Hiding in Plain Sight: Postpartum Depression

OVERVIEW

Postpartum depression (PPD) is a form of depression that develops following childbirth and impacts functioning to various degrees depending on severity. Onset is usually from the first few weeks postpartum up through the first year. Postpartum depression and a condition known as the “Baby Blues” may be confused. The differences between the “Baby Blues” and PPD are the duration, intensity, and severity of the symptoms. Approximately 80% of new mothers experience what is known as the “blues” (with symptoms such as lack of sleep, exhaustion, and a roller coaster of emotions), usually due to a hormonal imbalance. However, these symptoms typically peak around two weeks and then disappear. Some mothers react more strongly than others to the changes in hormone levels, be it post-partum or even post-weaning.

Unlike the blues, postpartum depression/anxiety symptoms persist and become more severe. Mothers often report feelings of worthlessness, guilt, despair, difficulty concentrating, or other similar feelings when depressed. Appetite and sleep patterns can be disrupted and a mother coping with postpartum depression may not be able to experience pleasure or interest in the baby or her family. Anxiety symptoms often accompany the depression. She may also have a difficult time adjusting to her new life as a mother while grieving the loss of her old identity and lifestyle. Many times, the mother may feel isolated due to lack of support. In some cases, a mother may have thoughts of wanting to hurt herself or her baby. Immediate help is required in these particular situations.

RISK FACTORS

Multiple factors are believed to contribute to PPD. Medical issues, such as hormonal changes and/or a thyroid imbalance, play a role; psychosocial factors do, too. The latter may include a lack of social support, substance abuse issues, breastfeeding issues, birth defects, etc. A family history of anxiety or depression can also contribute. When doing an evaluation for postpartum depression, it is incumbent for the practitioner to assess for all of these factors. A spectrum of PPD exists (ranging from mild to severe), and if left untreated can become more severe. Approximately 20% of new mothers experience PPD, and it can affect any mother regardless of age, race, or income.

RISKS AND STIGMAS

It is unlikely that a mother will admit to depression and anxiety. Instead, she may say something like “I cry almost every day, I don’t see a way out, everything looks hopeless,” or “It feels like I am a bad mother--I should have never had this baby.” Many new mothers are ashamed or embarrassed to admit to feeling depressed and/or anxious for fear of judgment or for fear of an authoritative figure deeming her unfit and taking her baby away. Unfortunately, these fears leave the mother in a state of isolation and silence.

Postpartum depression is shrouded in myths and stigmas hindering the understanding, creation, and accessibility of resources. This is due, in large part, to the societal expectation that a new mother should be happy about her baby or that after a brief transition following the birth, she should be able to adjust fairly smoothly to her new role. The cultural expectation that motherhood will come naturally is personified and reinforced by media representations of the perky mom with her happy baby. Furthermore, the media’s portrayal of postpartum depression and other perinatal mood complications is usually negative. Media coverage is further intensified when there is a tragic outcome. For all these reasons, greater compassion, understanding, and support are crucial to break through the barriers of these stigmas. Isolation only exacerbates the depression and impairs the mother and family’s well being.

THE IMPACT OF POSTPARTUM DEPRESSION ON FAMILIES

A cycle of perpetual negative reinforcement and isolation exists which leads to a continued deterioration of coping skills and a likely increase of family conflict. Postpartum depression has a ripple effect influencing the mother’s ability to bond with her baby, as well as adversely affecting her relationship with her partner or other family members. Oftentimes, the partner feels bewildered by the mother’s symptoms, is unsure of what to do, and/or feels helpless. S/he, however well intentioned, may expect the mother to “just snap out of it,” unable to understand that what she is experiencing is out of her control. The impact of untreated postpartum depression on the child could include low birth weight, disruption of the bonding process, insecure attachments, and social/behavioral problems in the older child. Early intervention and treatment is crucial to improve the outcome of the entire family unit.

SCREENING AND TREATMENT

A mother experiencing postpartum depression needs to understand that she is not alone, it is not her fault, and (with help) she will get better. Screening for PPD is crucial for identifying risk factors as early as possible. Ideally, screening would begin during pregnancy and occur during regular intervals during the postpartum period. It is the hope that in the future every hospital and birth center will have a screening protocol in place. The Edinburgh Postnatal Depression Scale (EPDS)1 is an example of a widely used screening tool that is adaptable in many languages and is easy to administer and score. Please note that the EPDS is a screening tool only - it does not assess the severity of the symptoms, nor is it a diagnostic tool. Follow up with the clinician is necessary to make an accurate diagnosis. Also, if the mother answers anything other than a zero on question number 10 (harm-related question), an immediate referral for further assessment and intervention is mandated.

The good news is that effective treatment for postpartum depression is available. Treatment includes individual counseling, support groups (face to face or online), one-to-one peer support, medication, or a combination of these. Individual counseling provides a trusting, supportive atmosphere where the mother can open up about her experience, focus on her strengths, and work on solutions to improve coping skills. Support groups are very powerful in that the mother can identify with others experiencing similar circumstances. This is a powerful affirmation that she is not alone. Several online support groups are available, making it a cost effective option and allowing the mother to participate from home. One-to-one peer support involves individuals, such as postpartum doulas, parent mentors, or other volunteers, communicating with the mother on a regular basis.

Finally, medication may also be a very helpful option in reducing depression and anxiety symptoms, thus increasing coping skills. However, many mothers are hesitant to consider medication for fear of stigma or how it will affect them or their babies. The decision to take medication is a personal one, and the risks and benefits of medication for the mother and her baby need to be carefully considered. The mother will need to be referred to a physician for further information and a medication evaluation. Resources, such as Lactmed, are available to help mothers and physicians evaluate pharmaceutical options.

POSTPARTUM DEPRESSION AND BREASTFEEDING

Mothers with PPD may feel that this condition is a contraindication to breastfeeding. However, it may be a situation where the mother needs to understand issues such as the use of medication, getting enough sleep, and family interactions, then figure out a strategy to meld these factors with breastfeeding. The interplay of these factors may or may not impact an individual mother’s decision whether or not to begin or continue to nurse.

Mothers with PPD may ask the following:

  • “Can I breastfeed while taking a particular antidepressant/anti-anxiety medication?”
  • “How can I maximize the amount of sleep I am getting while continuing to breastfeed?”
  • “I can’t/don’t wish to continue to breastfeed...am I a bad mother?”

The bottom line is the well being of the mother and child. In her article on breastfeeding and depression, Kathleen Kendall -Tackett points out the benefits of breastfeeding in a mother experiencing PPD. 2 Lactation consultants, Breastfeeding USA Counselors, and educators can be extremely helpful and supportive in helping the mother with breastfeeding questions and issues. This support is crucial if a mother wants to continue to nurse, especially if she is having problems. In cases of severe PPD, early intervention with medical consultation is important for the health and safety of mother and baby. The risks of untreated PPD to the infant are documented.

As Katherine Stone states,
“I know some mothers who suffered from PPD that felt incredible relief when they decided to stop breastfeeding, while others found their depression worsened. The decision to breastfeed (or not) is a very personal one. It is critical to recognize that breastfeeding is more important to some mothers than it is to others (whether that is biologically, intellectually, or emotionally determined). The relationship between PPD and sleep quality is critical. Unfragmented sleep is important in helping mothers to manage and overcome PPD. But if breastfeeding is highly valued to a particular mother (and to her mental health) and if the mother is breastfeeding successfully, then the sleep advice needs to be compatible with maintaining a healthy milk supply. Bad sleep advice could cause the mother’s milk supply to plummet and unnecessarily compromise her ability to breastfeed her baby.”3

Whatever decision the mother chooses needs to be respectfully accepted without judgment.

CONCLUSION

In summary, postpartum depression is an issue that needs to brought “out of the closet.” So many new mothers experience it, yet it is an issue that is shrouded in secrecy and shame. The good news is that more attention is being focused on PPD. Increasing services for advocacy, education and resources is crucial if we are able to encourage the many mothers and families who require help to receive it without shame or fear of repercussion. The new mother needs to understand that she is not alone, not to blame, and with help will get better.

REFERENCES
1. Cox, J.L., Holden, J.M. Sagovsky R. (1997). Edinburgh Postnatal Depression Scale

2. Kendall-Tackett, K. A new paradigm of depression in new mothers: the central role of inflammation and how breastfeeding and anti-inflammation protects maternal mother health. International Journal of Breastfeeding 2007, 2:6

3. Stone, K. (2013, June 6) Sleep management, breastfeeding and postpartum depression. Postpartum Progress

Nancy Layish, LCSW, ACSW is a licensed clinical social worker in the Orlando area specializing in perinatal mood disorders such as postpartum depression (PPD) and anxiety.