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Postnatal Depression

Margaret

Presenting condition

Margaret is a 28-year-old married housewife, mother of two (a boy aged 3.5 years and a girl aged 2 months), who lives with her husband and children in a rented subdivided room. Her infant daughter is mainly breastfed. She was referred by Maternal and Child Health Centre with an Edinburgh Postnatal Depression Scale score of 27 out of 30 in January 2018.

History of present complaint

Margaret presented with low mood with suicidal ideas. She was new to the mental health service. She delivered a baby girl on November 19, 2017, via vaginal delivery with no complications. She had multiple stressors from before her daughter's birth. These included her husband indulged in gambling and, recently, even online gambling; he would disappear for a few days a month in the past 3 years. The debt had increased to the point that the debt was paid using credit cards, and the debt now totals about US$30,000. The second source of stress was her son's problematic behavior since she became pregnant. The third source of stress is the crowded living environment. She had decided to live in the city because this would enable her son to attend kindergarten year 1 from January 2018. Margaret has limited support from her family of origin.

Margaret developed low mood, with a sense of worthlessness and helplessness. She would look at her children and become worried about their future; she felt that they were poor. Since giving birth, her mood further deteriorated, with her experiencing reduced energy and poor concentration at work. Her sleep was also disturbed by childcare. Margaret experienced appetite loss and lost 1-2 kg. She does not enjoy activities, feels the lack of money, and has no time for any entertainment; they do not even have a television set at home. Previously, she had fleeting suicidal ideas of jumping from heights, but these became less frequent since she moved to the city. In the city, her husband tended to stay at home most of the time. Margaret denied having a concrete suicide plan, had not acted on any suicidal impulses, was remorseful, and still cared about and worried for her children. Margaret denied alcohol or substance use and denied the existence of any psychotic symptoms. Occasionally, she would hit her son with bare hands or with a hanger; however, she would feel remorse afterward. There were no previous hypo-manic or manic episodes.

Family history

There is no family history of mental illness or suicide.

Personal history

Margaret was born in the country. She is the eldest of four siblings (two sisters who are 2 years younger and one brother). Margaret graduated from secondary school. She came to the city when she was 17 years old. She had a fair relationship with her family of origin. Her mother works in the market and her father works as a casual worker.

Margaret had an unhappy childhood; her father would hit her with a belt and a hanger until she developed skin lacerations; her mother would kick her over trivial matters. Her family was patriarchal. She was physically punished by her parents until she reached high school. Her parents disliked her studying and wanted her to work and earn for the family. Margaret insisted on working part-time and supporting her studies. She felt that she was an "extra" in her family. She had a better relationship with her younger sisters and brother.

Margaret was married at 24 years of age and moved back to the country; she would travel daily to work as a saleslady in a part of the city, which is near the country; she was the main breadwinner of the family. Her family of origin was not supportive of her marriage; they disliked her marrying and moving back to the mainland. Margaret does not "dare" to express her feelings to her family of origin and does not feel that she can ask them for support. She gave up her job in January 2018 to allocate her time to childcare. Margaret is currently unemployed and has been working as a housewife since moving to the city.

Her husband is 28 years old and from the country; he is without a city identity card. He previously worked as a waiter but became unemployed recently to take care of their son while Margaret worked and was the breadwinner. Her husband is currently waiting for his identity card and so he can find work. Husband and family depend on Margaret's savings. Margaret is a nonsmoker and nondrinker; she has no history of substance or alcohol misuse.

Past psychiatric history

Margaret is new to the mental health service.

Present treatment and management

On the first consultation in February, Margaret was found to have low mood and to be calm and settled, even though she was weeping. She presented within the normal range. Her speech was coherent and relevant and was of normal tone and tempo. She claimed that she had been troubled by fewer suicidal ideas. No psychotic features were detected. She had no violent ideas or any harmful ideas toward her children.

The overall impression was that Margaret was suffering from a moderate depressive episode whose onset was well before the birth of her last child and which was related to multiple stressors. Margaret felt initially relieved to live away from her family of origin but found that since moving to the city she was facing more problems, such as financial stress and stress in relation to the care of the children, with limited social support.

Treatment options were discussed with Margaret who was then started on Sertraline 25 mg and was referred to a medical social worker and to the community psychiatric nurse service. The issue of the use of benzodiazepines while breastfeeding was also considered.

Consultation

JM acknowledged that this was a thorough and thoughtful presentation. JM addressed the question of why Margaret developed depression after the second child and not after the first. The doctor responded that Margaret had to change her living environment on this occasion so that her son could attend the nursery in the city. This move brought greater financial stress on the family. It was clarified that Margaret had lived in the country with her first child and her husband. It was therefore made clear that the family is under stress because of the opinion that the children would have a better education in the city than in the country. The doctor pointed out that Margaret was familiar with the city where she lived from her early teenage years. Furthermore, Margaret had been working in the city while living in the country for quite a few years. The doctor pointed out that quite a few families do this as a matter of course. The doctor also pointed out that many people who live in the country believe that the city offers better education, better social care, and better health care.

JM pointed out the disappointment that Margaret must have felt when she was expecting the move to the city to represent an improvement in her family life and living conditions and found quite the opposite. The doctor pointed out that the family had taken steps to make their stay in the city permanent, such as applying for an identity card for her husband and expecting their son to continue making improvement and a good adjustment at the nursery. They expect that after the identity card is obtained, the husband will be able to work and, therefore, contribute to the family finances. The doctor added that this was a realistic plan, but also noted that employment in the city is difficult to obtain.

JM then inquired about the debt. The doctor clarified that the debt had accumulated because of the husband's gambling. The doctor added that husband was gambling his own and his wife's savings. JM inquired further about husband's gambling, and the doctor added that there is an indication that husband is still gambling online from home. The doctor further added that husband is likely to be given an identity card in a few months' time.

JM then asked, because there probably was a group of county people who worked without an identity card in the cash economy, in the black market, or simply manual jobs for lesser money but cash in the city, why the husband wasn't doing something of the sort. JM pointed out that the family situation is not an adequate explanation for husband's staying at home and gambling instead of going out to earn a living to support the family. JM then inquired further about the husband's role in the family and, in particular, whether he was supportive of his wife in other ways.

JM summarized that the basis of Margaret's depression is her view of her own future as without hope of something getting better. JM inquired whether her feeling of hopelessness was based on the absence of any active steps that her husband could be taking to improve their situation. In this sense, her view of the future was realistic; that is, that things are not going to get better if the husband continues to behave the way that he has been.

JM then shifted the focus to Margaret's psychopathology. As the eldest child, she was brought up to feel that she was responsible for supporting the family. She may have carried the same expectation-the expectation that her parents had for her-as her expectation of herself now and, as such, had low expectations of receiving help from her husband. In other words, she expected that everything was her responsibility, and that if things were not going well, she had only herself to blame. Therefore, one of the early...