The First Year of Parenting

Postpartum Mood Disorders

Most women experience some ups and downs in our moods in the first weeks after giving birth. But for some new mothers, these “baby blues” don’t go away, or we experience new and troubling feelings. These postpartum difficulties, termed postpartum mood disorders, include depression (sometimes mixed with anxiety), anxiety/panic disorder, obsessive-compulsive disorder, post-traumatic stress syndrome, and, rarely, psychosis. Estimates vary, but it appears that ten to fifteen of every one hundred women experience a postpartum mood disorder.

Many women who experience postpartum difficulties, afraid of being labeled a “bad” mother or “insane,” don’t tell anyone about our feelings. The stigma attached to mental illness can make it difficult or shameful to reach out to others. But postpartum mood disorders are treatable, and it is important, both for our own sake and for the sake of our families, to seek help.

Baby Blues or Postpartum Depression?

In the period following childbirth, many women feel irritable, moody, weepy, and overwhelmed. As noted on page 281, these “baby blues” are very common. They usually occur in the first two weeks and can last for days or a few weeks. Though you will have times of feeling down, you will also find yourself able to be consoled.

In contrast, postpartum depression is not short-lived, and it often includes more severe symptoms, including hopelessness, suicidal ideas, sleep and eating disturbances, an inability to experience pleasure or to be comforted, and social withdrawal. A woman experiencing postpartum depression may be unable or unwilling to care for her baby or perform the daily activities of her life. Postpartum depression is the most common postpartum mood disorder. It can start any time in the first year after giving birth.

I know that I don’t exude excitement and joy but I don’t know how to process what I am feeling. I just want to have one really good cry and let it all out but I’m ashamed to. I’m afraid that if I start crying I won’t be able to stop. There’s so much love going on around me and all I feel like doing is screaming until my head explodes. I don’t know how to share any of this with anyone, so I cry alone when I get a chance; just a few minutes here and there.

Other Postpartum Mood Disorders

Some women who have emotional difficulties in the months after giving birth do not experience a clear-cut depression but instead suffer from a variety of other postpartum mood disorders. Some women feel intense anxiety, fear, or panic, and experience symptoms such as rapid breathing, an accelerated heart rate, hot or cold flashes, chest pain, and shaking or dizziness. These are symptoms of an anxiety/panic disorder. Others may have recurrent frightening thoughts about ourselves or our babies, or may be compulsive about some behaviors, such as hand washing. These are symptoms of an obsessive-compulsive disorder. Others may experience a combination of depression with anxiety/panic disorder or obsessive-compulsive disorder.

Sometimes women who felt mistreated or powerless during the birth as a result of a distressing experience in the past develop post-traumatic stress responses. Women may experience symptoms such as intrusive thoughts, nightmares, agitation, avoidance behaviors, or even panic (for more information see page 104). A very small percentage of women will experience what is referred to as postpartum psychosis, a serious but rare illness affecting one to two of every one thousand new mothers. Women with postpartum psychosis may experience hallucinations and delusions and other symptoms including insomnia, agitation, and bizarre feelings and behavior. Postpartum psychosis generally develops within one to four weeks after giving birth.

Who Is At Risk?

Any woman can get a postpartum mood disorder. The hormonal changes that occur during pregnancy and birth appear to play a strong role in the development of these problems.

However, certain factors are associated with a greater likelihood of experiencing a postpartum mood disorder. These include severe or ongoing postpartum pain; health problems in the mother or baby; a “high- needs” baby; relationship, financial, or other major stresses; isolation; and a lack of social support. Ongoing sleep deprivation is also a risk factor for postpartum mood disorders.

Women who experience postpartum mood disorders are more likely to have a history of depression or other mental health issues; physical, emotional, or sexual abuse; substance abuse; or severe premenstrual syndrome. Adolescent mothers experience postpartum depression at a higher rate than the general population.

Getting Help

The exhaustion and feeling of being overwhelmed that many new mothers have can exacerbate any depression and anxiety we feel. If you are experiencing a postpartum mood disorder, try to ask for as much practical and emotional support as you can. If you have a partner—or other support people—available, ask him or her to share household chores and nighttime feeding duties. Do only as much as you can, and don’t blame yourself for leaving things undone. (For other ideas on practical help and self-care, see “Tips for the First Weeks,” page 283.)

Isolation can perpetuate depression and anxiety, so try to find at least one family member or friend with whom you can honestly share your feelings and your experience of motherhood. Meeting with a new mothers’ group can be a great way to connect with others and feel less alone. Many support groups and online chat rooms focus specifically on helping women who experience postpartum depression. (See “Getting Support,” page 282.)

Sometimes, however, the support and help of friends and family is not enough to get you through this period. If this is true for you, seek out a social worker, psychologist, or psychiatrist who is knowledgeable about postpartum mood disorders.

Treatment

The good news is that postpartum mood disorders often respond well to treatment. The two basic types of treatment offered by mental health professionals for postpartum depression and anxiety disorders are “talk therapy” and medication. Talk therapy involves regular discussions with a psychologist, social worker, or other therapist. Drug treatment for postpartum depression and anxiety disorders can include antidepressant medication, anti-anxiety medication, and sleep medication.

In the rare event that you experience postpartum psychosis, you will likely need to be hospitalized and treated with medications until you are stabilized.

Therapy

Therapy sessions can help you experience, express, and understand your feelings more fully. They can also help you explore possible solutions for postpartum challenges and learn better ways to communicate your needs and get them met. Therapists can direct you to other community supports for new mothers and families. A good therapist will monitor and advise you, providing support as well as guidance on when medication may be needed. If necessary, she or he can connect you with a psychiatrist or clinical nurse specialist who can prescribe medication.

When seeking help for postpartum mood disorders, it is best to see a therapist or medical provider who is knowledgeable about these problems. Finding a health care provider with training in postpartum depression, posttraumatic stress disorder, and/or perinatal mood disorders is critical, as some health care providers have inadequate or outdated knowledge. Postpartum Support International maintains a list of qualified practitioners throughout the United States and internationally. (For contact information, see “Where to Get Help,” page 292.) It may take some trial and error to find the right therapist for you; the key is that you have a good rapport and feel that your therapist is trustworthy and respects you.

Medications

Antidepressant medications known as selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed for postpartum mood disorders. SSRI medications include Prozac, Zoloft, Paxil, Luvox, Celexa, and Lexapro. Wellbutrin, Remeron, and Effexor are also widely prescribed; while these drugs are not SSRIs, they act on the brain in similar ways. All of these drugs are considered “second- generation” antidepressants because they have largely replaced the older antidepressants (known as tricyclics).

These drugs can be helpful for women with postpartum depression and anxiety, particularly when they are used in combination with talk therapy. However, there is some controversy over their effectiveness.¹  In addition, antidepressants (like other medicines) can produce negative effects, such as sleep, digestive, and sexual problems, and, rarely, more serious effects. Because of this, they should be taken only while under the care of a psychiatrist, psychiatric nurse, or other licensed professional who will monitor you regularly.

Some mothers experiencing postpartum depression recover without using medication, thereby avoiding the potential adverse effects, but other women may be in such crisis that talk therapy without medication would not be enough. (For more information on the potential benefits and harms of antidepressant medications, see “Depression During Pregnancy,” page 101.)

If you are breast- feeding, be sure to tell your provider. While the second-generation antidepressants do pass into breast milk, the short-term negative effects on babies, if any, appear to be transient. Additional research, particularly on the long-term safety of antidepressants for breast-fed babies, is needed. To learn more about the effects of medication on breast milk, work with a provider who is knowledgeable about medications and breast-feeding and consult Thomas Hale’s book Medications and Mothers’ Milk. (For more information, see “Resources on Medications and Breast-Feeding,” page 263.)

Deciding whether to take an antidepressant medication can be difficult. Depression can make bonding with your baby difficult, and it puts you at risk of relationship difficulties with your baby, which can affect the baby’s overall development. On the other hand, antidepressants may have adverse effects, may not work, or may be incompatible with breastfeeding. Medication decisions should be guided by your preferences, the severity of your illness, the risks of the medicines in question, and the known risks of depression for you and your baby.

If you decide to take antidepressants, keep in mind that many psychotropic medicines can take several weeks before they have an effect, and often you have to try several before finding one that works for you. Be assertive with your health care provider if you have concerns or questions. If any medication you are taking seems to be making you feel more frightened, despondent, suicidal, or violent, inform your doctor, who can monitor you as you slowly go off the medication.

End of excerpt.

Notes

1. L. Jones and M. Stone, “Clinical Review: Relationship Between Antidepressant Drugs and Adult Suicidality,” Food and Drug Administration, Center for Drug Evaluation and Research, accessed at www.fda.gov/ohrms/dockets/ac/06/briefing/2006-4272b1-index.htm, on November 16, 2006, p. 41.

Excerpted from Chapter 16: Life as a New Mother in Our Bodies, Ourselves: Pregnancy and Birth  © 2008 Boston Women's Health Book Collective.