By Michele Nevard

A young woman stands on a bridge with her two young children. She looks into the water below and considers jumping off, ending it all. Another woman is driving on a busy motorway. She considers how easy it would be to end it all now, crash into the hard shoulder. Then she remembers she's on her way to the nursery to pick up her young daughter.  Only this prevents her and only this, bringing a child into the world, is what has caused her distress.

These two women are the tip of a very large iceberg called postnatal depression. This is a mammoth that dramatically and horrendously changes the lives of previously contented women. It's also the largest single cause of maternal deaths through suicide. According to the Confidential Enquiry into Maternal Deaths (2000-2002), 50 women in England and Wales had killed themselves in the first year after giving birth and another 14 died from accidents or overdoses that were likely to be self-inflicted.  When set against thrombosis, which is considered the largest direct cause of maternal deaths, with a figure of just 30 women, it puts postnatal depression into stark reality.

According to Cheryll Adams, acting lead professional officer for Community Practitioners and Health Visitors Association, "It cuts across all social divides. But it seems quite prevalent amongst professional women who have waited to have their families." And this can be explained, in part, by the demands placed on successful business women. As Cheryll explains, "You're in control of your life as a highly trained professional. But babies don't respond to the same sort of rules. Expectations can be higher if you've been in control of your job and it can shatter your confidence. Suddenly at 35 you're at home, socially isolated and many of your friends are still in the workplace."

Recognising these issues, and following lobbying and input from various organisations such as Cheryll's, MIND and PNI-UK, a new guideline for professionals, has just recently been published by the National Institute for Health and Clinical Excellence, (NICE). The guideline focuses on the detection and treatment for women with antenatal and postnatal mental health disorders, and calls for healthcare professionals to really listen to women, so they can pick up signs of distress early on. This is crucial as postnatal depression can often go undetected for a long time, and can continue even years after the birth. Fiona Shaw, a patient representative and member of the Guideline Development Group, (GDG), said, "Many women I speak to are concerned they will not be listened to if they come forward, or that they will be judged, or that their condition is not serious enough to warrant help from a healthcare professional. This guidance is about spotting what is not normal for each individual woman - this may be feeling highly anxious for a prolonged period, not eating, not enjoying anything, or maybe just staying in night-clothes, day after day, finding it increasingly difficult to go outside."

"It cuts across all social divides. But it seems quite prevalent amongst professional women who have waited to have their families."

Mandy Charteris, media and PR director of PNI-UK, recognises those feelings of isolation. She suffered from postnatal depression and says, "I felt helpless, like I was in a living hell. When Lucy was 15 months I started to self-harm. The GP said, 'I had someone in like you last week who committed suicide.' I felt thoroughly ashamed, distressed and didn't know if I could carry on anymore."  Two other women who received help and support from PNI-UK, and now also work for the organisation, echo Mandy's sentiments. Claire Inglis was a successful accountant, working in London's financial sector, who gave up full-time work to raise a family. She had such vivid visions of harming her children she became convinced she would kill them. And graphic designer, Nicola Muckelroy spiralled into psychosis and suffered from hallucinations following her baby's birth.

PNI-UK refers to postnatal depression as perinatal illness. As Mandy explains, "It is not a general depressive illness. It is a consequence of pregnancy." And no woman is exempt. The organisation's patron, Fern Britton, co-presenter of 'This Morning' has suffered from postnatal depression. Princess Diana famously talked of her experience with Martin Bashir in a 1995 Panorama programme. Brooke Shields, Elle MacPherson, and Judy Finnigan are just a handful of well-known women who've suffered after the birth of their children.  And the reasons women suffer from postnatal depression are mixed.

With successful women, the desire for perfectionism can be a factor. Birth trauma, exhaustion and hormonal surges are often contributory causes. Social and family elements need to be considered. For instance, these days people often live distances away from their extended families who could offer support. And some women may have a past history of depression. But most importantly it's crucial health professionals pick up the first signs. As Emily Woofter, policy officer for MIND says, "Health professionals need training. A lot of problems occur around professionals not addressing the problems." And that can be hard as Mandy says, "A mum will cover up. There's such a lot of pressure to be a perfect mother, so women will lie." Cheryll concurs, "It gets overlooked an awful lot, about 50 percent of the time. Mothers are brilliant at concealing it. It takes a very skilled person to pick it up."

Ironically just as the NICE guideline comes into force a new survey by the National Family and Parenting Institute reveals that the number of health visitors in England fell from 9,800 to 9,000 last year. And these are the very people new mothers need for support.

The Community Practitioners and Health Visitors Association found 55 percent of health visitors are making fewer visits to families. Cheryll says, "Support is the common factor and it's complex." She says, "Whether the guidelines get implemented properly comes down to the local primary care trusts. It could make a difference but it's very early days."

It may be early days but considering the devastating knock-on effects of postnatal depression for mothers and their children, time is not on their side. Lives can quickly be shattered, sometimes irreparably.

Organisations such as PNI-UK play a crucial support role for women with postnatal depression. Testimonials from women using their website speak volumes - 'I have found the emergency phone line an absolute saver, I have been able to express my deepest worries and thoughts without feeling judged' - 'Those were the hardest, darkest day's I've ever known. My life is 200 percent better now. If it wasn't for you guys I'd have given up', and 'It is the first time that anyone has understood me saying I was scared to be alone with the children'.

Drugs and counselling can both play an important part in rehabilitating women. It can be a slow process and services can be limited. In Leicestershire, for instance, there's a three-year waiting list for one to one psychotherapy. And there are only eight specially designated mother and baby units across the whole country. More often mothers are put in a side room on a psychiatric ward, alongside people such as drug addicts and those with extremely serious mental health issues

Postnatal depression is not a new problem. The Greek physician Hippocrates knew of it over 2,000 years ago, believing it might be caused by breast milk going to the brain. In the 21^st century the hope is that the new NICE guideline may help more towards identifying mothers at risk and offering them the necessary support. As Emily says, "Eight out of ten women experience the 'baby blues' which is a common reaction. But one in ten suffer from postnatal depression." In this day and age, that might be considered one too much.

www.pni-uk.com

www.mind.org.uk