Sara, 23, and Raphael, 28 just became parents of a much wanted baby boy. The brit was a joyous event but Raphael noticed that his wife was distant and preoccupied throughout the morning. Over the following weeks, Sara, usually a cheerful, easy going and very social young woman, seemed more and more changed. She kept calling Raphael at work, worrying whether Sammy, their new son, was getting enough breast milk and if she was bonding to him properly. She was so nervous that she couldn’t sleep more than an hour or two at a time or eat properly. In fact, she had lost 12 pounds since the brit two months earlier. Sarah had no interest in sex or other activities that used to give her pleasure such as getting together with friends or shopping. Their parents tried to help out, but things weren’t improving much.
The above fictional story describes a typical scenario of post partum anxiety/depression (PPA/D), a condition that affects 10-15% of women giving birth across all cultures and nationalities. Thus, far from being a rare or obscure situation, this impressive statistic makes PPA/D the most common complication of modern obstetrics. In addition to the symptoms experienced by the new mother, she feels a secondary level of shame as it seems ungrateful and even sinful to feel depressed and miserable about what should feel like a joyous blessing.
The cause for PPA/D is not yet fully understood. We know that women’s moods are affected by the female hormones estrogen and progesterone. Women are twice as likely as men (20% as compared to 10%) to experience depression during their menstruating years and many women describe mood sensitivity in the days right before their periods (PMS – pre menstrual syndrome). Certainly all women experience a marked hormone drop right after giving birth and the majority (80%) describe “baby blues”, moodiness and even tearfulness, that usually resolves within 2-3 weeks. We still need to learn why 10-15% of women experience extra sensitively to this hormone shift and develop full blown PPA/D. This syndrome is characterized by nervousness, often obsessional worrying, as well as classic signs of depression such as sadness, despondency, and changes in sleep, appetite, libido and concentration. It can begin shortly after birth and left untreated, persist for months, even up to a year.
Are there any predictors of PPA/D? Women who have previously experienced anxiety or depression are more likely to develop the condition after they give birth. Screening during pregnancy can be very helpful as depression during pregnancy is a risk factor for PPA/D following birth. If we can identify women at risk earlier, we can offer them treatment and support that may lessen or prevent development of greater distress. Women may develop PPA/D after their first baby or after a later birth. Effective treatment however, is readily available to the informed couple, and PPA/D need not be a factor that limits family size.
When Raphael tried to help out by offering to take care of the baby for a day, Sara said some scary things like “Maybe you and Sammy would be better off without me”. Raphael felt frightened and confused. He was also getting impatient. He thought he had done everything he could for Sara, even getting her a baby nurse for the first few weeks even though they really couldn’t afford it. Wasn’t becoming a mother what all women looked forward to? What had happened to his bright, vivacious wife? What was the rest of his life going to be like?
Post partum mood disorder impacts hugely on marriages. Husbands like Raphael are shocked by the sudden change in their wives. They feel scared and don’t know what to do. Some men withdraw, other find themselves losing their temper. Support for husbands is a key component of recovery. As a clinician, I must say that treating women with PPD/A is one of the most gratifying experiences of my work. New mothers are incredibly motivated to get better and their recovery has huge impact on their baby, their husband, and the entire family. I have much experience with this syndrome and want to reassure readers that the vast majority of women who experience PPD/A and get treatment make a full recovery relatively quickly and go on to lead happy, fulfilled lives.
Access to treatment is key. Unfortunately, shame about psychological illness and stigma keep people from getting the help they need. People worry that any hint of mental health trouble will have negative consequences for the family’s reputation and on future marriage prospects for their children. We must all work to combat prejudices like this.
Evaluation by a health professional is a first step. Hopefully, Raphael would encourage Sara to talk to her ob/gyn or to Sammy’s pediatrician. That physician should ask some basic screening questions and then refer the Sara to a mental health professional who might be a psychiatrist, psychologist, or social worker. Bikur Cholim is another superb resource for such referrals. Raphael should accompany his wife to that appointment to demonstrate his support, give history and get advice on how to best cope with his own feelings as he helps in Sara’s recovery.
Treatment for PPD/A can include a number of modalities. A caring, comprehensive interview by the mental health professional will include past personal, medical and family history. Talking through the issues of parenthood is crucial in helping the new mother process the complicated, life changing experience of becoming a parent. Brief psychotherapy is invaluably supportive to women going through PPD/A. It is crucial for husbands to be involved in this process and to get support as well. Some women derive great benefit from being in a peer support group with other new moms going through similar experiences. Organizations such as Bikur Cholim sometimes offer “big sister” woman-to-woman support. Certainly family support, household help, good nutrition, and reasonable exercise all factor in recovery.
Medication to alleviate the symptoms of anxiety and depression might be prescribed. Breastfeeding is not incompatible with psychiatric medication. Consultation with the pediatrician makes sense here. Other treatments might include light therapy which is particularly helpful with women with a history of depression during the darker months, referred to as seasonal affective disorder (SAD), meditation/mindfulness practice and nutritional supplements such as omega 3 fatty acid.
At the core of recovery is the integrity of the couple. Psychiatric illness is disorienting and upsetting at any time and even more so following a happy event such as the birth of a new baby. Husband and wife can easily feel overwhelmed and isolated from each other. It is easy to bicker or withdraw. Going through anxiety or depression can feel like being stuck in a long dark tunnel. One of the basic roles of the mental health professional is to check in on how the couple is doing and to remind them both that there is light and happiness ahead.
Raphael told Sara he was worried about her and asked her to call Sephardic Bikur Cholim. She said she would make the call but a few days went by and she didn’t. Raphael called himself and was directed to an intake worker who was compassionate, concerned took a brief history over the phone and referred Raphael to a psychiatrist. Raphael went with Sara to the appointment where he sat in the waiting room with the baby as their babysitter fell through at the last minute. Raphael and the baby went in for the last part of the appointment. The doctor asked Raphael for his perspective and then outlined a treatment plan that included anti-depressant medication and a support group. Sara met with the psychiatrist regularly over the next 9 months. At first she went weekly and then tapered to monthly visits. She asked Raphael to come a few times and meet together with the doctor for a few minutes. By Sammy’s first birthday Sara felt “better than before”, able to be fully and happily engaged in her life but most of all, delighted with her little son and the joy of her family.
Daf of the Day
