Dr Philips Ekpe is the Medical Director of Guinea Savannah Medical Centre, Abuja, and a member of the American Society for Reproductive Medicine, the European Society of Human Reproduction and Embryology, and the Society of Obstetricians and Gynaecologists of Nigeria. In this interview with IJEOMA NWANOSIKE, he sheds light on postpartum blues, postpartum depression and postpartum psychosis, while drawing lessons from the Lindsay Clancy case.

What is postpartum depression and postpartum psychosis, and how do they differ from the normal baby blues that many women experience after childbirth?
Postpartum blues, postpartum depression and postpartum psychosis are part of a spectrum of mental health disorders that can occur after delivery. Postpartum blues, also called baby blues, is the most common and generally the mildest. It can affect between 50 and 80 per cent of women globally. It usually begins within hours of delivery, may peak around the fourth or fifth day and often resolves within about a week without treatment.

A woman experiencing baby blues may be anxious, irritable, and tearful or exhausted, partly because of the sudden change in her circumstances, the new responsibilities and the demands of caring for a baby.

Postpartum depression is more serious. The woman remains in touch with reality but may become unhappy, withdrawn and isolated. She may have intrusive thoughts, including thoughts of harming herself or her baby, and therefore requires treatment and support.

Postpartum psychosis is more severe. It can begin within hours of delivery and may involve hallucinations, delusions and loss of contact with reality. The woman may not recognise that she has a baby or may believe that the baby is her enemy. She may harm herself, the baby or people around her.

These conditions therefore range from the mild baby blues to depression and then psychosis. Depression and psychosis require medical attention, while psychosis may require admission because of the immediate danger to the woman and those around her.

What are the warning signs that husbands, relatives and caregivers should look out for in such cases?
With postpartum blues, the woman may be irritable, tearful, anxious and exhausted. She may appear overwhelmed by the sudden responsibilities of motherhood. With postpartum depression, relatives may notice that she has become withdrawn. She may stop talking to people, refuse to answer questions, lose interest in things around her and prefer to stay alone. She may also express feelings that the baby is not hers or show a significant change from her usual behaviour.

With postpartum psychosis, the changes can be much more obvious and sudden. The woman may begin talking to herself, saying things that other people do not understand, experiencing hallucinations or delusions, becoming violent or saying that she does not have a baby or that the baby is not hers.

No blood pressure reading or pulse rate tells you that a woman has postpartum depression or psychosis.

Recognition is largely through observation of her behaviour and activities. Once psychosis is suspected, she should not be left alone. She requires support and urgent medical attention, and the baby should be kept away from her until she receives appropriate care.

Can a woman develop postpartum psychosis even if she has never experienced depression or any other mental illness before?
Yes. It is possible for it to happen for the first time. Previous postpartum depression or psychosis may make doctors more watchful, and a family history of psychosis can also be relevant, but a woman who has never experienced the condition before can still develop it. A woman may also have delivered previously without experiencing any problem and then develop postpartum depression or psychosis following a subsequent delivery.

Environmental factors can also play a role. The relationship between the woman and her husband, the state of the marriage and the availability of psychological and social support can become triggers.

For example, a woman who is alone with a baby, exhausted, trying to cope with a crying child and other responsibilities may become overwhelmed. That kind of exhaustion and lack of support can contribute to postpartum difficulties.

In Nigeria, how do stigma, cultural beliefs and spiritual interpretations of mental illness affect women who need help?

Stigma is still a major problem. In our environment, people may interpret mental health problems from a spiritual or cultural perspective rather than recognising them as medical conditions.

A woman who is behaving abnormally may be scolded, taken for prayers or deliverance, taken to a traditional healing centre or even accused of witchcraft.

In some cases, people may lock the woman up rather than take her to a hospital.

These things delay treatment. The earlier the condition is recognised and the woman is taken to a professional, the better the opportunity to intervene before the situation becomes more serious.

Awareness is increasing, partly because of social media and greater access to information, but there is still a lot of work to be done.

The Lindsay Clancy case brought postpartum psychosis into the global conversation. What lessons should families and healthcare providers draw from such cases?
The important lesson is that we need to recognise the condition early and have a high index of suspicion. We should ask questions about how pregnancy has affected the woman at home, her relationship with her husband and whether she has adequate support. Antenatal and prenatal classes should also involve couples so that husbands understand what can happen and what signs they should watch for.

When early warning signs appear, the woman should receive professional attention rather than being left to seek help only from a pastor, traditional healer or other non-medical source. The case should also remind us that postpartum psychosis, although rare, can have very serious consequences. It is therefore important to identify the woman who is developing symptoms and intervene early.

Is there any relationship between the mode of delivery and postpartum depression or psychosis?
From the research I have done, there is no statistically significant difference between women who had vaginal delivery and those who had a Caesarean section in terms of developing these conditions. One may think that the pain or trauma associated with delivery could contribute, but the research did not show a significant difference based on the mode of delivery.

What is important is the support available to the woman. In our environment, we have communal support from in-laws, sisters, church groups and women’s groups, and these can help reduce stress and the risk of depression by ensuring that the woman is not left to cope alone.

How prepared is Nigeria’s healthcare system to identify and manage postpartum mental health conditions?
Our mental health system is still underdeveloped. There are not enough mental health facilities, particularly outside major cities and state capitals, and there are not enough psychiatrists to meet the need. The migration of health professionals has also affected the system.

We need to integrate mental health into routine healthcare rather than treating it as something that should only be addressed in specialised psychiatric facilities. There could be counselling rooms within hospitals and primary healthcare settings where patients can receive help when they present with emotional or psychological problems. There is also a need for more funding, facilities, manpower and political will to strengthen mental healthcare.

For a mother who is suffering in silence because she fears that admitting her symptoms may make her seem like a “bad mother,” what advice would you give her and the family?
The most important thing is to seek help early. She should not keep frightening thoughts or unusual symptoms to herself. She should tell her husband, sister, mother or another trusted person and seek medical attention.

Families also have an important role. Relatives should observe the woman after delivery and pay attention to significant changes in her behaviour. At the early stage, a woman may still have some insight and recognise that something is wrong. As the condition progresses into psychosis, she may lose touch with reality and no longer recognise that she needs help. Women should therefore not be left alone during the early postpartum period. Family members and caregivers need to be alert and supportive.

Read the remaining part of this interview on www.guardian.ng