Understanding postpartum depression

Beyond the Baby Blues: Understanding postpartum depression

By Katharine Partridge

The eastern sun glinted off the windshield of Bronwen Bruch's Volkswagon Jetta. She and her children, six - month - old Emily and two - year - old Michele, were on their way to an outing near their Oakville, Ontario home, and everything that shiny June morning in 1991 seemed to radiate happiness - that is, until they got stuck in traffic. That's when Bruch's fingers began to tingle. Then they went numb. Before long, her arms were rigid to her elbows. The 29 - year - old mother was terrified. She thought she was having a stroke.

She wasn't. Doctors at a nearby hospital told her she was having a panic attack. It was a physical manifestation of the general anxiety that had enveloped her for the past month and that had been pushed to the brink by the stress of her father's recent illness. Bruch visited her GP, who told her to look after herself - set up a social network, take a weekend away with her husband, come back and see him if she had a relapse.

That summer Bruch lived in a state of constant anxiety. She awoke every morning with her stomach in knots. She stopped driving, stopped taking her kids for walks. She began to worry about her children's future. She did not believe she would be around to see the birth of her sister - in - law's baby in August. She felt very alone.

It was not until the fall, and only after two more panic attacks, that Bruch returned to her doctor. She was referred to a psychiatrist who provided a diagnosis: clinical depression with a panic disorder. The label alarmed Bruch, and her self - esteem plummeted. A round of antidepressant treatments and a stress management course followed. Slowly, she began to recover.

Then, in March, she came across an article in her local paper about a support group for women with postpartum depression (PPD) - a condition, she learned, that affects between 10 and 20 percent of new mothers. This was what Bruch had been searching for for so long: moms who were just like her, who she could talk to openly, who would really understand what she was going through. Finally, by sharing her experience with other mothers at weekly support meetings, and after ten months of distress, Bruch was able to accept her condition, to come to terms with the stigma of seeing a psychiatrist and taking medication. And, at long last, she was able to begin putting her life back in order.

Today, Bruch is president of PASS - CAN (Postpartum Adjustment Support Services - Canada), the organization that helped her five years ago, and one of several groups in Canada offering support to the 60,000 Canadian women and their families who, each year, have difficulty adjusting after the arrival of a new baby. Bruch is passionate about raising awareness of PPD among mothers and their doctors. "Mine was a harrowing experience," she says. "But I know that a lot of people suffer much more than I did. We are trying to destigmatize postpartum depression. We want women to know it can happen to them so that they can get help early, so that they don't have to go through what I went through, so they know they are not going crazy." As a PASS - CAN article succinctly puts it: "It shouldn't hurt to be a mom."

How do women with PPD feel?

Postpartum depression is, according to PASS - CAN executive director Christine Long, the second most common complication of childbirth (hemorrhoids are the first). It comes in many forms and severities. Unlike the blues, it is often marked by a pervasive melancholy or worry that does not go away. Women feel exhausted even when they are getting enough sleep, lose interest in food and sex, and have difficulty concentrating. They feel overwhelmed, helpless and hopeless. As Bruch did, they may become anxious, panicky, fearful, and obsessive about their health or the health of the baby. Without treatment, PPD may get progressively more serious, in extreme cases causing the woman to have suicidal thoughts or thoughts of harming her baby.

Onset of postpartum depression may be sudden or may develop slowly, most often occurring within the first three to nine months after delivery. It crosses all cultures and economic levels. It can occur after any birth; a woman may skirt it after the birth of her first child but succumb after her second. She may get it once, or it may recur after the birth of subsequent children.

What causes PPD?

What is not known is its cause, even though as long ago as the 4th century B.C., Hippocrates described the disorder, and more than a century ago, the medical profession knew enough about it to give it its name. Today postpartum depression is classified alongside other general depressions. "A lot of doctors don't see the difference," says Long. But, she asserts, it is glaringly different "because it hits when the woman must take care of another person." As Bruch puts it, "At a time when I was a new mother, I needed mothering myself."

Doctors believe that postpartum depression is caused by a combination of biological, psychological and social factors - but there are a lot of unknowns. Certainly there are radical fluctuations in a woman's hormone levels following the birth of a baby that may play a part - particularly in early - onset PPD. However, according to Dr. Donna Stewart, a professor of psychiatry and obstetrics and gynecology at the University of Toronto, "you can measure hormones in women who get postpartum depression and in those who don't, and you find no difference." It may be, she suggests, "that some women are simply more vulnerable to these changes" and sink into depression when hormonal fluxes coincide with other stressors (see "Who's at Risk?" p. 88).

Fortunately, the feelings associated with postpartum depression go away. Sometimes they disappear on their own, but other times, without treatment, they can linger for up to a year. The key to recovery is getting women the help they need. That's difficult, says Sherry Thompson, co - ordinator of the maternal support programs at St. Joseph's Women's Health Centre in Toronto, because women often don't understand what is happening to them. "The arrival of a new baby is supposed to be the happiest time. If it isn't, women think there must be something wrong with them." Christy Taylor, who went through the St. Joseph's program, agrees. "I thought it was me. There was never a point when I looked at what I was experiencing on a day - to - day basis and said, 'Oh, there must be some emotional disturbance going on here.'"

Women who blame themselves often perceive their feelings as irrational and, like Bruch, hide them. Sue Russell (not her real name), a Calgary mother who is experiencing PPD for the second time, says that during her first bout, she was unable to confide even in her husband, despite their strong relationship. "I felt foolish because I wanted to have a baby so badly. I had everything I could ever want. I was ashamed because I felt I had no right to feel the way I did."

The partners left on the outside are often bewildered. At a recent Toronto conference on postpartum depression, Gil Roberts described his reaction to his wife's increasing agitation. "I can no longer talk to my wife, my best friend, my lifelong companion...Her indecision causes me to be angry and I become unsympathetic to her problems...I stop communicating with her, withdraw and we start to grow apart...I feel helpless, useless and totally lost."

As in Russell's case, the crisis eventually strengthened Roberts' marital relationship. But not all endings are happy. Annie Ceschi, a Vancouver mother, believes that PPD led to the demise of her marriage. "Both my partner and I needed huge amounts of support," she says. "We didn't know how to give it to each other."

Nor are the children immune. Some studies suggest that children whose mothers have severe postpartum depression lag behind in the development of language and social skills. While the research is limited and, therefore, controversial, Dr. Lynn Wilson, a family physician at St. Joseph's who specializes in postpartum issues (and, interestingly, had PPD herself after the birth of her baby nine years ago), stresses that more must be done: "We should not ignore the issue of the children." "But," she adds, "it makes no sense to mother - blame."

Indeed, many mothers with postpartum depression seem to have that market cornered. One mom, who suffered from PPD after the birth of each of her children and a subsequent miscarriage, confesses in PASS - CAN's literature: "I believed I was a terrible mother, a complete failure...I started having panic attacks about being home with my children. I was so afraid I would 'lose it,' get angry, start crying and upset the children. With such an unstable mother, I was afraid they would be ruined for life." Yet, despite being depressed, says Dr. Stewart, "some women continue to mother very well." Stewart acknowledges that discussing the issue of parenting and PPD means treading on touchy ground. "I don't want to make these women feel badly," she explains. "Postpartum - depressed women feel guilty enough about how they take care of their babies." Nevertheless, she adds, it's important to recognize that some women are so seriously depressed, they simply can't look after themselves or their babies very well.

Where to get help

To help mothers avoid that descent, women like Taylor and Bruch, who have had PPD, are volunteering at the more than a dozen support centres across Canada. At the heart of the centres' programs are the telephone help lines and weekly group meetings that let women share their fears and, as they begin to recover, their triumphs. Russell used the telephone - buddy assistance at Calgary's Parent Development Centre during her first depression. "Although I still felt awful," she says, "just knowing I could talk to someone felt so much better. I had an inkling of hope, a little light at the end of the tunnel." This time, Russell is learning to cope by sharing her story with other mothers at a weekly group.

The centres also serve the needs of the family. Gil Roberts, for example, helps run a monthly support group for fathers at PASS - CAN. Calgary's Postpartum Support Society recently amalgamated with Parents Anonymous to offer broader support to families in stress. And at St. Joseph's, an important component of the maternal support program is infant emotional health.

The centres are also working with the medical community to help health - care professionals recognize and treat the women who seek their help. Last year, for example, Taylor worked with Toronto prenatal teachers to pilot an in - class education program for expectant parents. PASS - CAN sends anonymous information packages to the doctors of women who seek its services. Says Long: "The doctors call to thank us saying, 'I don't know who said to send it, but I can use this to help other women.'"

Awareness is being promoted from within the medical community as well. In Ontario, for example, Dr. Wilson is working with a multidisciplinary team of GPs, nurses, midwives and prenatal teachers to develop an expanded prenatal record, the document used to assess the health and progress of pregnant women. When it is completed, medial practitioners will have an improved tool to help them screen and respond not only to a woman's physical well - being but also to her vulnerability to such social risks as substance abuse, family violence and psychiatric problems, including PPD.

What's the best treatment?

Getting more information into the hands of the medical profession will be instrumental in giving women the confidence to turn to professionals for help. Russell confesses that she did not speak to her GP about her first bout of depression until symptoms reappeared after the birth of her second child. She'd heard stories of other mothers being put into psychiatric hospitals to treat PPD. "I knew I didn't want that so I didn't feel my doctor would be able to do much for me."

And like many women, weaned, as one mother recalls, on tunes like the Rolling Stones' 19th Nervous Breakdown, Russell is adamantly against medication. "I believe it masks the emotions you're feeling. Then you're not dealing with them, and I want to learn how to do that." Russell is also concerned that "once you go off medication, there's a good chance you're going to plummet back to where you were."

Certainly "it's a big mistake just to pop people on drugs and forget about them," says Stewart. "You need to tailor treatment to the woman and the severity of her condition." Women with moderate PPD, for example, may respond well to the social support and affirmation provided through postpartum centres. But, says Stewart, if a woman is distraught and unable to function, medication can augment those supports.

Unlike tranquilizers, which are thought to mask symptoms, or stimulants, which produce a "high," antidepressants work by rebalancing the brain's chemistry that depression sends awry. While they won't change the stresses in a woman's life, they can help her cope with them as she begins to feel more like her normal self. Nor are antidepressants habit - forming. If the mother's depression returns once she's off the medication, it may be a sign that the chemical imbalance is still there or that a general depression rather than PPD (depression tends to be a recurrent condition) has set in.

Still, drugs aren't always a smooth or quick fix. Because the effects of antidepressants are delayed, it typically takes two to six weeks before the woman will begin to notice a change in her outlook. As well, it may take some experimentation before the right drug and dosage is found. And antidepressants do have some side effects. For new mothers, the most controversial is the impact on breastfeeding. While some experts note that antidepressants pass through breastmilk in extremely small quantities, others have reservations. "If I was depressed and on medication, I think I would stop breastfeeding," says Stewart. "There are a lot of things we just don't know."

Ultimately, says Christine Long of PASS - CAN, the choices surrounding medication, like all aspects of treatment, are best left to the individual. Long's goal is to "empower the woman with education and information so that she can make decisions appropriate for her and her family." And, while the work of support groups and the medical profession is essential, it's not enough. It's up to women who have had PPD, contends Bruch, to break the silence: "If depression was talked about like C - sections or hemorrhoids, women would recover much more quickly. Those of us who have recovered owe it to ourselves, our friends and our daughters to let others know they are not alone, it's not their fault and their postpartum depression will go away."


PASS - CAN (Postpartum Adjustment Support Services -- Canada), P.O. Box 7282, Station Main, Oakville, Ont. L6J 6L6; (905) 844 - 9009, fax (905) 844 - 5973. PASS - CAN will send an information package to anyone who requests it, and has links to PPD support groups in communities across Canada. If there is no support group in your area, PASS - CAN suggests contacting your community health department or local Canadian Mental Health Association office.

After Baby Comes -- What about Fathers? A support program for dads only. Contact Dr. William Watson, St Michael's Hospital, 61 Queen St. E., Toronto, Ont. M5C 2T2; (416) 867 - 7426.

Post Partum Depression and Anxiety: A Self - help Guide for Mothers, Pacific Post Partum Support Society, #104 - 1416 Commercial Dr., Vancouver, B.C. V5L 3X9; (604) 255 - 7999.

Shouldn't I Be Happy: Emotional Problems of Pregnant and Postpartum Women, by Dr. Shaila Misri, The Free Press (Canadian distributor Distican), 1995.

This Isn't What I Expected: Recognizing and Recovering from Depression and Anxiety after Childbirth, by Karen Kleiman and Valerie Rasking, Bantam, 1994.

Postpartum Survival Guide: It Wasn't Supposed to Be Like This, by Ann Dunnewold and Diane Sanford, New Harbinger Publications, 1994. To order: 1 - 800 - 748 - 6273.

Mothering the New Mother: A Postpartum Resource Guide, by Sally Placksin, Key Porter Books, 1995.

Is it PPD or Just the Blues?

postpartum depression is not the "baby blues," that sadness and emotional instability that settles on 50 to 70 percent of women three to four days after they give birth and lifts of its own accord within a week to ten days. Nor is it postpartum psychosis, a much rarer disturbance (affecting one mother in 500) that occurs within the first few days to weeks following the birth, is marked by confusion, delusions and detachment from reality, and requires hospitalization, therapy and anti - psychotic drugs.

Dr. Gail Robinson suggests women can distinguish postpartum depression from the blues by looking at three factors:

Sleep: While most postpartum women are tired, one with PPD never seems to feel rested. Rather than waking during the night to care for her baby and then dropping off to sleep again, a depressed woman will find herself awake before her baby cries and will often be unable to get back to sleep after feeding.

Reactions: Most new moms, no matter how exhausted or harassed, can respond happily when their baby is not fussing. Women who are depressed feel wretched all the time -- nothing makes them feel better.

Ability to Think: A woman with PPD has difficulty making decisions and functioning on a day - to - day basis. Robinson tells the story of a busy executive who seemed to manage very well at work but would sit in her kitchen for an hour, unable to decide where to put the diapers she bought on her way home.

Who's at Risk?

The factors that can put a woman at risk for postpartum depression are numerous. The problem is, cautions PASS - CAN executive director Christine Long, "a woman can have all of [these factors] and not get postpartum depression, or she can have none of them and get it." They include:

a history of emotional problems or depression;

earlier postpartum depression (the recurrence rate is between 20 and 30 percent);

a difficult delivery or high - need baby;

isolation or inadequate social support;

grief over the loss of freedom, career or spontaneity;

recent major stress;

an unsupportive partner, no partner or difficulty in the relationship;

low family income;

difficulty asking for help (the perfectionist or "supermom").

The Positive Side of Postpartum Depression

Although postpartum depression is a harrowing experience, virtually all of the women interviewed for this article spoke of the strength they gained from their suffering. Here's what some of them had to say:

Mary Gale, 36, Calgary: "I wouldn't wish postpartum depression on my worst enemy, but it's the best thing that ever happened to me. I've come in contact with women who have opened up a whole new world, a different life. Even with the stress of an emergency C - section with my second child, I knew, because of what I had learned, that I could cope. I knew how to take care of myself and how to ask for help."

Christy Taylor, 35, Toronto: "I think I was lucky to have postpartum depression. It was a gift. I came to a crisis and I climbed out. It allowed me to find out who I am, what I want, who I want to join me along the way, and the strength to take that journey."

Annie Ceschi, 38, Vancouver: "Is there anything positive about postpartum depression? Absolutely. It showed me how strong I was, how capable. It started a process of discovery that I will continue for the rest of my life. Now with my children, I feel so centred and present. It's so much clearer to me what their needs are, and what mine are - both to be a mom and to be myself."

Sue Russell (not her real name), 33, Calgary: "I believe there is a reason I'm going through this. It's given me the learning tools to have a healthy relationship with myself, with others and with my children."