“Postpartum depression emerges at a time in a woman’s life when both the demands and stakes are high. In addition to the disturbing feelings and symptoms, there is one more complicating factor. There is a baby in the picture. This makes everything more dramatic, more precarious, and much more urgent.
Whether it’s her first bout of depression or one of many, experiencing these symptoms while she transitions into her role of mother, can make her wonder if this is just what being a mother feels like. Too often, a woman is unaware she is suffering from a treatable condition. Rather, it is perceived as a character flaw, a defect in the vision of maternal perfection she held so close to her heart.
For this reason, it is insufficient to treat only the illness when treating postpartum depression. Handing out a prescription for antidepressants and telling her to come back in a few weeks for a follow up may, in the short run, relieve some symptoms, but it fails to address her wounded self-esteem and belief that she will never be a good mother. In doing so, we abandon the heart of a mother who has been injured beyond belief at a time when she expected what everyone else expected – that this would be the happiest time in her life. It seems our society should stop insinuating that this is so. As exciting as this time is for many women and their families, it is also a time in their lives when many are at risk for emotional illness. It would be prudent for women to prepare for the possibility of depression rather than expect maternal bliss and then be blindsided by the illness.” –-Therapy and the Postpartum Woman: Notes on healing postpartum depression for clinicians and the women who seek their help. (Routledge, 2009)
Postpartum depression (PPD) is a dramatic illness. Recently, high profile accounts are grabbing headlines and drawing public awareness in unprecedented fashion. That’s the good news. The not-so-good news is, while this attention to postpartum depression increases, two things are happening. First, in spite of efforts to educate and promote a better understanding, widespread misinformation and misperceptions persist. Second, as early screening programs and policies evolve, women who suffer with postpartum depression and anxiety continue to get lost in the shuffle. Healthcare providers aren’t always sure what to do with the high number of women at risk or those in the throes of a major depressive episode.
Postpartum depression is more than an illness. It is an experience that pierces the soul of the woman who endures it and challenges everything she thought she knew about herself. She may fear it is a state of craziness that is so often exaggerated and sensationalized by the media. Or, she may think it is a condition that only affects women who did not want their babies, or women who are not good mothers, or women who are weak.
And some women, indeed most women, believe it is something that only happens to somebody else.
We now know that these presumptions are not true. Postpartum depression and anxiety can affect women who are happily married or women who are in constant conflict with their partners. It can affect women who are eager to get pregnant, and women who are totally unprepared for pregnancy. It can affect women who come from stable, supportive families with no history of mental illness or women from dysfunctional families of origin, who had previous episodes of depression. It can strike any woman, immediately after the birth of her baby, or it can surface many months later.
Unfortunately, PPD has been misunderstood for some time, by mothers, family members and the medical community at large. There are many reasons for this:
- Medical professionals have been taught to expect a certain degree of emotional upheaval during the postpartum period, so there is a tendency to normalize such responses and perhaps not take the woman’s concerns seriously.
- We live in a society that does not tolerate a mother’s feelings of fear, ambivalence, and rage. Often the expression of these feelings is interpreted as inappropriate and out of control.
- Women strive to keep up with their own high expectations of motherhood and when they fall short, they are besieged with feelings of inadequacy, guilt and enormous grief. They hesitate to reach out for help for fear of being labeled a “bad mother.”
- Symptoms of depression and anxiety after childbirth often fall through the cracks of the medical community – with women bouncing back and forth for support among psychiatric, obstetric, pediatric, and general family practice disciplines.
What causes postpartum depression?
Many people confuse postpartum depression with the more common phenomenon of baby blues. The “blues” refer to a hormonally triggered state that is characterized by tearfulness, depression, fatigue, irritability, and anxiety. Research shows that the incidence of baby blues is as high as 80 percent of all new mothers. Onset is usually soon after delivery and remits spontaneously within two weeks. No treatment is required other than understanding of the situation and support. If symptoms of what appears to be baby blues persist beyond two weeks, the possibility of PPD should be considered.
Although no single cause is known, experts agree that the emergence of postpartum depression, (15-20% of all new mothers) involves a combination of hormonal, biochemical, psychosocial, and environmental influences. An example of this is that although it is suspected that hormones play a large part in the development of PPD, we also know that fathers and adoptive mothers have suffered with PPD, which tells us that it is not strictly hormonal.
Many things can put a woman at risk for postpartum depression. Some of these risk factors are:
- Previous postpartum depression
- Depression/anxiety during pregnancy
- Family history of anxiety/depression (genetic predisposition)
- Unsupportive spouse or poor social support
- Recent separation or divorce
- Major loss in past two years (death of loved one, move, job)
- Obstetric complications or difficult infant temperament
- Environmental or life stressors
- Single marital status
- Childcare stress
- Low self-esteem
- Difficult infant temperament
- Psychological or psychiatric vulnerability
- Sleep deprivation
These risk factors do not cause postpartum depression. Many women can have a number of these risk factors and never get depressed. We don’t always know why. Other women can have one or even no risk factors and end up with a full blown major depressive episode. What we do know is that these risk factors make a woman more vulnerable and if she knows she is at risk, she can begin to take preventative measures, such as mobilizing a support network and fortifying her resources.
How do you know if what you are feeling is “normal” or if it is PPD?
What makes the diagnosis of PPD complicated is that there is no standardized, scientific test to determine the degree of adjustment difficulty. Confirmation of PPD is made by clinical assessment, that is, a combination of what mom reports, how she looks, how she sounds. But women aren’t always sure. After all, don’t all new mother cry? Aren’t all new mothers anxious? Certainly we expect a degree of emotional lability during the early postpartum weeks. How do we know, therefore, how much is okay and when to seek professional help?
First of all, it’s important to keep in mind that it is not just what you are feeling, but how long you’ve been feeling it, how bad it feels and how much it is interfering with your day. For example, as we’ve noted, all new mothers feel tearful during the first few days or weeks. But if a mother is crying all day, or for no reason, and feels her crying is unexplainable and she doesn’t feel like herself, these are more intense feelings that may need further assessment. Similarly, it is common for a new mother to feel anxious intermittently throughout the early months. It may be a concern, however, if her anxiety is impairing her ability to function or if she experiences racing thoughts and panic attacks.
Because of this overlap between what is “normal” for new mothers and because some PPD symptoms are heightened states of what any new mother (without PPD) may feel, it is easy to understand why symptoms may too often be casually dismissed as temporary and expected responses to the postpartum adjustment period. In other words, if a new mother tells her doctor she is feeling weepy and tired, he/she may remind mom that this is “normal” and she will feel better soon. This may or may not be true. Medical professionals need to be more responsive to the statements of the mother who is concerned about the way she feels. Unfortunately, most women are not eager to share their emotional anguish and unless the right questions are asked, her level of acute distress may continue to go unnoticed. Thus, it’s important for women to be alert to how they are feeling and feel prepared to advocate for their own well-being and mental health by asking for and getting the help they need.
Trust your instincts
If you think something is wrong, it probably is. That does not mean that anything bad is happening. But it may mean you are experiencing some symptoms of depression that need to be addressed. Untreated depression can get worse over time and becomes harder to treat, the long you wait. It is not easy to ask for help. But it’s not easy to take care of a baby when you feel you are free falling into despair. Postpartum depression responds well to treatment and early intervention and treatment is associated with better recovery and prognosis. Let someone know how you are feeling.
Some symptoms of postpartum depression:
- Difficulty concentrating
- Feeling sad, hopeless, despair
- Unable to enjoy things you previously enjoyed
- Feeling guilty or inadequate
- Unable to sleep even when your baby is sleeping
- Increased anxiety or panic
- Loss of appetite
- Fatigue, lack of energy
- Irritability or anger
- Thoughts that are scaring you
Most experts agree that postpartum depression is best treated with medications, psychotherapy, or a combination of both. Antidepressant medication (generally SSRIs) is indicated for moderate-to-severe depressive symptoms, or when a woman does not respond to nonpharmacologic treatment.
Psychotherapy has been shown to be as effective as medication in many cases for the treatment of postpartum depression. It is easy to see that it may take more than a pill to help a woman feel better about herself when she is in the throes of a deep depression that has fractured her soul. Talk therapy can help her reclaim feelings of self-esteem and empowerment during this time when so much is demanded of her.
Although more research is necessary to determine the effectiveness of complementary or alternative interventions with respect to postpartum depression, many, such as light therapy, acupuncture, exercise, and good nutritional choices, are attractive options to women struggling during this time of their lives. By and large, they are not terribly expensive and may appeal to women who would prefer not to take medication. A word of caution, however is that alternative therapy is best suited for mild depressions or as adjunctive treatment with methods such as therapy and/or medications, in which efficacy has been well documented.
A word about breastfeeding
Women who are breastfeeding are particularly concerned about safe treatment options. There is much reliable research on the use of medications while nursing if symptoms indicate that medication would be helpful. This is why it is so important to be evaluated by someone who is familiar with the literature and can help women determine the best course of treatment for both her and her baby. The breastfeeding relationship is sacred to many and a woman needs to make careful decisions when weighing the risks and benefits of continuing to breastfeed while treating her symptoms so she can get better.
A word about scary thoughts
Thoughts that are negative and intrusive are extremely common during the prenatal and postpartum period. Most women are afraid to disclose these thoughts for fear they will be misunderstood or judged. Healthcare providers need to educate themselves on the agitated nature of postpartum mood and anxiety disorders so they can respond appropriately to the expression of these thoughts that can be so distressing to moms. By the same token, women need to understand that these scary thoughts are anxiety-driven and do not mean she will act on them. Once her anxiety is addressed and treated, these thoughts will become less stressful and begin to resolve.
Despite increased attention to the illness, women with postpartum depression are still hesitant to reveal to their healthcare practitioners how bad they are feeling. Fearing judgment or casual dismissal, they hold tight to their private worries and simply hope they will go away on their own. Fortunately there has been a huge shift in current thinking about postpartum depression brought on by increased public awareness and tremendous advocacy. Groundbreaking legislation for improved screening practices and treatment options has paved the way for women who are seeking treatment. Ideally, this will lead to better and universal screening, assessment and treatment.
Women need to know that postpartum depression is a very treatable condition and the prognosis is excellent for complete recovery. Healthcare practitioners need to ask the right questions. Postpartum women need to let their providers know how they are feeling and what they need.