Read an Excerpt
Overcoming Postpartum Depression and Anxiety
By Linda Sebastian, Bob Hogenmiller
Addicus Books, Inc.Copyright © 1998 Linda Sebastian
All rights reserved.
The Unexpected and Unknown
I was so excited about this baby. We had waited four years after we were married and saved our money, so I didn't have to go back to work. I worried about the baby having all its parts or being healthy, but I didn't worry about me. When I couldn't stop crying after I got home with the baby, I was so scared and thought I was a terrible mother. No one told me this might happen.
Annette, 32-year-old mother
Annette's anticipation of the birth of her child is very common. Most women expect an uneventful pregnancy and delivery. If anything, women usually worry more about the health of their babies than about their own health. For the majority of women, this time in their lives is, indeed, healthy. However, many women experience problems with depression and anxiety both during their pregnancy and after delivery. Because information about the potential emotional complications after childbirth is usually not shared with women, those who do have these problems often feel alone and isolated.
Postpartum depression describes a spectrum of mood disorders that typically occur in about 1 in 10 women after delivery. These mood disorders range from postpartum blues on the mild end of the spectrum to postpartum major depression, postpartum anxiety disorders, and postpartum psychotic depression on the more severe end of the spectrum. Such illnesses can devastate a woman and her family, as well as affect her newborn.
A majority (60 to 80 percent) of all women who bear children experience milder problems, such as postpartum blues. About 10 to 15 percent of women who have a baby will develop major depression or severe anxiety. Only a small percentage (about 1 in 1,000) develops the more severe psychotic depression.
Just as most women who suffer from major depression also have some anxiety, women with anxiety disorders usually experience some depression. There is a strong connection between anxiety and depression. Usually these problems occur together. These disorders are covered separately later in this book to help you clearly understand the symptoms.
Why is this problem misunderstood?
You may be unclear about postpartum mood disorders as a result of the terms used to describe them. The term postpartum depression is commonly used to describe the whole range of emotional problems surrounding childbirth. A majority of women know about the mild form called postpartum blues, which is often erroneously referred to as postpartum depression. The more serious forms of depression and anxiety that require professional help are also labeled postpartum depression. This overlapping language only creates confusion among women and their families, as well as health care professionals unfamiliar with psychiatric problems. The lack of clarity may cause the more severe problems to be confused with the less severe postpartum blues. Since the more severe problems are not recognized, they often go untreated.
To promote clarity, this book uses the specific terms postpartum blues, postpartum depression, postpartum psychosis, and postpartum anxiety rather than the more generic postpartum depression. When a general term is required, the phrase postpartum mood disorders is used. Since postpartum mood disorders have different symptoms, different treatments, and possibly different causes, it is important to discuss each one separately. Bear in mind, however, that sometimes the problems overlap and may be difficult to distinguish from one another. For example, in the second- or third-week postpartum, it may be difficult to tell if you are experiencing postpartum blues or postpartum depression. For this reason, it is important to consult a mental health professional as soon as you notice problems.
Two secondary factors also contribute to the lack of information about postpartum mood disorders. First, in today's smaller families, women usually have little experience caring for the babies of others or being around women who are having babies. Their lack of experience, coupled with unrealistic expectations, increases their fear of inadequacy. Many women have never known anyone else who had depression or anxiety after delivery. Because there is a stigma associated with psychiatric disorders in our society, women do not tell other women what has happened to them. This may contribute to the lack of information about risk factors for these problems. Second, extended families usually live too far away to help at home during the crucial first two weeks after delivery. Many working women who give birth feel alone because both their peer and social groups remain at work or their families are unavailable. Having a baby separates a woman from her support system and keeps her isolated at home. As you will discover later in this book, this isolation may contribute to mood disorders.
Culturally, our society pays a lot of attention to women and their partners during pregnancy and delivery. There is an expectation that all will be well after delivery. The mother should go home to do what comes naturally: take care of her baby without help or guidance. However, more attention should be paid to the new mother and her mental health. The postpartum period is the time of highest risk for a woman to be hospitalized with a psychiatric disorder.
Compounding the confusion for new mothers and their families is health care professionals' lack of awareness about these disorders. The major obstetric and gynecologic texts in use today, like those of the past forty years, generally do not mention the risk of postpartum mood disorders. If they do, it is only briefly. They neither list the risk factors nor provide a guide to treatment. As a result of this oversight, nurses and physicians who work with pregnant women and their families are not consistently assessing women for mood disorders.
There does not seem to be a clear reason for this oversight in the training of health care practitioners. Dr. Robert Barnett, an obstetrician and gynecologist in the Midwest, describes his experience in his residency program:
We were taught almost nothing about psychiatric disorders related to pregnancy and delivery. In my residency, the emphasis was on illness or problems related to gynecology or obstetrics. In four years of medical school, we probably received about one hour of lecture on psychiatric problems.
Dr. Grace Morrison, another Midwestern obstetrician, proposes that postpartum disorders are not well-known because women's problems have often been overlooked in medicine. Most of the research, treatment guidelines, and medical and nursing training has been conducted on or about men. Another possible reason for the oversight is the medicalization of childbirth, according to Manya Schmidt, a certified nurse-midwife in Kansas:
Childbirth was brought into the hospital, and women were taken away from their families. The entire pregnancy and after delivery was once a midwife's domain. What was once a natural event became a medical event with little attention paid to the woman after delivery.
The consequences of this lack of medical training is clear. It means that no one may be educating you or your partner about these risks. No one may recognize these serious problems when they occur.
Childbirth preparation classes often prepare women for the physical complications of delivery — infection and hemorrhage — but many never mention the possibility of postpartum disorders. Yet the incidence of postpartum depression is greater than the incidence of either of these other two potential complications. The rate of postpartum infection after a vaginal delivery is about 3 percent. As stated previously, the estimated rate of severe postpartum depression is about 10 percent.
Furthermore, our health care system divides our bodies into physical and mental parts. This specialization encourages health care professionals to know only one part of the body well. For all intents and purposes, they are ignorant about the rest of the body. When illnesses like postpartum mood disorders involve both psychological and physical aspects, the problems often do not fall within a health care specialist's domain. So often the problems go unrecognized and untreated.
The tragedy inherent in the unclear language, the lack of information for health care professionals, and the compartmentalization of health care means that we cannot identify who is most at risk for developing postpartum problems. Even though postpartum depression is one of the few mental health problems for which we can predict who is most at risk, many women do not receive the treatment they need to prevent more serious problems. Additionally, many women receive treatment only when symptoms get so severe that they are unmanageable. This means that it takes longer for the symptoms to subside.
Are postpartum mood disorders a new problem?
Since the time of Hippocrates, we have known that mothers can experience problems with their mood after delivery. The first medically documented study of emotional disorders after childbirth was in 1838 by a French physician, Dr. Jean E. Esquirol. Another French physician, Louis Marcé, continued to study these disorders and wrote extensively about them in the mid-1800s. Marcé delineated three kinds of problems related to the postpartum period: problems first seen in pregnancy, those seen immediately after delivery, and those seen about six weeks after delivery. His pioneering work helped clinicians recognize that there is more than one kind of psychiatric problem related to pregnancy and childbirth.
Marcé's work is still viewed today as the first attempt to categorize postpartum psychiatric disorders. Marcé also believed that problems in the postpartum period were unique to this time in a woman's life, distinct from psychiatric problems outside the postpartum period. The Marcé Society, an international organization devoted to the study and treatment of postpartum disorders, is named in his honor. It is a major source of information and collaboration about postpartum psychiatric disorders worldwide.
After Marcé's work, there was little investigation of postpartum psychiatric problems until the 1980s. In the 1920s, psychiatrists who developed a classification system for psychiatric disorders left out postpartum mood disorders because they did not consider them distinct from other psychiatric disorders. As a result, generations of psychiatric professionals such as psychiatrists, psychiatric nurses, psychologists, and social workers are not fully aware of the psychiatric risks accompanying childbirth.
Yet postpartum problems are among the few psychiatric disorders that mental health professionals have been successful in preventing, or at least in modifying their severity. There is still debate, however, as to whether postpartum disorders are unique to this time period or are similar to depression and anxiety found in both men and women at other times in their lives. In one British study, women who had gynecologic surgery were compared to women who had delivered a baby. A questionnaire examined their mood changes. Significant differences between the two groups of women support the idea that postpartum mood changes are unique to childbirth.
Just as postpartum disorders were found in ancient civilizations, they are found worldwide today. Women in both industrialized countries and "undeveloped" countries demonstrate an increased risk of hospitalization for psychiatric reasons after childbirth.
Who is at risk for developing anxiety and depression?
If you have previously suffered postpartum depression or other episodes of depression or anxiety, you are among the most likely to develop problems with the birth of a child. You are also at risk if you have experienced severe postpartum blues or have had mood changes related to your menstrual cycle. Another risk factor is major stress or change during pregnancy, such as a move, a death in the family, conflict with a spouse or partner, or potential problems with the unborn baby. Problems during delivery, either with the baby or the mother, also increase the risk of mood disorders after delivery. Other risk factors include social isolation after the mother and baby are home and a lack of supportive family members who actually help with the housework and help care for the baby.
Two significant risk factors for depression are childhood abuse and trauma. Sexual abuse, physical abuse, neglect, and overwhelming traumatic experiences such as the loss of a parent or sibling place women at risk for depression and anxiety even without the added stress of pregnancy and mothering.
To detect women at risk and refer them to appropriate psychiatric professionals, obstetricians and nurse-midwives could easily ask a few questions about the mental health history of the soon-to-be-pregnant woman or expectant mother. Questions about the stress levels in the woman's life — especially about the quality of her marital relationship — are just as important as questions about physical symptoms, to which Lisa's story attests:
When I was pregnant the first time, we had just moved to a new town, and my father had died. I was stressed during my pregnancy and was very depressed after the baby came, but I never told anyone or got any help. No one asked about my mental state.
This time, I was asked about stress in my pregnancy and previous depression. I was told I was at risk and was referred to a therapist in the third trimester. I was so relieved to have someone recognize that I needed psychological help as well as monitoring of my pregnancy. Things went much better because I had emotional help and support.
As a psychotherapist, in my own work I provide a list of symptoms and screening questions to obstetric nurses and physicians. They are now better able to detect potential and actual cases of postpartum depression, resulting in preventive action or early treatment in many cases.
In addition to the lack of awareness of these problems, our society minimizes the impact of having a baby, especially a first baby. Recently, "drive-through deliveries" have gained widespread attention in the media and even in the U.S. Congress. Insurance companies, managed care companies, and other third-party payers want to reduce costs, so they require the hospital stay to be as brief as possible. In other words, this trend reflects the attitude that having a baby is "no big deal" and that a woman should quickly return home to carry on with her life. But, in fact, the physiological and psychological changes that you experience at delivery are unparalleled in your entire life.
What can I expect to feel if I have postpartum problems?
When depression or anxiety affects you as a new mother in the postpartum period, you may not realize what is happening. You might think fatigue is making you feel unable to care for your baby, or you might think your hormones are making you "jittery." Because all of us are different, it is impossible to predict exactly how you are going to feel or react to having a baby. Most women report tearfulness as a primary concern, but for others it is irritability.
For most women, as symptoms worsen, they often try to hide their problems and avoid contact with others. Unaware that other women share her problem, they feel alone. They believe they are "bad" mothers to be having the feelings that accompany postpartum depression. Isolation, guilt, and shame worsen this depression. Tragically, this situation is all too common, but it is one that can often be prevented. If new mothers and their families realize that depression and anxiety are possible, they may seek early treatment before the symptoms worsen.
What influence does weaning the baby have?
If you are having mood changes and do not feel as well as you think you should, weaning the baby may seem like a solution. In fact, for some women, a stop to breast-feeding improves their mood because they are likely to get more rest and may return to a more stable, pre-pregnant state. Some women notice no difference in their mood upon weaning the baby. However, other women experience mood changes only when they stop breast-feeding. If mood changes occur during weaning, it is likely that a woman will experience similar problems with weaning after future deliveries. Consider the story of Paulette, a twenty-eight-year-old mother of two.
I noticed that I became very depressed for about one month after I stopped nursing my first baby. I cried for no reason, couldn't sleep, and generally felt miserable. I thought it was because I missed nursing.
With my second baby, it happened again. I was working then as a nurse. Nursing was a stress and a strain, and I didn't want to do it. When I got very depressed again, to the point where I could not get out of bed or take care of my kids, I knew I needed help.
It is believed that changes in the level of prolactin, a hormone present in high levels during breast-feeding, may be responsible for mood changes related to weaning. If you are having problems with your mood, consult a mental health professional before attempting to wean on your own.
Excerpted from Overcoming Postpartum Depression and Anxiety by Linda Sebastian, Bob Hogenmiller. Copyright © 1998 Linda Sebastian. Excerpted by permission of Addicus Books, Inc..
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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