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May 2008
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Postpartum Depression: You Don't Have to Suffer Alone
By Roberta Nubile
"I always thought postpartum depression was in a woman's head," says Deb Guerra of Chester. "I thought they were just trying to get attention. I didn't think it was real." Before she experienced postpartum depression (PPD) eight years ago after the birth of her fourth child, Guerra, 43, shared the prevailing attitude of many people who have never had PPD - and some who have.
"It hit in the hospital," Guerra recalls. "I was overcome with sadness and emotion. I kept crying. I was overwhelmed and didn't want to go home. I remember picking up the baby and just crying. I would hold her and sob."
The hospital kept Guerra an extra day, but soon after she got home, things escalated. "I was saying things like, 'I miss her,' to my husband, while he would point out that I was holding the baby."
Guerra feels she may have been grieving the apparent twin, detected by ultrasound, that had died early in the pregnancy. "I was so concerned with the baby who was alive that I didn't have time to grieve. I also never nested, as I had been put on bed rest toward the end of my pregnancy and didn't get things ready." Bereavement is one of the risk factors for PPD.
Guerra was diagnosed with PPD and started on a short-term regimen of Zoloft, an antidepressant which is considered safe while breastfeeding, and counseling. These interventions, which are one of the many treatments available now for PPD, helped to alleviate the uncontrollable crying for Guerra. Her symptoms eventually went away completely, and around nine months after delivery, she was able to stop the medication.
PPD is prevalent in 10 to 20 percent of women after birth or miscarriage, according to the National Women's Health Information Center. Onset occurs between a month and a year after delivery. The condition is widely thought to be under-reported and under-diagnosed.
The exact causes are not well understood, although most medical practitioners agree that the dramatic hormonal shift following birth or miscarriage affects mood-related neurochemicals in the brain. For some women with risk factors (see sidebar), this shift tips them out of the more common and short-lived "baby blues" into full-blown PPD.
What differentiates the baby blues from PPD is that they are transitory and will go away without treatment. Reported in up to 75 percent of postpartum women, the baby blues may develop within hours after delivery, peak around day three or four, and last up to two weeks. This period of time is sometimes referred to as the "fourth trimester," as the woman's body continues to regulate itself hormonally. PPD's onset is generally later, weeks to months after delivery, and does not go away without some kind of treatment. Not understanding this difference may lead some to shrug off PPD as normal.
Lisa Oliver's story began after the birth of her second child. "I didn't want to hold him other than breastfeeding," recalls Oliver, 29, of Bristol. "I didn't pick him up to comfort him, I felt no emotional attachment. I was crying every day, would just sit in the bathroom and cry. My milk wouldn't flow when I cried. I wasn't eating or sleeping. I thought, 'I don't want this baby.' I wasn't suicidal - just very down. Part of me thought - how could you be feeling and thinking this way?"
Oliver didn't seek help right away because, she explains, "I was in an abusive relationship at the time. I thought, Of course I feel like this. I was in denial. I was isolated from family and friends because of the relationship." Oliver didn't know at the time that an abusive relationship is a risk factor for PPD. When she'd had enough, her physician started her on Zoloft when her child was around five and a half months, and about a month later, she started to feel better. Oliver reports feeling very close to her now five-year-old son. "He is more socially introverted," she observes, "maybe because he didn't have the care he needed in the beginning."
Just before the birth of her third child, Oliver started to have familiar depressing thoughts. She spoke with her visiting nurse and midwife and together they decided to restart Oliver on antidepressants, before she "went on the rollercoaster again." This time, when her child was born, Oliver says, "I cried out of happiness and gratitude, not sadness."
Symptoms of PPD can include anxiety, panic attacks, spontaneous crying, difficulty sleeping and lack of interest in the new child. There may also be feelings of guilt, worthlessness, and decreased energy and motivation. Some women experience profound anger and have thoughts of hurting their children or themselves.
In extremely rare cases - less than one percent of new mothers - women may develop something called postpartum psychosis. It usually occurs within the first few weeks after delivery, and symptoms include manic behavior such as lack of appetite, frenetic energy, extreme paranoia, and, as with PPD, thoughts of hurting themselves or their baby, but with a strong likelihood that the thoughts may be carried out. Postpartum psychosis usually requires hospitalization, and is often associated with a preexisting psychiatric disorder.
Sometimes women experiencing normal PPD seem mentally unstable to themselves. Guerra remembers "wanting someone to understand and tell me that it was 'Okay,' and that I wasn't losing my mind. It was such an odd sensation to be holding my baby and, at the same time, feel like my heart was heavy and breaking because I missed her so much.
"I know that doesn't make any sense," Guerra adds, "but I'm sure you've learned talking to other mothers that postpartum depression doesn't make sense, which is why I think it's so misunderstood."
The good news is, at least here in Vermont, women's health care practitioners are on the lookout for PPD in their pregnant and postpartum clients. "Many organizations work very hard to pick up depression," says Dr. Kim Blake of Affiliates in Obstetrical and Gynecological Care in Burlington, citing a few: Healthy Babies, Kids and Families of the Vermont Health Department; the Visiting Nurses Association; Better Beginning, a Blue Cross/Blue Shield program; and the Vermont Child Health Improvement Program at the University of Vermont (UVM). "I agree with their recommendations," Blake adds. "Screening during pregnancy, spreading the word to all patients and families, and careful follow-up postpartum with phone calls and visits."
Dr. Charlotte Ladd is a psychiatrist with the Mood and Anxiety Disorders Clinic of UVM and Fletcher Allen Health Care which, she says, handles "moderately to severely affected clients." She reports being pleased with the level of detection and care given to mild and moderately affected clients with postpartum depression by their family practitioners, OB/GYNs, and midwives.
At prenatal visits, clients with and without risk factors are counseled as to the warning signs of PPD. Prenatal questionnaires are used to assess baseline moods and risk factors, and postpartum screening tools, such as the Edinburgh Postnatal Depression Scale, are used in follow-up visits.
Celebrities who write about their experiences with PPD in the popular press, such as Brooke Shields and Marie Osmond, have helped bring the subject to light. Even the exposed CIA agent Valerie Plame Wilson addressed it candidly in her memoir about being betrayed by the White House, Fair Game, devoting a chapter to her experience. Recalls Plame Wilson, "I felt that I had extremely high coping skills, but the depression hit me like a ton of bricks. I had no idea what was happening to me. My publisher indulged me in letting me tell this little piece of the story, because I feel passionate about it, about education and advocacy."
Martha Redpath, a certified nurse midwife with Tapestry Midwifery in Vergennes who has worked in women's health care for 20 years, says she is "relieved that the mystique has diminished. Over the last several years I have noticed it is easier for women to come forward."
Guerra did not come forward; her feelings, she thought, needed to be masked. "One of the hardest parts was trying to pretend that nothing was wrong," she remembers. "I didn't really want to leave the house, because everywhere I went people would ask how I was or how things were going. I remember trying so hard not to let my emotions show. I was, after all, a new mother and was supposed to be thrilled and excited.
"Trying to carry on with daily life like nothing was wrong was such a challenge, but I had three other children who needed their mom, so I had no other choice. Looking back now, it seems like the more I tried to hide it and carry on, the harder it got."
Treatment of PPD may include short-term antidepressants, group or one-on-one counseling, exercise, acupuncture, homeopathy, Chinese medicine, natural hormones, chiropracty, nutritional supplements, aromatherapy, hypnotherapy - or a combination of any of these.
Dr. Dyhano (Diane) Pierson is a Burlington psychiatrist who specializes in homeopathic remedies for her clients. She names sepia - the dark fluid that cuttlefish secrete defensively - as "a time-honored treatment for the postpartum period since the 1800s. It is very effective in rebalancing the hormones and getting the mother back on track. I also will recommend that the mother get support and help with the baby." Nathalie Kelly, a hypnotherapist in Shelburne, says, "Overwhelm and exhaustion can be addressed well with conscious thinking. The mind can take in a suggestion like, 'I am well rested after 15 minutes of sleep.'" (Kelly will be teaching a workshop to her professional colleagues, in fact, entitled "Using Hypnosis for Postpartum Depression" at an upcoming convention of the National Guild of Hypnotists)
The not-so-good news, says Dr. Blake, and the obstetrician-gynecologist's greatest concern, is that some women "fall through the cracks, or deny their symptoms and try to tough it out." And, screening tools are not infallible; a woman still needs to recognize and voice her need for help. As midwife Redpath says, "It is a vulnerable position to be in to call and say, 'I'm struggling.'"
Kate is one who couldn't ask for help until she had to. Kate, who requested that her last name be withheld, struggled with depression on and off in her life. With her first child, she had an easy pregnancy and a natural birth. However, as her baby had respiratory issues at birth, they stayed five days in the neonatal intensive care unit.
"At the same time," says Kate, "my husband was looking for work. I felt strongly that I would be the stay-at-home mom, and he should just focus on his work. For 10 months I did the night feedings. Even though he offered, I refused. I wouldn't accept help from others, I thought I could do it all alone. Well, at around 10 months, I started hating my child. I was angry and didn't want to be around her. I resented her at nighttime, especially as she would start to wake up and I wanted to sleep. I was sad, anxious, and thinking, something is wrong with me. I would find activities to get from one moment to the next - so I could be attentive to the schedule and not her. Then one week, I had moments where I wanted to shove her up against the wall, or break my own head against the window.
"I thought, I need to get help. This can't be normal. I was on vacation at the time, and I went to the hospital ER there. They immediately gave me an antidepressant and put me on a 24-hour watch. What this did to me was shut me down. I was scared they would take my daughter away. I began to tell them, 'I'm fine, nothing's wrong.' I had to call them every day for two weeks, or they would call me if I missed. After that, we moved to Vermont and I finally settled in. I was still angry, confused, and sad. My doctor suggested I get counseling. I was scared to, and afraid to talk about it, after the experience with the ER. I put it off. When I finally did, I almost broke down as I knew right away it was a safe place. And still, it was only a month ago, after being in a support group for over a year, that I was able to talk about it all."
With her second child, Kate had a more difficult pregnancy. She was on bed rest for seven months and delivered five weeks early. This time, Kate was proactive and spoke with her obstetrician about prescribing her an antidepressant. At six weeks after her child's birth, she began to feel the same frustrations and decided with her caregiver, to start Zoloft. Kate says she is now in biweekly counseling, a weekly support group, and tries to stay connected to her community. "Isolation makes it harder," she says.
"It takes a village," says Laura Mann, a certified nurse midwife with Dhatri Foundation for Compassionate Integrative Health. "The more support a woman can get, the better. She needs a community of women to bring her food, shop for her so she doesn't have to go out. Let prolactin (a hormone released during breastfeeding) do its job - be in a fog. That's okay, don't fight it. Postpartum depression is multilayered - it's hormonal, physiological, spiritual. The thought in American culture is that women should just get on with it - as opposed to what is called laying-in for six to eight weeks in other countries. We leave our babies quicker than we take puppies from their mother in our culture."
According to South Burlington psychotherapist Emily Miller, a current term for the spectrum of postpartum experiences is called postpartum stress. (Karen Kleinman coined this term. She is the founder of the Postpartum Stress Center in Pennsylvania, author of several books on postpartum depression, and a champion for pregnant and postpartum women.) Miller facilitates a support group for women experiencing difficulty coping with postpartum stress and adjusting to motherhood.
"The group fosters connectedness and nonjudgmental support," says Miller. "Studies have shown that women grow in connectedness. The postpartum period is isolating. When a woman becomes a mother, she not only gives birth to a baby, but to a whole new psychological mindset: new physical tasks, new roles, a new relationship with her partner. I don't agree with some of the 'birth plans' women are encouraged to get attached to. I counsel pregnant women that they will do better in the postpartum period if they develop openness and flexibility around the birth."
Miller says women can do specific things to empower themselves and prepare for the postpartum period: "They can seek social support, foster openness and flexibility, join a community, like a pre- or postnatal yoga class or playgroup. I have also seen a difference in the postpartum period with women who have support during labor, from a doula or obstetrician that does births. I see the whole birth experience as a huge opportunity for growth in a woman - we need to move attention to that."
Guerra wrote via email, "I can't agree with you more about getting the word out to women that they are not alone. I wanted to do something back when I went through it, but life has a way of getting in the way and I never had the opportunity. I'm thankful to have this chance now to possibly make a difference. I am not concerned about privacy at all. I think part of the problem is that women are led to believe that it's 'their' fault and they should keep it quiet. I learned first hand that postpartum depression is not something that a woman has any control over, and there is nothing to be ashamed of."
Roberta Nubile is a freelance writer living in Shelburne.
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Vermont Woman is a forum for news, issues, features, arts and entertainment from the perspective, experience, and voices of Vermont women. Vermont Woman is a monthly newspaper published in South Burlington, Vermont and is excerpted here on this site. All content ©Copyright 2006, Vermont Woman Publishing |
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