Postnatal depression is a serious problem that affects up to 15% of women following the birth of a baby. This difficult and often disabling condition is frequently denied by women who are experiencing it or dismissed by their loved ones as insignificant.
Joy is the anticipated emotion after the conclusion of a planned and healthy pregnancy but this is not always the case. In fact, the American College of Obstetrics and Gynecology reports that 70-80% of women report some depression, the “baby blues”, after giving birth. Fortunately for most women this is a brief problem that does nopersist. What I would like to address is the more significant issue of true postnatal depression.
Recognizing the Problem
The signs and symptoms of depression are similar to those of all forms of depression:
- almost daily feelings of sad, depressed mood, often with anxiety.
- loss of interest in people and activities, unable to feel enthusiasm about the baby.
- changes in sleep-insomnia or oversleeping.
- restlessness and agitation or the opposite; the feeling of being slowed down with difficulty moving.
- fatigue and loss of energy.
- feelings of worthlessness, preoccupation with a sense of personal failure and inadequacy.
- problems concentrating, making decisions or thinking about complex issues.
- thoughts of death, suicide or harming the baby. Feelings of hopelessness, “might as well be dead.”
- crying easily or feeling too numb to experience emotions.
- these problems persist and intensify as the weeks and months since the birth pass.
Denying the Problem
Guilt is one of the central symptoms of postnatal depression (PND) so many women in the throes of PND will hide their feelings from their family and friends and try to pretend that everything is fine. Imagine the pressure on these women. Motherhood is still considered one of the most essential and important roles a woman plays. Women with PND are surprised and upset by their own reactions. They often feel something is terribly wrong with them; that they are bad, inadequate or shameful so they will try to hide what they are experiencing. This leads to the problem going longer without being addressed and the longer it continues, the worse the PND will get.
A further difficulty is that sometimes when a woman does confide in a trusted family member-her own mother or sister, the father of her baby, the well meaning family member, in an unfortunately wrong headed approach, will respond by re-assuring the new mother that she is fine, that she’s doing a wonderful job, that it will get better if she just give herself some time. When her disclosure is met with this type of response the mother is likely to feel that she is making too much of everything and hide her feelings more deeply. This often delays the time before the woman gets help.
What can confuse the issue further is the fact that for many people the birth of the baby does present real challenges and changes even to the best prepared families. Changes in routines and schedules are enormous. Babies often have their own medical complications that can be stressful in the early weeks. Couples must quickly adapt to very changed circumstances and work out effective ways of working as a team to accommodate the new family member.
There may be financial stresses. Babies bring many added expenses and parents may have reduced income if they have taken leave from work. Many babies were not planned and parents may be ambivalent about their arrival. Single motherhood is on the increase so many women may lack the emotional, social and financial resources they need to cope effectively with a new baby.
These normal problems of changing families can lead the mother to think her postnatal depression is to be expected and that no intervention is required. Financial, occupational, marital or social difficulties can cause the mother to minimize her own emotions. She may feel it is unfair of her to add her struggle to cope with her feelings to what seem like more serious or justifiable problems. Many people do not take depression seriously and feel they need to just pull themselves together and deal with it without burdening others.
Postnatal depression is a true medical illness that has identifiable biological causes. The culprit is hormones. During pregancy a woman’s hormones change markedly. Both estrogen and progesterone increase greatly to cause the essential bodily changes that occur so that a woman can carry and deliver a baby. These hormonal levels plummet rapidly after giving birth. Major hormonal shifts affect the brain and, very commonly, the emotional centers of the brain. Mood changes with menstrual cycle or menopause are well known. The puzzling part is that not all people are affected and even in people who are affected, the impact is not always consistent. Still, the connection is well established. Thyroid hormones are also well known to affect mood. Too little thyroid hormone and people become depressed and fatigued, too much and they can become anxious, restless or even psychotic. The effects of the hormone testosterone are also well documented. Excessive testosterone occuring in athletes who use anabolic steriods is believed to cause increased aggression and reduced frustration tolerance. Those who are low in testosterone can experience depression or slowed thinking.
All women who give birth have wide swings in their hormonal level of estrogen and progesterone. We do not not know why this leads to postnatal depression in some women and not all women. Women are not routinely screened for these hormone levels although one study (Ahokas, et. al. Journal of Clinical Psychiatry 2001) measured 23 women with PND and found low estrogen levels in all the women in the study. 16 of the 23 met criteria for “gonadal failure.” Their symptoms were significantly relieved with supplementary estrogen.
Women who have had one episode of PND are at higher risk for recurrence with subsequent pregnancies as are women with a prior history of Depression or a family history of Depression. Women with multiple concomitant social and/or emotional stressors are also at higher risk.
While plunging hormones may trigger the postnatal depression, hormone levels are likely to be normal by the time a woman seeks treatment as that may occur weeks or months later. It is likely that the severe and rapid shifts in hormone levels bring on the PND and that once it is set in motion it continues as it’s own event.
For a much smaller percentage of women postnatal depression can be quite severe. Postnatal psychosis is the most dangerous complication and is usually manifested by feelings in the mother of wishing to harm herself or her baby. Luckily cases of women harming or murdering their newborn babies are extremely rare but these are almost always cases of postnatal psychosis. More common, but still relatively rare, is for the mother to have thoughts or feelings of wishing to harm the baby. Most women will never act on these feelings but often they will avoid telling anyone because it is so frightening. Women have told me, “I didn’t want my husband to think I was crazy.” By keeping these thoughts secret these women suffer a terrible sense of fear, failure and guilt.
It is a great tragedy that so many women suffer in silence with postnatal depression due to lack of understanding or feelings of guilt that their feelings mean they are not good mothers. PND is highly responsive to treatment-and the sooner the better! The earlier help is sought, the less severe the PND is likely to become and the sooner the mother can feel well and enjoy her baby. Every week that a woman does not seek help is a week that she has difficulty feeling close to her baby and enjoying the great pleasures that motherhood can bring. The baby with a depressed mother may miss out on important early bonding which may be essential to future healthy development.
Excellent and highly effective treatment is available. Both psychotherapy and medications, often in combination, can rapidly bring symptoms under control. Besides professional help, self help groups such as www.ppdsupportpage.com are excellent resources. Do not suffer in silence and embarassment. The actress Brooke Shields did a wonderful public service by publicizing her battle with PND. Postnatal depression is difficult enough, I urge you to get help.
Article posted 10 November 2009
Robin Goldstein, EdD, is a licensed psychologist practicing in Boca Raton, Florida, USA. She has over 30 years experience and has worked extensively with divorce related issues.