On Christmas Eve of 2013, Jennifer* walked along a dark Pacific beach, the black waves of high tide crashing nearby. Her two children and mother were back at the rented cottage. She realized that no one would see if she slipped into the surf. She imagined just doing it — taking her own life.
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“In the midst of absolute apathy, this obsessive focus felt so good. My suicidal thoughts made it easier to white-knuckle it for another day, allowed me to feel something,” she says.
Jennifer, a former outdoor educator who lives in north Seattle with her husband and now three children, recalls hardly being able to function, yet she did not initially recognize that she could be suffering from some kind of postpartum mood disorder (PPMD) after the birth of her first child. Her anxiety and distress worsened when she became pregnant with second child, a boy, and dragged on after he was born.
Her guilt and shame at her perceived failure as a mother pushed her further into isolation and depression. It was not until that Christmas Eve that she decided to finally seek help.
Like any other disease
Postpartum mood disorder is a term used to describe any mood disorder that can occur during and after childbirth. It includes symptoms such as depression, anxiety, obsessive-compulsive behavior, apathy and, in rare cases, psychosis. Historic emphasis on depression in new mothers leaves out the other telling signs of this condition.
“Although postpartum depression is discussed most frequently, women can develop a range of symptoms and illnesses during pregnancy or following childbirth,” says Veronika Zantop, M.D., a psychiatrist at Swedish Medical Center’s Lytle Center for Pregnancy & Newborns in Seattle, who strives to educate mothers about the vast range of experiences possible.
According to the American College of Obstetricians and Gynecologists, women in their childbearing years account for the largest group of Americans with depression. Postpartum mood disorder can develop during pregnancy and up to 18 months after giving birth. “National studies estimate that between 14 and 20 percent of women suffer from some form of postpartum mood and anxiety disorder, and prior incidence of PPMD puts a woman at 50–80 percent higher risk of recurrence in subsequent pregnancies,” Zantop says.
The danger is that women who experience this distress may discount it as the anxiety of being a new parent, when in fact it is a highly amplified version of nature’s parental biochemical response. “A mother and her support system should consider depression like any other disease during pregnancy, like diabetes or high blood pressure, and that it is treatable,” Zantop says.
“While we are definitely seeing a shift in terms of awareness that these mood disorders exist, there is often still silence, stigma and shame on the part of the women experiencing them,” says Juliana K. Tyler, perinatal and postpartum counselor at Chrysalis Counseling Services in Everett, and former board member of Perinatal Support Washington.
What is postpartum mood disorder?
Most common symptoms
Symptoms can include lack of energy, mood swings, feelings of hopelessness and worthlessness, irritability or anger, forgetfulness, sleep difficulties, lack of sex drive, rapid weight loss or gain and feelings of self-harm or suicide.
Anxiety symptoms can include excessive worry that is hard to control, restlessness, edginess, muscle tension, difficulty in concentrating and difficulty in sleeping.
Symptoms can include anxiety, feelings of dread, fear of dying or going crazy, racing heartbeat, nausea, feelings of choking or smothering, shaking and trembling, hot flashes and chills, sweating and feeling disoriented.
This disorder is marked by obsessions that cause anxiety and distress, compulsions characterized as repetitive behavior or mental acts that a person feels driven to perform because of obsession or a set of rigid self-imposed rules.
Less common symptoms
Post-traumatic stress disorder
This disorder can be accompanied by the above disorders in addition to being distinct for the source, i.e. the experience of an event that was perceived as traumatic. Symptoms can also include flashbacks, intrusive memories, nightmares, exaggerated startle response, hyperarousal, hypersensitivity to injustice, fantasies of retaliation, cynicism or distrust.
Bipolar disorder occurs in about 2.6 percent of the general population and is characterized by intense mood episodes that fluctuate between major depression and mania. Symptoms of hypomania (shorter, less intense episodes of mania) and mania include racing thoughts, unrealistic self-confidence, delusions, immersion in plans or projects, excessive spending, impaired judgement, impulsive sexual activity and changes in physical condition, such as increased energy and reduced need for sleep.
According to research, most psychotic episodes in the postpartum period are caused by bipolar disorder, and occur in the first few days or weeks after birth. Symptoms can include hallucinations, agitation, rapid mood swings, incoherence, sleep disturbance, loss of motivation and blunting of affect or emotions.
Source: Perinatal Support Washington
Why the stigma?
The defining of PPMD as a distinct medical condition is relatively new, and as recently as a generation ago, a mother might have been labeled mentally ill for exhibiting what we now recognize as PPMD symptoms.
A new mother might believe she is expected to feel joy at the birth of her child, and that the admission that she is suffering somehow implicates her baby, therefore making her also ungrateful. Research from the Centers for Disease Control and Prevention suggests that societal expectations of happy motherhood and the persisting stigma of mental illness, sometimes combined with additional hardship of marital strife, poverty and lack of family support, can further compel a mother into isolation.
“Untreated maternal mental health has long-term negative effects both in individual relationships as well as larger communities,” Zantop says. The risks to the pregnant woman include a higher risk of substance abuse, poor prenatal care, relationship stress, obstetrical complications and depression. After pregnancy, a distressed mother is at risk for abuse or neglect of her child, difficulty sustaining primary relationships and in the worst cases, suicide.
Infants of parents with psychiatric disorders are particularly vulnerable and have a higher risk of developing psychiatric disorders in adulthood. “Poor mother-infant attachment can lead to delayed cognitive linguistic skills and impaired emotional behavioral development,” Zantop says.
Depression that begins early in life versus in adulthood is of particular concern, according to a study published in the journal Pediatrics & Child Health. Exposure to depression in childhood is associated with adverse outcomes in adulthood: greater severity of the illness, and higher risk of suicide and other violent behavior.
Infants of parents with psychiatric disorders are particularly vulnerable and have a higher risk of developing psychiatric disorders in adulthood.
Jennifer’s experience mirrors that of other mothers reluctant to seek treatment. A combination of self-imposed stigma and isolation kept her from admitting she needed help. She briefly tried group therapy, but eventually shied away from it. “I did not seek other forms of help because I didn’t want to admit that I might have a problem; it was so closely tied to how I judged my ability as a mother.”
Recognizing the need for public health awareness and the potential long-term impact of helping mothers early, federal and state agencies are now setting policies to identify and treat mothers susceptible to PPMD. New Jersey became the first state to mandate PPMD screening of new mothers in 2004.
Since 2010, the Affordable Care Act (ACA) requires all new insurance plans to cover depression screening for adults as part of preventive care. While it does not mandate specific depression screening of pregnant women or new mothers, the ACA nonetheless recognizes mental health as a primary care issue. And just this January, the U.S. Preventive Services Task Force recommended depression screening for all women during and after pregnancy, and subsequent treatment as necessary, no matter the insurance coverage.
When to intervene
The symptoms of PPMD during and after pregnancy include chronic crying, panic attacks, anxiety, sadness, compulsiveness, rapid weight gain or loss, sleep problems, feeling detached from the baby, anger, excessive fear for the baby’s health and safety and frightening thoughts.
Another Seattleite, Alice**, mom of two kids, credits the intervention of her mother and husband for getting her on an ongoing path to recovery from PPMD. Alice had no history of depression prior to having her first child. She describes herself as “a typical oldest child — striving, upbeat, able to get through the tough times.” So the intense mood swings she experienced two months after the birth of her son felt totally out of left field.
Deciding how to treat PPMD is an individualized decision.
“I didn’t feel depressed — instead, I felt overwhelmed and anxious, like I was losing control. I began to fixate on small things that wouldn’t have bothered me before having kids. I retreated into myself. I slept a lot. It was all I could do to maintain a facade of normalcy during the day, then come home and collapse,” she says.
The treatment of PPMD is a specialty, and experts advise working with a therapist who is trained in and experienced with this particular branch of psychology. Three things often needed to help a woman recover are psychotherapy, medication and increase in support, Tyler says.
“A lot of women need medication, or a combination of medication and therapy, to manage their illness,” Zantop says. Medication is not a cure-all, but it can relieve women of the weight of distress, allowing them to more easily manage their symptoms during their recovery.
Questions about medication
Some women are concerned about the impacts of medication during pregnancy or breastfeeding. But stress and anxiety during pregnancy can pose a risk to the fetus, too.
According to a recent study published by the Center on the Developing Child at Harvard University, researchers speculate that high cortisol levels (related to stress) in the pregnant mother may alter the development of the fetal brain, making the child more vulnerable to depression or anxiety as an adult.
“Many women fear taking medications during pregnancy or while breastfeeding, but the reality is that there is no such thing as no exposure,” Tyler says. “Babies are either exposed to maternal depression and/or anxiety or to the by-products of the medications taken to control these things.”
If certain medication can provide relief to a mother during or after pregnancy, studies now support its safe use. The recent 2015 study of the use of selective serotonin reuptake inhibitors (SSRIs, such as Prozac and Paxil) during and after pregnancy, published in BMJ (British Medical Journal), found that use of SSRIs early in pregnancy poses little or no risk for birth defects.
Despite a recent study by Canadian researchers associating greater risk for autism spectrum disorder (ASD) after antidepressant use during pregnancy, that research is still considered inconclusive in the greater medical community. Writing for the New England Journal of Medicine Journal Watch, associate editor Allison Bryant, M.D., MPH, observed that the outcomes for ASD were not significantly greater among the medicated mothers than for the unmedicated mothers suffering from depression. She stresses that ASD still has no pinpointed cause, and halting all drug therapies may have other consequences.
Alice based her own decision to try medication on available research. “I got encouragement from my family to look at medication as a tool, rather than a crutch, or sign of weakness,” Alice says. “Why not clear a path for resuming a sane-feeling existence? Looking into the research on antidepressants confirmed for me that they could help and were not harmful.” She consulted with her primary care provider and now sees a psychiatrist, who manages her medication.
Between her first and second child, she tried going off her medication. “The symptoms came roaring back,” she says. “I had a very hard second pregnancy, and though I took Prozac, I still experienced intense perinatal depression. Being armed with knowledge about what was happening and having coping mechanisms made it bearable.”
Deciding how to treat PPMD is an individualized decision; both Zantop and Tyler emphasize the importance of managing depression during and after pregnancy in whatever capacity is best for the mother and at the direction of her health care provider.
The Puget Sound region is rich in health care facilities, and more services have come online in recent years. Perinatal Support Washington connects families to the network of support and resources, as well as to outreach and education options via therapists, doulas, midwives, nurses and physicians. Its website provides links to services through private practice and nonprofit organizations.
More recently, Swedish Medical Center in Seattle established the Lytle Center for Pregnancy & Newborns in 2013, which is open to any new mother, even if she is not a Swedish patient. The center provides a comprehensive perinatal mood disorder program with psychiatrists, social workers and family counselors who specialize in maternal mental health, in addition to other services valuable to new parents, such as lactation consulting, baby checkups and a retail store of supplies.
Parenting education and support groups can be found throughout the region, such as the Program for Early Parent Support (PEPS) neighborhood parenting groups. Support groups also exist for parents going through specific issues, such as the loss of a child, infertility or traumatic birth (see resources to the right). Additionally, the region supports many complementary health care and wellness providers (such as massage therapists, acupuncturists, doulas and naturopathic physicians) who specialize in treating women during pregnancy and early motherhood.
Jennifer’s recovery is still ongoing. She and her husband spent a year in couples therapy to strengthen their union and to recognize and prevent Jennifer’s triggers for isolation and fatigue. She has never taken medication for her depression, which persists to this day.
“However, since I started writing regularly about having depression, it doesn’t seem to have the same grip on me,” she says. As for Christmas memories? Jennifer is now grateful for her role as a mother: “I look forward to the simple rituals my kids and I have created, like ice skating and going to see the Christmas Ships.”
*Last name omitted for privacy
**Name changed for privacy