Postpartum Depression: Depression or Something More?
Identifying, Coping with and Treating PPD
By Barbara Pal and Susan Chick
Depression after childbirth is not uncommon. Many mothers at MOBI have endured extraordinary stress and are at high risk for depression. This article talks about postpartum depression, including symptoms, risk factors, coping suggestions, and treatment options.
The Onset of Postpartum Depression
Feelings of vulnerability and extreme emotional sensitivity are universal to mothers in the days, weeks or months after their babies are born. An estimated 85% of women experience the “baby blues” about three or four days after giving birth. Typically, these symptoms resolve themselves within one or two weeks. Symptoms include tearfulness, anxiety, irritability, insomnia, poor concentration, fearfulness, and emotional instability. “Baby blues” are thought to be the result of a hormonal swing after childbirth.
However, for 10-15% of women these symptoms do not resolve. When they persist for two weeks or longer and are present most of the day, postpartum depression may be the cause.
For another group of mothers, postpartum depression may not occur until several more weeks or even months have passed. If depression occurs within the first year after birth, it is considered postpartum depression. If depression occurs later than one year, it may be related to maternal exhaustion.
However, for 10-15% of women these symptoms do not resolve. When they persist for two weeks or longer and are present most of the day, postpartum depression may be the cause.
For another group of mothers, postpartum depression may not occur until several more weeks or even months have passed. If depression occurs within the first year after birth, it is considered postpartum depression. If depression occurs later than one year, it may be related to maternal exhaustion.
Symptoms of Postpartum Depression
A woman may have some or all of these symptoms of postpartum depression:
(a) Daily crying, persistent sadness
(b) Loss of concentration
(c) Loss of energy
(d) Insomnia or sleeping too much
(e) Loss of enjoyment in things that you once enjoyed
(f) No interest in making love after getting physician’s okay to resume
(g) Loss of or increased appetite with cravings for sugar, carbohydrates
(h) Increased irritability and sensitivity
(i) Feelings of hopelessness/helplessness
(j) Suicidal thoughts
(k) Thoughts or fears of hurting the baby or others.
(a) Daily crying, persistent sadness
(b) Loss of concentration
(c) Loss of energy
(d) Insomnia or sleeping too much
(e) Loss of enjoyment in things that you once enjoyed
(f) No interest in making love after getting physician’s okay to resume
(g) Loss of or increased appetite with cravings for sugar, carbohydrates
(h) Increased irritability and sensitivity
(i) Feelings of hopelessness/helplessness
(j) Suicidal thoughts
(k) Thoughts or fears of hurting the baby or others.
Stress, Anxiety and Obsessive Compulsive Symdromes: Related Postpartum Issues
Approximately one in five mothers1 have symptoms that are more intense than baby blues, for longer than the baby blues period, but not as severe as in postpartum depression. These mothers may be suffering from Postpartum Stress Syndrome. A mother with Postpartum Stress Syndrome may appear to be coping well on the outside and be able to physically care for herself and child. On the inside, however, she may feel exhausted, anxious, inadequate, and plagued by self-doubts because she is unable to live up to the very high standards she is used to achieving. She may have great difficulty adjusting to life with a newborn, and while it is common to feel stress adjusting to life with a newborn, she may feel helpless as well.
Postpartum Anxiety Syndromes, panic disorder and obsessive-compulsive disorder, occur in about 2-5% of women postpartum, either accompanying or following postpartum depression. Panic disorder involves attacks lasting 10-30 minutes during which a mother feels like something terrible is about to happen. She may have a sense of unreality, like she's dying or about to have a heart attack, and experience symptoms such as heart palpitations, shaking, stomach upset, hot flashes or chills, a sense of choking, of being unable to breathe, and of feeling dizzy and light-headed.
With obsessive-compulsive disorder, a mother may experience repeated urges or thoughts that make her anxious or uncomfortable, that she knows are ridiculous and tries to avoid. She finds herself doing specific tasks in a specific way in order to avoid feeling extremely uncomfortable.
Postpartum Anxiety Syndromes, panic disorder and obsessive-compulsive disorder, occur in about 2-5% of women postpartum, either accompanying or following postpartum depression. Panic disorder involves attacks lasting 10-30 minutes during which a mother feels like something terrible is about to happen. She may have a sense of unreality, like she's dying or about to have a heart attack, and experience symptoms such as heart palpitations, shaking, stomach upset, hot flashes or chills, a sense of choking, of being unable to breathe, and of feeling dizzy and light-headed.
With obsessive-compulsive disorder, a mother may experience repeated urges or thoughts that make her anxious or uncomfortable, that she knows are ridiculous and tries to avoid. She finds herself doing specific tasks in a specific way in order to avoid feeling extremely uncomfortable.
Risk Factors for Postpartum Depression
A woman with a history of depression is at higher risk to develop postpartum depression (PPD). That said, having experienced PPD with one baby does not mean that it will recur with another, and having not experienced PPD with a prior baby is no guarantee that PPD will not occur with a later baby.
A number of factors can combine to contribute to a difficult adjustment in the postpartum and increase the risk for PPD. For instance, lack of sleep and disturbed or interrupted sleep contribute to problems adapting. Mood changes due to fallen energy levels, high energy (anxiety), emotional vulnerability, and sensitivity to change make the postpartum period a hard time for some mothers. The loss of one’s old way of life, routines, structure in the day, identity, relationship with partner, time for self, and freedom will take time to get used to.
In terms of personality, mothers who lean towards perfectionism or who have extremely high standards for themselves may have a more trying time in the postpartum period. Organizational and management skills can trip some mothers up when it comes to baby-care. Infants are unpredictable. No patent rules apply to all babies. We learn to expect the unexpected and be on our toes. This can be frightening and takes getting used to.
Our social environment can also be a risk factor. When there is adequate social support in the postpartum period from family, friends, and from one’s partner, mothers may adjust more easily. When there is marital tension, general life stress (financial, for example), and isolation from supportive friends or family, adjusting in the postpartum period can be more difficult.
On a deeper level, a mother’s expectations and hopes regarding pregnancy, childbirth, breastfeeding, life with a newborn and motherhood may not have been met, and she may be grieving their loss. For example:
A number of factors can combine to contribute to a difficult adjustment in the postpartum and increase the risk for PPD. For instance, lack of sleep and disturbed or interrupted sleep contribute to problems adapting. Mood changes due to fallen energy levels, high energy (anxiety), emotional vulnerability, and sensitivity to change make the postpartum period a hard time for some mothers. The loss of one’s old way of life, routines, structure in the day, identity, relationship with partner, time for self, and freedom will take time to get used to.
In terms of personality, mothers who lean towards perfectionism or who have extremely high standards for themselves may have a more trying time in the postpartum period. Organizational and management skills can trip some mothers up when it comes to baby-care. Infants are unpredictable. No patent rules apply to all babies. We learn to expect the unexpected and be on our toes. This can be frightening and takes getting used to.
Our social environment can also be a risk factor. When there is adequate social support in the postpartum period from family, friends, and from one’s partner, mothers may adjust more easily. When there is marital tension, general life stress (financial, for example), and isolation from supportive friends or family, adjusting in the postpartum period can be more difficult.
On a deeper level, a mother’s expectations and hopes regarding pregnancy, childbirth, breastfeeding, life with a newborn and motherhood may not have been met, and she may be grieving their loss. For example:
- A difficult birth, an unplanned C-section, or a premature baby can set the stage for depression.
- If there are any problems with the baby's health or a baby is chronically fussy a mother is more vulnerable to depression. Constant fear for a child's health and/or struggling to calm a fussy or crying baby can be emotionally exhausting.
- Breastfeeding complications, such as having to take the learning curve to deal with supplemental feeding devices, pumps, and pumping and feeding techniques, or seeking a therapist for her baby’s issues, can also wear a mother out. However, once a mother has a strategy in place she may feel relief from depression—once she knows what she has to do, feelings of helplessness may subside.
Weaning: An Easy Solution that Often Makes Things Worse
Many times, well meaning people will advise a tired, depressed mother to wean, in an effort to remove stress from the mother. What they may not consider is that the mother and baby benefit from the close physical contact that breastfeeding provides, and that the hormones involved with breastfeeding may provide an oasis of peace and comfort in an otherwise chaotic day. Additionally, the sudden hormonal shift caused by abrupt weaning can cause or worsen postpartum depression. So while some mothers do experience relief through weaning, for many others it can contribute to the problem, and both the mother and baby may grieve the loss of the relationship. Mothers should be encouraged to explore the following strategies before making the important decision to wean.
Coping with Postpartum Depression
- Remember to eat in intervals of two or three hours to keep your blood sugar stable. Low blood sugar directly affects mood and energy. Snack on healthy, unsweetened foods you can grab like plain yoghurt, a banana, or nuts. Order in meals if you have to, or buy frozen foods to prepare while your energy is low. Think of this as a temporary measure until things get better. Try to limit your intake of sugary foods or refined carbohydrates and get more green vegetables, protein, healthy fats, and complex carbohydrates. Don’t be afraid to ask a spouse, partner, or friend to help you prepare lunch and snacks to have available during the day.
- Make Rest a Priority. Persistent sleep deprivation is a risk factor for developing depressive symptoms. To help prevent PPD, rest when the baby sleeps, co-sleep, or move the crib next to the bed. Mothers who are already coping with depression or anxiety attacks often find that falling sleeping or staying asleep is a problem, and “sleeping on demand" when baby naps is nearly impossible. Take opportunities when baby is sleeping to rest and not use that time for all those chores that pile up. Interestingly, for some depressed people insomnia is not the problem, they want to sleep all the time. Even if it feels like the last thing you want to do, getting out of the house can make a big difference.
- Talk with your spouse, partner or a loved one about how you are feeling. Be honest. Sometimes when suffering from depression it is difficult to communicate just how bad you feel. Sharing these feelings often brings at least some relief. Keep the lines of communication open and ask for what you need.
- Lower housekeeping standards. Ask for help from your partner, extended family, neighbor, or get hired help. If you need your partner to find or hire the helpers for you, ask.
- Get moving. When your energy is up, try to get out for a little walk, 15 minutes per day. Exposure to sunshine and a little exercise can act as a natural antidepressant by increasing endorphins in the brain.
- Know that just because you feel like you’re a bad mother, or wonder whether you should have had your baby, it doesn’t mean that you don’t love your child or that you are inadequate. Acknowledge what you are doing everyday: feeding your baby, changing his/her diaper, responding to his/her cues, helping him/her to fall asleep, holding him/her to comfort, and taking him/her for a walk in the stroller. That’s a lot of care and nurturing.
- This is an opportunity to review your core values and beliefs. Release perfectionism, unrealistic expectations, and self-judgment. Let go of comparing yourself to others. Compare yourself to you: what you have been able to handle over the course of your life, how you are feeling now, how you hope to feel when things get better again.
- Joining a new mother group may help you realize you’re not alone. Many mothers feel overwhelmed, tired and frustrated, but mothers with depression often feel as though they’re the only ones who are feeling this way, and believe they are inadequate.
- Speak with your healthcare provider (midwife, physician, etc.) about how you are feeling. Perhaps a referral for counseling or medication would be helpful. If making the phone call is just too difficult, ask your husband, partner or a trusted loved one to do it on your behalf.
- If you have a history of depression, either during the pregnancy or at another time in your life, make arrangements with someone you trust during your pregnancy to let you know if they see symptoms of depression in you. Many times, as a mother sinks into depression, she does not recognize the symptoms. She may have a feeling of hopelessness and what is called invariability – as if this state has always been and always will be. “I always have felt like this, I always will feel like this. There is no hope. Nothing can change.” A close friend may recognize these symptoms before you do.
Treatment Options
Psychological counseling provides relief for postpartum depression in often half the time of medication. Cognitive Behavioral Therapy is a proven and effective treatment for depression. This type of counseling focuses on modifying patterns in your thoughts and behavior. Other talk therapies have also been shown to be helpful.
Counseling used in combination with antidepressant medication is a common treatment. Before starting medication, it is a good idea to have your thyroid and hormone blood levels checked. While there is no physical test for depression, the blood test could rule out that it is being caused by a hormonal imbalance. Medication can help but patience is needed. It can take as long as 4 to 8 weeks before symptoms subside. The course of treatment lasts at least 6 months. If you start to experience other symptoms, such as anxiety, racing thoughts, or panic attacks please consult your doctor. Going off of antidepressant medication should always be done under the guidance of your physician. Never abruptly end treatment on your own.
There are many different antidepressants, most of which are commonly prescribed to breastfeeding mothers and have minimal side effects. Many obstetricians are knowledgeable about treating with medications in breastfeeding mothers. If your doctor hesitates to prescribe medication because you are breastfeeding or advises you to wean, ask them to consult Dr. Thomas Hale, PhD’s book Medications and Mothers Milk, or seek a second opinion.
Dietary changes may also help. In her book, Mother Food, Hilary Jacobson writes that dietary measures can help keep one’s blood sugar levels steady, can promote a balanced thyroid function, can increase levels of iron to treat or avoid anemia and can provide potassium – all of which help to avoid postpartum depression. She writes, “Poor diet, lack of EFA’s (especially omega 3s), vitamin B-complex, folic acid and zinc can lead to depression when the brain lacks the nutrients to make crucial neurochemicals.”
Counseling used in combination with antidepressant medication is a common treatment. Before starting medication, it is a good idea to have your thyroid and hormone blood levels checked. While there is no physical test for depression, the blood test could rule out that it is being caused by a hormonal imbalance. Medication can help but patience is needed. It can take as long as 4 to 8 weeks before symptoms subside. The course of treatment lasts at least 6 months. If you start to experience other symptoms, such as anxiety, racing thoughts, or panic attacks please consult your doctor. Going off of antidepressant medication should always be done under the guidance of your physician. Never abruptly end treatment on your own.
There are many different antidepressants, most of which are commonly prescribed to breastfeeding mothers and have minimal side effects. Many obstetricians are knowledgeable about treating with medications in breastfeeding mothers. If your doctor hesitates to prescribe medication because you are breastfeeding or advises you to wean, ask them to consult Dr. Thomas Hale, PhD’s book Medications and Mothers Milk, or seek a second opinion.
Dietary changes may also help. In her book, Mother Food, Hilary Jacobson writes that dietary measures can help keep one’s blood sugar levels steady, can promote a balanced thyroid function, can increase levels of iron to treat or avoid anemia and can provide potassium – all of which help to avoid postpartum depression. She writes, “Poor diet, lack of EFA’s (especially omega 3s), vitamin B-complex, folic acid and zinc can lead to depression when the brain lacks the nutrients to make crucial neurochemicals.”
When to Seek Immediate Help ?
Some women with postpartum depression have thoughts of harming themselves or their baby. In rare cases, a mother can develop postpartum psychosis (which can begin as early as 2-3 days after birth). This condition makes it difficult for the mother to control any impulse to harm herself or others. Always take any persistent thoughts of hurting anyone very seriously and immediately call your health care provider, go to the nearest emergency room, or call 911.
You Don't Have to Feel this Way
Sometimes mothers hesitate to seek help because they have the feeling that in fact, nothing can help. This feeling of hopelessness is the depression speaking. After beginning therapy, mothers wonder why they waited so long. Postpartum depression is a treatable illness. You owe it to yourself and those that love you and are counting on you to seek recovery.
For what MOBI mothers have to say about Postpartum Depression, click here.
For what MOBI mothers have to say about Postpartum Depression, click here.
Resources
The National Suicide Hotline, National Hopeline Network, at 1-800-784-2433
The National Child Abuse Hotline at 1-800-422-4453
Dr. Thomas Hale, Breastfeeding Pharmacology
Motherisk - resource regarding medication and affect on breast milk
Resources for Calming a Fussy Baby
The Happiest Baby on the Block by Dr Harvey Karp (video) this short video shows 5 techniques that can calm a baby.
The Fussy Baby Book, Parenting Your High Need Child From Birth to Age Five by Martha Sears and Dr William Sears. This book has a wealth of ideas that can help worn out moms and dads find one more thing to try to calm their baby.
Crying Baby Sleepless Nights, Why Your Baby is Crying and What you can Do About it. Sandy Jones offers help for weary parents includes a handy chart that can help parents find the words to describe the baby’s symptoms to their health care provider. “He cries.” is just not enough information!
Endnotes
1 Kleiman, Karen R., Raskin, Valerie D. This Isn’t What I Expected: Overcoming Postpartum Depression. Bantam Books: New York, 1994, p. 14.
2 John Hopkins University Bloomberg School of Public Health, news release, March 8, 2006.
3 Ibid.
Bibliography
Kleiman, Karen R., Raskin, Valerie D. This Isn’t What I Expected: Overcoming Postpartum Depression. Bantam Books: New York, 1994.
http://www.postpartum.org/
Jacobson, Hilary. Mother Food: Food and Herbs That Promote Milk Production and a Mother’s Health. 2004
The National Child Abuse Hotline at 1-800-422-4453
Dr. Thomas Hale, Breastfeeding Pharmacology
Motherisk - resource regarding medication and affect on breast milk
Resources for Calming a Fussy Baby
The Happiest Baby on the Block by Dr Harvey Karp (video) this short video shows 5 techniques that can calm a baby.
The Fussy Baby Book, Parenting Your High Need Child From Birth to Age Five by Martha Sears and Dr William Sears. This book has a wealth of ideas that can help worn out moms and dads find one more thing to try to calm their baby.
Crying Baby Sleepless Nights, Why Your Baby is Crying and What you can Do About it. Sandy Jones offers help for weary parents includes a handy chart that can help parents find the words to describe the baby’s symptoms to their health care provider. “He cries.” is just not enough information!
Endnotes
1 Kleiman, Karen R., Raskin, Valerie D. This Isn’t What I Expected: Overcoming Postpartum Depression. Bantam Books: New York, 1994, p. 14.
2 John Hopkins University Bloomberg School of Public Health, news release, March 8, 2006.
3 Ibid.
Bibliography
Kleiman, Karen R., Raskin, Valerie D. This Isn’t What I Expected: Overcoming Postpartum Depression. Bantam Books: New York, 1994.
http://www.postpartum.org/
Jacobson, Hilary. Mother Food: Food and Herbs That Promote Milk Production and a Mother’s Health. 2004