Postpartum Depression: Whose Problem is it?

Mother with sad expression holding newborn

Postpartum depression and anxiety  are getting tons of attention in the media. From catastrophic accounts of misdiagnosed psychotic episodes, and an increase in state legislative action, to emerging research, as well as an explosion of passion-driven personal narratives from women who have recovered.

All of this translates into greater awareness and activity in research, in clinical practice and in the collective consciousness of women at risk.

This can only be good, right?

Certainly we are moving in a positive direction and the trajectory toward improved outcomes is at an all time high.

Why then, do so many women continue to suffer?

Why is it that postpartum depression and its related conditions continue to be misunderstood by so many healthcare professionals?

Women with postpartum depression and anxiety have been falling through the medical cracks for decades. When my first book, This Isn’t What I Expected was published, back in 1994, few doctors were routinely discussing postpartum depression with their patients, even those at high risk. But many are talking about it now. This is great progress. Some get it right. Others remain stymied by rampant misinformation.

Why is there still such a discrepancy between what those of us on the front lines observe and treat and what the public and some professionals presume to be true?

It’s complicated.

It seems to me that when a medical condition intersects with several areas of specialization, the focus becomes diluted, thereby making it impossible for it to be given full attention from any one of the multidisciplinary areas of study or practice. While obstetricians, psychiatrists, primary care physicians, pediatricians, midwives, lactation consultants, doulas and psychotherapists all share, to varying degrees, opportunity, interest and responsibility for the identification of, and ultimately, treatment for, her symptoms, not all are trained to do so.

Unlike conditions that are definable through tangible medical assessments, such as an x-ray, MRI, or laboratory findings, postpartum mood and anxiety disorders are diagnosed by a relatively outdated, albeit reliable and validated screening tool or, by clinical observation and assessment. All too often, essential clinical assessments hinge on the specific training, expertise, and quite frankly, the personality and inclinations of the person doing the evaluation.

There is far too much ambiguity there for my comfort.

This leaves many postpartum women hostage to the readiness, willingness and wherewithal of their healthcare providers.

Women are rebelling against this lack of clarity and fuzzy parameters for detection of such a serious medical condition with their collective outcry for recognition and support. They are joining forces and doing an impressive job educating and enlightening the community at large. There is a constant call to reduce stigma so moms can feel comfortable revealing their symptoms as well as an unwavering plea to healthcare professional to pay attention and ask the right questions.

Even so, misinformation permeates our healthcare system like the fog of depression itself. You cannot always see it, but its impact is undeniable, and those who are in the best position to recognize it are not always able to see it for what it is.

Postpartum women continue to get very sick and remain reticent to ask for help. Women are struggling to get through the day while they, somewhat amazingly, manage to lovingly care for their infants who depend on them. Although coping skills can kick in when survival is threatened, they require energy and reinforcement to be sustained. When women are let down by a medical response too misinformed or too preoccupied to take notice, they settle into their fatigue and absorb the incongruity by way of their fragile self-esteem. It must be me. I am flawed. I am not a good mother.

It seems so clear to those of us who see these women after being dismissed, condescended to, or misunderstood by their healthcare provider.  And so we say, please take heed:

  • This is serious.

Studies suggest that during the first postpartum year, 1 out of every 7 women walking into your office experiences symptoms of depression, (the number is higher when we factor in anxiety, bipolar illness and obsessive compulsive disorder.

  • Ask the right questions.

Screen for postpartum depression and anxiety. Collaborate with a well-trained expert in the treatment of postpartum mood and anxiety disorders and hand their name and number to your patient who is overwhelmed and unable to determine the next step. Take the time to tell her that she needs a comprehensive evaluation with the same authority you would tell her to get a mammogram if you felt a lump.

  • Do your homework.

Baby blues is not postpartum depression.

Postpartum depression is a clinical depression which emerges during the first postpartum year and meets diagnostic criteria for a major mood disorder.

Postpartum depression is not postpartum psychosis.

Every single woman with postpartum depression is at risk for suicide. You cannot always tell by looking.

  • Be accountable.

Do not pass your patient along to the next discipline and make it someone else’s problem.  Refer, do not defer. Do not simply tell her to “call a psychiatrist” or “get more sleep,” even if both would be beneficial.  If she is in your office, she is your responsibility. Provide her with reliable resources and follow up with this action.

A woman with postpartum depression tirelessly weaves in and out of various medical offices, whether or not she is in the mood, has the time, or is able to make her own needs a priority. Even without depression present, between her physiological changes, her baby’s well-being, her sleep deprivation, her exhaustion, and her transition to motherhood – she hardly knows what to do first.

All healthcare practitioners who are dedicated to providing care for women during the first postpartum year should feel compelled to make sure each new mother is receiving optimal care and excellent clinical support and guidance. Be informed. Join forces with interdisciplinary advocates. Do not let her slip through that crack.

Her life may be in danger.

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