Postpartum Depression by Gayle Peterson, LCSW, PhD

CATEGORIES OF POSTPARTUM DEPESSION

Baby blues:
Feeling intense emotional swings in the first 2 weeks after giving birth, along with teariness and some feelings of sadness occurs in up to 80% of women. These swings are attributed to the physical changes, especially hormonal swings that occur during this period. The baby blues usually resolves within 2-3 weeks without treatment.

Postpartum Syndrome:
Postpartum depression syndrome which is marked by continued teariness, feelings of sadness and sometimes angry outbursts, accompanied by suicidal feelings and sometimes a fear of hurting herself or the baby, or feelings of inadequacy to care for the baby can occur as early as one month, but commonly begin between one and 4 months. The depression generally lasts through the first year, and if left untreated, can continue beyond one year. PPD is serious and needs treatment. It occurs in up to 15% of mothers.

Postpartum Psychosis:
Postpartum Psychosis may be marked by an inability to take care of the baby, severe risk of suicide and/or hurting the baby, hallucinations, and thought disorder. It occurs in only 1-2 per one thousand of women and, unlike postpartum syndrome, it occurs at the same rate for both western and non-western societies.

Clinically, postpartum syndrome is the category that the psychotherapist will most likely be dealing with in depth. For that reason, we will begin with a summary of symptoms and treatment for postpartum syndrome, and then move to psychosis.

Postpartum Depression Syndrome

Although we see women in regular prenatal care for an average of 6 months prior to delivery, we do little to help them prepare for the psychological task of motherhood, which is the psychological work of pregnancy, along with the preparation for childbirth itself. Our traditional prenatal care is focused on the physical aspects of pregnancy. However, by adding 2-4 counseling sessions to the prenatal care program, (see : http://www.askdrgayle.com/html/counseling_services4.html and the book “An Easier Childbirth for description of the Peterson Prenatal Preventative Counseling model, and the Body Centered Hypnosis Course on psychceu.com ) by a therapist trained in addressing perinatal issues, we can provide benefit not only to identify women at risk for postpartum depression, but also to help all women experience a smoother, more satisfying transition to motherhood.

Sadly, we not only miss this opportunity for prenatal screening of postpartum depression, but when women recount to their medical practitioners that they are having a hard time with motherhood they are more often than not simply reassured that this is normal. Repeatedly, women who complain of symptoms of postpartum depression are turned away without referrals or further intervention or assessment of any kind.

Cultural Loading of Motherhood
In truth, all women experience some difficulty with integrating the role of mother in their lives. It is a continuum of difficulty. Ambivalence is normal in motherhood and definitely understandable in our culture. Motherhood is a greatly underestimated transition and one of the most profound in a woman’s life. Our society pressures women to be good mothers, but simultaneously devalues the work of nurturing.

The cultural loading of motherhood and its effects on women is greatly overlooked. Yet, is fact that women experience a much greater sense of responsibility (translate into “worry”) for the outcome of their children than do fathers. This does not mean that fathers do not love a care for their children, however they do not feel the weight of society’s eyes upon them!

For example: Women who have crying babies in public areas, such as a grocery store report more often than not irritated looks by other adults who do not offer to help. Fathers, on the other hand, with the same situation experience smiles and friendly offers of support or even help. Is it any wonder that mothers feel more “ to blame” if something is not going right in a child’s life? Society punishes women and judges them around the concept of “good mother” at a much higher rate than fathers. Although this awareness of fathers’ involvement and responsibility is increasing, it is ever so slowly catching up the level of scrutiny women absorb in the role of “mother”.

see my articles on cultural loading:

Becoming a Family: Placing Love in Equal Relationships to the Primacy of Work in Modern Day Society
http://www.askdrgayle.com/html/becomfam.html

When Women Become Mothers And the Impact of Family Self-Esteem
http://www.askdrgayle.com/html/wwbm.html

Husband is Great but I still have to "Ask" for Help
http://www.askdrgayle.com/html/qa3.htm

Women experience cultural pressures to be “good mothers” in a society that devalues the basic work of mothering. This situation sets up a breeding ground for low self esteem and for depression in women. The cycle reveals itself in women’s behavior that is a result of the internalization of these pressures.

Example: Women that I see in my practice who are not working outside the home, often do not feel they are entitled to paying for childcare in order to get a needed break or to develop any other part of themselves as women. I encourage them to take back their rights to decision-making on how to spend the family income at to take care of themselves. Loss of decision-making power is one sign of this internalization.

Likewise, women who work outside the home, often continue to carry the responsibilities for making all the doctor appointments, school conferences and house chores without sufficient help from a spouse/father, despite asking for help! Couples therapy is in order for an over loaded mother!

Overloading and loss of power in the family decision-making when a woman becomes a mother, relegates her to a compromised position in the family, which promotes depression.

When left untreated, postpartum depression infiltrates the family relationships, causing stress on marriage, mother-infant relationships and vital family processes. Ongoing postpartum depression erodes a woman’s self-esteem and all family relationships as well as negatively impacting child development affected by depression in the major caretaker. When left untreated, more than 15 % of women will remain depressed at one year following childbirth.

Symptoms:

Causes:

Biological: It is important to send a woman for a physical work-up to assess whether there are any physical problems that need to be addressed that could be contributing to postpartum depression. The two below are specific to postpartum.

Hormonal imbalance
Although tests can be run on hormonal levels, little is usually done to treat depression from this standpoint. Still, it is important to rule out excessive imbalances.

Thyroiditis
10% of postpartum women experience a dsyregulation of thyroid function following childbirth. Appropriate medication may be required to help a woman balance her system. The thyroid tests, however, must include a full battery of thyroid screening ( by an endocrinologist, as thyroid problems can be very difficult to diagnose.
(see: http://www.thyroid-info.com/articles/postpartum.htm
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1515829&dopt=Citation
The normal thyroid pattern after pregnancy, is for the thyroid to go into hyperactivity for the first 3-4 moths, then into hyoactivity for the next 3-4 months, and to stabilize at pre pregnant levels by 7-8 months after birth. However, women may respond to thyroid dysregulation at different levels of intensity. Biological screening and treatment can help women who experience depression related to thyroid dysregulation.
Symptoms that relate to thyroiditis can include:
Hair loss
Debilitating fatigue
Depression
Anxiety
Insomnia
Low milk supply

Still, psychosocial factors appear to be the largest contributor to postpartum depression syndrome.

Psychosocial Factors
1. Lack of social support network, including help with caretaking
2. marital discord, lack of spousal and father support
3. loss of freedom
4. Cultural/gender programming resulting in: overwork for the mother and/or loss of decision-making power in the family
5. Unresolved childhood relationships (childhood neglect, conflicted mother-daughter relationship, childhood losses
6. Past history of depression and/or other mental illness
7. Past postpartum depression
8. Past family history of mental illness, particularly if disrupted the mother-daughter relationship, such as hospital stays that created absences, postpartum depression in the mother’s mother.
9. Traumatic or negative childbirth experience (women who have cesarean births are at greater risk for PPD)
Childbirth is often ignored as a significant event in a woman’s life. Because it is not a neutral event, it is one that must be processed (positive or negative) if a woman is to integrate it into her development as a person. It is a critical and overlooked (likely devalued because it is feminine) life process. (see my article: Childbirth: The Ordinary Miracle Effects of Devaluation of Childbirth on Women's Self-Esteem and Family Relationships http://www.askdrgayle.com/html/com.html
Below is an excerpt from the article above:

“ The experience of pregnancy and childbirth is uniquely female. Not all women give or want to give birth. However women who do give birth whatever the circumstances, are faced with the reality of one of nature’s most powerful events. The fact that women can express extremely negative or incredibly positive experiences of childbirth is evidence of the generic power of the experience itself. This most basic fact, that childbirth is a powerful force to be respected, has been lost in the overall devaluation of the feminine in our society.
Women often feel alone with the responsibility of motherhood, even when they have supportive partners. Mothers are criticized quickly when things go awry in childrearing, while their positive contributions go unsung. In fact, many aspects of female development remain invisible to our culture at large. Childbirth is no exception. The message of our society is that the experience of childbirth is unimportant .

Countless women have come to see me in my practice because they could find no one to talk to about their childbirth experience. Their psyches called out for an integration of this very powerful event, that brought their babies into their lives, their hearts and their minds. But they are questioned for their need to process it, as if the tremendous physical transformation of a newborn emerging from within their bodies were not significant enough to address. Their obstetricians often express dismay that they should want to talk further about the experience for any reason, because after all they have a healthy baby! Women are left with the implication that to continue to have any need to discuss the experience means they don’t really care about the baby, or they have missed the point of it all. Again, this is a way of saying that the experience of giving birth should not matter to a woman. This gives women the message that their own development does not matter once they become mothers.

To not take a woman’s needs seriously, is to contribute to a lowered sense of self esteem which may also have effects on her available energy for bonding and enjoying her baby, and may even contribute to postpartum depression. Without a way to integrate the experience, women are left to try to feel better by denigrating childbirth. This approach serves the overall social structure which itself devalues the process. But in the end it undermines a woman’s sense of the worth of her own significant life events.

DEVALUATION OF FEMALE EXPERIENCE

Because our culture devalues that which is feminine, even the most intimate and basic processes of women’s lives become targets for judgment. Our society encourages competition in every aspect of life. Mothers themselves are exploited to compete with one another, making their own birth experience a valid or invalid one, arguing whether the experience of giving birth is sacred, beautiful and powerful or a denigrating process to endure, even a worthless joke on women. Women comedians sarcastically attack women who want to experience natural birth, “You are stupid women! You have nothing to prove. You’re not a man!” It makes for good entertainment, but this polarization distorts the continuing problem of devaluation at the heart of our experience of womanhood. When a mother’s self esteem is undermined, family relationships suffer as well. Perhaps it is possible for us to validate and share our female experiences in a manner that would build rather than devalue a woman’s sense of self.

Childbirth is and always will be a woman’s experience. This does not mean that men are not participants, involved in the process, but they do not undergo the transformation of physicality inherent for their mate. For this reason, childbirth is feminine. It is an experience of sufficient power to generate tremendous amounts of anxiety, fear, excitement and anticipation. Labor is not by it’s nature, a neutral event. Our experience of ourselves and our sense of personal identity is in constant flux with our life’s unfolding. Because of the intensity of such an experience as childbirth and all that it entails, it is one that will help formulate a woman’s identity. Like any powerfully significant event in our lives, it has the potential for mastery or overwhelm, empowerment or devastation. Getting trapped in a battle about “the right way to give birth” or “the right way to feel about your childbirth experience” misses the very real need to integrate the experience. A woman needs opportunity to explore the relationship to her changing body and identity, as she becomes a mother, if she is to feel at all “ready” for childbirth. There is no right method or experience. There is a basic need to psychologically metabolize all that is happening!”
Gayle Peterson, MSSW, PhD

Treatment
A. Biological work-up for thyroid and other physical problems

B. Counseling/Psychotherapy to address past unresolved trauma including:
Childbirth, mother- daughter relationship, and childhood loss issues

C. Antidepressant medications only if needed to augment psychotherapy.
Several antidepressants have been found to be safe in pregnancy and breastfeeding, including: Zoloft, Paxil, ,Prozac and Celexa. The benefits of breastfeeding have been found to far outweigh any possibilities of risk to the infant.
Reference: “Beyond the Blues” : A guide to Understanding and treating Prenatal and Postpartum Depression” by Shoshan Bennett, PhD and Pec Indman, MFT, moodswingspress, 2003… www.beyondtheblues.com

D. Group support: a group for postpartum depression is by far the most effective, rather than a mother’s support group in general. Most moms with PPD feel isolated and increased anxiety when attending a regular mom’s group as opposed to a specifically designed program for depression. Visit: http://www.postpartum.net/ for help finding a postpartum depression group in your area.

E. Involve the Father!

Couples therapy focused on the father having a primary caretaking role is essential to the health of the marriage and therefore, the baby in the long term. It is necessary for a father to experience changing diapers, dealing with a crying baby, learning how to soothe his child without the mother present so that he develops not only an appreciation for the role of caretaking, but is a competent parent to his child. This not only relieves stress on the mother, but supports bonding between father and child. Without this primary nurturing role, a father is likely to become peripheral to the family, depressed himself and feeling outside of the “heart” of the family life. (refer to my article: http://www.askdrgayle.com/html/becomfam.html ) for more on this family dynamic.

Postpartum Psychosis
Psychosis refers to a woman being out of touch with reality. When coupled with motherhood, this category of mental illness can be deadly. Psychosis occurs in 1-2 per thousand of mothers with an onset of 2-3 days postpartum. This disorder has a 5 % suicide rate and a 4 % infanticide rate.
Symptoms:
1. Auditory and/or visual hallucinations
2. Thought disorder with delusional thinking (need to kill baby, taking care it somewhere inapproiate, speaking of killing baby or self)
3. Delirium and/or mania

Risk factors:
1. Previous postpartum psychosis or bipolar episode or diagnosis of schizophrenia
2. Family history of psychosis, bipolar or schizophrenia

Treatment:
1. Antipsychotic medication, such as haldol (recommended as safe for breastfeeding mothers)
2. Mood stabilizers: lithium depakote, tegretol (Tegratol and depakote are approved by the American Academy of Pediatrics for breastfeeding. Lithium is not recommended.)
3. Psychotherapy
4. Family therapy to increase support and awareness of safety issues for caring for the baby.

Conclusion
Postpartum disorders
…baby blues, which resolves in the first few weeks after birth does not require treatment. However: Encouragement for mothers in their caretaking role, and processing the childbirth event are important in a woman’s development and in the service of increasing her confidence in herself as a mother and her satisfaction in the role. Also, addressing the cultural loading of motherhood is a benefit to all mothers and families, regardless of whether postpartum depression is diagnosed.
See: http://www.psychceu.com/Peterson/hypnosis.html
for further training in addressing the posttraumatic stress of childbirth and prenatal counseling for improved psychological preparation for birth.
… .postpartum depression syndrome occurs in up to 15% of mothers with onset at one month to one year. Without treatment, postpartum depression can damage family relationships and women remain depressed at a rate of 15% by one year.
… .It is crucial that women get the help they need when dealing with the transition to motherhood, the postpartum period. Preventative measures are best, providing counseling for women prenatally to give them the opportunity to process the psychological work of becoming a mother and what it means to each woman with respect to her history and to her present family relationships, in particular her relationship with spouse or partner.
As a psychotherapist working with individuals, it is important to recognize this transition to parenthood when it comes up in the lives of your client. Awareness of the issues facing women and men, in the postpartum period will help you better help them navigate this important change which can make a difference in the lives of children and their children to come.

Give appropriate referrals to support groups, physicians, and therapists specializing in this life transition when red flags are identified in your client’s psychotherapy. If you are interested in providing treatment to women who suffer from postpartum depression, obtain further training in this area. Experience and information are critical at this juncture in the family life cycle. It is a very rewarding path, should you choose to specialize, but do not take it lightly. It is necessary to get appropriate training to address this very important disorder, and to have a background of knowledge about the particular concerns of women becoming mothers today.

Further Study and References
As mental health professionals, it is important that we study women and their life cycle, including, but not limited to the transitional life stages and challenges of pregnancy, postpartum and motherhood. Below is an article for further study and references made available by the National Institute of Health on women and mental health.

Women Hold Up Half the Sky

Women and Mental Health Research

Mental illnesses affect women and men differently. Some disorders are more common in women, and some express themselves with different symptoms. Scientists are only now beginning to tease apart the contribution of various biological and psychosocial factors to mental health and mental illness in both women and men. In addition, researchers are currently studying the special problems of treatment for serious mental illness during pregnancy and the postpartum period. Research on women's health has grown substantially in the last 20 years. Today's studies are helping to clarify the risk and protective factors for mental disorders in women and to improve women's mental health treatment outcome.
Depressive Disorders
In the U.S., nearly twice as many women (12.0 percent) as men (6.6 percent) are affected by a depressive disorder each year.1 These figures translate to 12.4 million women and 6.4 million men.2 Depressive disorders include major depression, dysthymic disorder (a less severe but more chronic form of depression), and bipolar disorder (manic-depressive illness). Major depression is the leading cause of disease burden among females ages 5 and older worldwide.3
Depressive disorders raise the risk for suicide. Although men are four times more likely than women to die by suicide,4 women report attempting suicide about two to three times as often as men.5 Self-inflicted injury, including suicide, ranks 9th out of the 10 leading causes of disease burden for females ages 5 and older worldwide.3
Research shows that before adolescence and late in life, females and males experience depression at about the same frequency.6,7 Because the gender difference in depression is not seen until after puberty and decreases after menopause, scientists hypothesize that hormonal factors are involved in women's greater vulnerability. Stress due to psychosocial factors, such as multiple roles in the home and at work and the increased likelihood of women to be poor, at risk for violence and abuse, and raising children alone, also plays a role in the development of depression.8
While many women report some history of premenstrual mood changes and physical symptoms, an estimated 3 to 4 percent suffer severe symptoms that significantly interfere with work and social functioning.9,10 This impairing form of premenstrual syndrome, also called Premenstrual Dysphoric Disorder (PMDD), appears to be an abnormal response to normal hormone changes.11 Researchers are studying what makes some women susceptible to PMDD, including differences in hormone sensitivity, history of other mood disorders, and individual differences in the function of brain chemical messenger systems. Antidepressant medications known to work via serotonin circuits are effective in relieving the premenstrual symptoms.12,13 Women with susceptibility to depression may be more vulnerable to the mood-shifting effects of hormones.
Postpartum depression is a serious disorder where the hormonal changes following childbirth combined with psychosocial stresses such as sleep deprivation may disable some women with an apparent underlying vulnerability. NIMH research is evaluating the use of antidepressant medication and psychosocial interventions following delivery to prevent postpartum depression in women with a history of this disorder.
NIMH researchers recently found that women who suffer depression as they enter the early stages of menopause (perimenopause) may find estrogen to be an alternative to traditional antidepressants. The efficacy of the female hormone was comparable to that usually reported with antidepressants in the first controlled study of its direct effects on mood in perimenopausal women meeting standardized criteria for depression.14
Anxiety Disorders
Anxiety disorders, which include panic disorder, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), phobias, and generalized anxiety disorder, affect an estimated 13.3 percent of Americans ages 18 to 54 in a given year, or about 19.1 million adults in this age group.15 Women outnumber men in each illness category except for OCD and social phobia, in which both sexes have an equal likelihood of being affected.16,17
Results from an NIMH-supported survey showed that female risk of developing PTSD following trauma is twice that of males.18 PTSD is characterized by persistent symptoms of fear that occur after experiencing events such as rape or other criminal assault, war, child abuse, natural disasters, or serious accidents. Nightmares, flashbacks, numbing of emotions, depression and feeling angry, irritable, or distracted and being easily startled are common. Females also are more likely to develop long-term PTSD than males and have higher rates of co-occurring medical and psychiatric problems than males with the disorder.19
Eating Disorders
Females comprise the vast majority of people with an eating disorder. Anorexia nervosa, bulimia nervosa, or binge-eating disorder.20 In their lifetime, an estimated 0.5 to 3.7 percent of females suffer from anorexia and an estimated 1.1 to 4.2 percent suffer from bulimia.20 An estimated 2 to 5 percent experience binge-eating disorder in a 6-month period.21,22 Eating disorders are not due to a failure of will or behavior; rather, they are real, treatable illnesses. In addition, eating disorders often co-occur with depression, substance abuse, and anxiety disorders, and also cause serious physical health problems.20 Eating disorders call for a comprehensive treatment plan involving medical care and monitoring, psychotherapy, nutritional counseling, and medication management.20 Studies are investigating the causes of eating disorders and effectiveness of treatments.
Schizophrenia
Schizophrenia is the most chronic and disabling of the mental disorders, affecting about 1 percent of women and men worldwide.23 In the U.S., an estimated 2.2 million adults ages 18 and older, about half of them women, have schizophrenia.2 The illness typically appears earlier in men, usually in their late teens or early 20s, than in women, who are generally affected in their 20s or early 30s.13 In addition, women may have more depressive symptoms, paranoia, and auditory hallucinations than men and tend to respond better to typical antipsychotic medications.24 A significant proportion of women with schizophrenia experience increased symptoms during pregnancy and postpartum.25
Alzheimer's Disease
The main risk factor for developing Alzheimer's disease (AD), a dementing brain disorder that leads to the loss of mental and physical functioning and eventually to death, is increased age.26 Studies have shown that while the number of new cases of AD is similar in older adult women and men, the total number of existing cases is somewhat higher among women.26,27 Possible explanations include that AD may progress more slowly in women than in men; that women with AD may survive longer than men with AD; and that men, in general, do not live as long as women and die of other causes before AD has a chance to develop. Research is being conducted to find ways to prevent the onset of AD and to slow its progression.
Caregivers of a person with AD are usually family members?often wives and daughters.27 The chronic stress often associated with the caregiving role can contribute to mental health problems; indeed, caregivers are much more likely to suffer from depression than the average person.28 Since women in general are at greater risk for depression than men, female caregivers of people with AD may be particularly vulnerable to depression.
References
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2Narrow WE. One-year prevalence of mental disorders, excluding substance use disorders, in the U.S.: NIMH ECA prospective data. Population estimates based on U.S. Census estimated residential population age 18 and over on July 1, 1998. Unpublished.
3Murray CJL, Lopez AD, eds. The global burden of disease and injury series, volume 1: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Cambridge, MA: Published by the Harvard School of Public Health on behalf of the World Health Organization and the World Bank, Harvard University Press, 1996.
4Hoyert DL, Kochanek KD, Murphy SL. Deaths: final data for 1997. National Vital Statistics Report, 47(19). DHHS Publication No. 99-1120. Hyattsville, MD: National Center for Health Statistics, 1999.
5Weissman MM, Bland RC, Canino GJ, et al. Prevalence of suicide ideation and suicide attempts in nine countries. Psychological Medicine, 1999; 29(1): 9-17.
6Birmaher B, Ryan ND, Williamson DE, et al. Childhood and adolescent depression: a review of the past 10 years. Part I. Journal of the American Academy of Child and Adolescent Psychiatry, 1996; 35(11): 1427-39.
7Bebbington PE, Dunn G, Jenkins R, et al. The influence of age and sex on the prevalence of depressive conditions: report from the National Survey of Psychiatric Morbidity. Psychological Medicine, 1998; 28(1): 9-19.
8Sherrill JT, Anderson B, Frank E, et al. Is life stress more likely to provoke depressive episodes in women than in men? Depression and Anxiety, 1997; 6(3): 95-105.
9Johnson SR, McChesney C, Bean JA. Epidemiology of premenstrual symptoms in a nonclinical sample. I. Prevalence, natural history and help-seeking behavior. Journal of Reproductive Medicine, 1988; 33(4): 340-6.
10Rivera-Tovar AD, Frank E. Late luteal phase dysphoric disorder in young women. American Journal of Psychiatry, 1990; 147(12): 1634-6.
11Schmidt PJ, Nieman LK, Danaceau MA, et al. Differential behavioral effects of gonadal steroids in women with and in those without premenstrual syndrome. New England Journal of Medicine, 1998; 338(4): 209-16.
12Yonkers KA, Halbreich U, Freeman E, et al. Symptomatic improvement of premenstrual dysphoric disorder with sertraline treatment. A randomized controlled trial. Sertraline Premenstrual Dysphoric Collaborative Study Group. Journal of the American Medical Association, 1997; 278(12): 983-8.
13Pearlstein TB, Stone AB, Lund SA, et al. Comparison of fluoxetine, bupropion, and placebo in the treatment of premenstrual dysphoric disorder. Journal of Clinical Psychopharmacology, 1997; 17(4): 261-6.
14Schmidt PJ, Nieman L, Danaceau MA, et al. Estrogen replacement in perimenopause-related depression: a preliminary report. American Journal of Obstetrics and Gynecology, 2000; 183(2): 414-20.
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16Robins LN, Regier DA, eds. Psychiatric disorders in America: the Epidemiologic Catchment Area Study. New York: The Free Press, 1991.
17Bourdon KH, Boyd JH, Rae DS, et al. Gender differences in phobias: results of the ECA community survey. Journal of Anxiety Disorders, 1988; 2: 227-41.
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