If you had postnatal depression again,

would you like to receive the same

treatment?

(a) Why would you like/not like to

receive the same treatment?

4. Would you recommend the treatment

you have had to a friend with postnatal

depression?



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Current knowledge on this subject

. Although antidepressant medication has been shown to be an

effective treatment for PND when used as prescribed, research

has shown that depressed patients consistently receive either

no medication or consistently low doses of medication

. The symptoms of PND require effective treatment as they

have a far-reaching negative impact on both the mother and

her infant. Despite the difficulties with the prescription of antidepressants

to women with PND, antidepressants remain the treatment of

choice for primary care practitioners

What this study adds

. Women’s beliefs about antidepressant medication have a

direct impact on their medicine taking, in particular a fear of

dependency. Women require ongoing support, monitoring and informa-

tion from their GP to allow them to make an informed

decision about taking antidepressant medication for PND. In the absence of appropriate support from a GP, an

alternative treatment for PND would be more appropriate

than antidepressant medication



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Documents

Women's views of antidepressants in the treatment of postnatal depression