A Closer Look: Understanding Mood Disorders
by Diana Lynn Barnes, Psy.D, MFT
“My baby had been crying for an hour. I felt nauseous. I had a 4-year-old in the next room, a screaming baby, and I felt myself unraveling away from my backbone. I started to shake. The quivering came from the deepest part of my soul, a place that you’re only aware of when you’re about to die. I needed to throw up, but I couldn’t get out of bed. I tried to sit up, but my eyes couldn’t see,, and I was dizzy. I felt scared. I thought I had made a horrible mistake. I didn’t want to take care of this baby.”
In recent years, there has been increasing public awareness and concern about the necessity to educate and inform women and their families about their risks for a postpartum mood disorder. Research indicates that women are more vulnerable for developing a mood or anxiety disorder in the months surrounding birth than at any other time in their life (O’Hara, 1999). Fifty to 80 percent of mothers will experience some change in their mental health within the first year after delivery. Approximately 10 to 15 percent of these women are at risk for postpartum depression with potentially serious consequences for themselves, their families, and their newborns—the most devastating being suicide and infanticide.
There is a critical need for early assessment and effective treatment. When ignored, the symptoms of a postpartum depression are far more likely to exacerbate, to become treatment-resistant and cyclical in nature with deleterious repercussions for the developing attachment relationship between mother and child.
Additionally, there is growing evidence that a mother’s ongoing depression may impair a child’s cognitive and social development. (Murray, 1997).With proper screening and risk assessment during pregnancy and in the early months of the postpartum period, postpartum mood disorders are very treatable and even preventable.
Marriage and family therapists (MFTs) are frequently called upon to help families cope during tenuous periods along the lifecycle. The birth of a baby is a life cycle event of dramatic proportions. A physically and emotionally taxing experience, childbirth involves a renegotiation of family roles in order to create a space for the newest member.
Stress in the postpartum period is a predictable developmental crisis that disturbs the equilibrium of the family system. For many women, a postpartum mood disorder is a maladaptive response to the normal and appropriate feelings of loss that surround the birth of a child.
Shrouded in cultural myths arid expectations, new parents tend to revel in the ideals that society promotes about motherhood and childbirth without accounting for the psychological, environmental, and biological stresses that this normally joyful event brings to the family. As a result, new parents often fail to prepare themselves for the enormous emotional changes and physical demands that occur after a baby’s birth, particularly during the first year. This lack of preparation leaves some women much more susceptible to the hormonal and chemical changes that occur during pregnancy and after childbirth.
A woman may believe that mothering is an instinctive phenomenon that requires no outside training or influence, or that the bond with her baby will be immediate and intense. As she comes face to face with the contrast between her expectations and the reality, guilt and fear may interfere with any expression of conflicted feelings.
Because MFTs are privy to so much of a family’s biological and psychological history, they are also in an excellent position to assess a woman’s risk for postpartum depression even before she becomes pregnant. With an understanding of the emotional process and dynamic shifts that occur during the first year after birth, clinicians can help families create psychological supports in advance of the postpartum period, as well as in the early months following delivery, while normalizing this developmental transition for families.
DIAGNOSIS AND ASSESSMENT
What Is Postpartum Depression?
Postpartum depression is a biological illness caused by changes. in brain chemistry that can occur following the birth of a child. During pregnancy, hormonal levels elevate dramatically, particularly progesterone, estrogen, and cortisol, falling rapidly within hours to days after childbirth. In addition, the amount of endorphins produced by the placenta during pregnancy drops significantly after delivery.
Female reproductive hormones assist in maintaining the balance of neurotransmitters that regulate the chemical activity of the brain. A disruption in that activity with a corresponding fluctuation in the normal levels of serotonin, norepinephrine, dopamine and/or acetyicholine can lead to depression, panic, and even psychosis. Even the thyroid gland can be affected by the enormous chemical shifts associated with pregnancy and childbirth, leaving women more vulnerable to a depressive episode.
The literature on postpartum mood disorders distinguishes between three broad types of psychiatric conditions. They are classified along a continuum based on the severity and duration of symptoms as well as the timing of onset. At the mild end of the spectrum is the commonly called “baby blues,” which is characterized by tearfulness, irritability, anxiety, and feelings of overwhelm that generally present by day three or four postpartum. These symptoms are transitory, usually diminishing by day 14 without any need for medical and/or psychological intervention. Because some women go on to develop a major depression with postpartum onset, however, women should be monitored during this initial period. Symptoms that persist beyond two weeks should be evaluated immediately to determine whether medical and/or psychological support is indicated.
At the extreme end of the continuum is postpartum psychosis, a potentially life-threatening medical emergency that is biochemical in origin. Approximately one out of every thousand women who give birth will experience a psychosis. If ignored, postpartum psychosis can prove costly to both mother and child. Notable about psychosis is its abrupt onset anywhere from three to 14 days after childbirth. Significant confusion, disorientation, and rapid mood cycling along with auditory hallucinations and delusional thinking are the predominating features of this condition. Mothers who develop this illness frequently have intrusive and obsessive thoughts about harming their infant and/or themselves. Personal and family histories of women with psychosis indicate a higher incidence of mood disorders, particularly bipolar disorder and schizophrenia.
At least one out of 10 women who give birth will develop a major depressive disorder with postpartum onset. Among the characteristic symptoms listed in diagnosis are dysphoric mood accompanied by sleep and appetite changes, psychomotor disturbance, fatigue, excessive guilt, and suicidal ideation. In addition, women with pronounced postpartum depression experience feelings of confusion and disorientation (they describe it as “being in a fog”) that is sometimes accompanied by memory impairment. The singular feature that seems to distinguish postpartum disorders from the normal and appropriate stressfulness of the initial postpartum period is the inability to sleep, despite exhaustion. What is especially striking and most touching about a woman’s experience with postpartum depression is her own awareness that she is having difficulty engaging with her infant, yet feeling immobilized to act on her intuitive sense. Some women describe themselves as ”going through the motions” of caring for their newborn, but feeling emotionally detached.
While most of the symptoms of postpartum depression are generally akin to the Diagnostic Manual’s (DSM-lV) diagnostic criteria for a major depressive disorder, women with postpartum depression are especially prone to feelings of guilt, anxiety, and maternal inadequacy with accompanying distortions in their thinking. They often feel frightened about being left alone with grave concerns that they will be unable to cope with the overwhelming demands of caring for an infant. Many women in the throes of this depression believe quite genuinely that their infant would do better in the care of a different mother, and they see themselves as replaceable. These overpowering feelings of maternal inadequacy and incompetence surface with debilitating consequences for the new mother, resulting in her painful sense of helplessness against seemingly unexplainable physiological and psychological forces.
Many women find their depressive symptoms intensified by overwhelming feelings of anxiety. For some new mothers, however, it’s not uncommon for postpartum depression to coexist with another diagnostic component such as a postpartum panic reaction or post-traumatic stress reaction. For others, the compelling feature of their depression is an obsessive-compulsive reaction in which they are plagued by spontaneously occurring, but persistent and disturbing thoughts or images, usually having to do with harming their baby. Generally, these clinical varieties of postpartum mood disorders originate with some family and/or personal history of anxiety disorder, panic attacks, or obsessive-compulsive behaviors. Because childbirth is so physically and emotionally stressful, it frequently restimulates sensations and memories of an earlier traumatic event for women diagnosed with post-traumatic stress disorder.
Although the time frame for postpartum depression is the first four to six weeks following childbirth, any woman who has given birth within the past year is vulnerable. Weaning a baby from the breast and the return of the menses are significant events that also alter the biochemical balances in the body affecting the timing of a depression.
Many women frequently delay in asking for medical and therapeutic help out of shame, guilt, and mistaken beliefs that a “good mother” should be content and capable of caring for a new baby with little or no need for her own care. Too often, family members and health care providers fail to recognize the symptoms of a postpartum depression, attributing a mother’s complaints instead to the stressful adjustment of caring for a new baby.
Who is at Risk? Although there is no exact way to predict the occurrence of a postpartum depression, it is possible to identify the psychosocial factors that increase risk. Isolating the numerous biological, environmental, and psychological stressors that contribute to onset helps to determine the focus of treatment.
The most important risk factor for postpartum depression is a personal and/or family history of depression and/or bipolar disorder. In fact, more than 50 percent of women who have had a previous postpartum depression are at risk of a recurrent depression following a subsequent birth. Women are also more vulnerable if they have been depressed during their pregnancy or have a history of premenstrual mood syndrome.
Stressful situations that include marital tension, health problems with the baby, a complicated pregnancy and/or delivery, and a lack of social support also place a woman at increased risk for postpartum depression.
Among the psychological factors that set the stage for a postpartum mood disorder are an early history of sexual abuse or trauma, chemical dependency in the family of origin, ambivalent or negative feelings about the pregnancy, and ambivalence about the maternal role.
Other issues that may have an impact on a woman’s mental health during the postpartum period are previous fertility problems and unresolved losses, such as miscarriage and stillbirth. It is not uncommon for delayed grieving to date as far back as childhood experiences of loss, like divorce or the death of a parent, and be restimulated by the birth of a child.
There are several screening tools used to detect postpartum depression, including the “Postpartum Depression Predictors Inventory” (Beck, 1998) and the “Antepartum Questionnaire” (Posner, 1997). Currently, however, the Edinburgh Postnatal Depression Scale (Cox, Holden, 1987) is the most widely used screening tool to assess for postpartum depression. This self-assessment scale consists of 10 short statements, each with four possible responses, designed to help the new mother report to the practitioner how she has been feeling over a seven-day period. Responses are scored according to the increased severity of symptoms and receive a rating of 0,1,2, or 3. Mothers who receive a total score above 12/13 are likely to be suffering from a depressive illness. However, the Edinburgh is designed to identify possible depression and not intended to replace clinical judgment.
Decisions about treatment for postpartum mood disorders vary according to the severity of symptoms. Professional consensus, however, seems to support the use of antidepressant medications in combination with either interpersonal or cognitive behavioral psychotherapy. Group psychotherapy has also been found to alleviate some symptoms by reducing the feelings of isolation that many women feel after childbirth and during a depression. The more severe the depression, the more experts usually recommend the use of medication. Women who present a personal and/or family history of psychiatric illness tend to be good candidates for antidepressants and other mood stabilizers.
Since the feelings associated with postpartum blues tend to ameliorate by two weeks, most women with “the baby blues” do quite well with added rest and extra help caring for their infant, along with reassurance and emotional support that their feelings are normal and temporary. For the mother with severe symptoms, such as suicidal or psychotic thoughts, hospitalization may be necessary to protect her and her child while the depression is being stabilized. Other symptoms that suggest the need for emergency treatment include rapid weight loss without intentional dieting, refusal to eat, and sleep deprivation of more than 48 hours duration. In those extreme cases when a mother is not responding to trials of medication or has a psychotic depression with postpartum onset, she may benefit from a course of electroconvulsive therapy. ECT or electroshock therapy involves the induction of a series of brain seizures under anesthesia as a way of stabilizing the depression.
For women with depression that intensifies and persists beyond the time frame of the blues, psychotherapy provides a supportive framework in which psychosocial stressors can be addressed, At a psychological level, postpartum depression is a reflection of profound feelings of loss that are left unexpressed. Concurrent with the overwhelming demands of caring for an infant is a loss of time with one’s spouse, the loss of adult companionship, loss of a previously known freedom, and a departure from the way things were. The struggle for most families is their wish to return to that which is familiar and the conflicted feelings inherent in knowing that their lives will never again be the same.
A woman’s partner may have his own reactions to the birth of their child as he experiences the loss of time with his spouse or worries about his new role as a provider for the family. When a postpartum illness occurs, he may have additional concerns about his wife’s health and fear that their lives are deteriorating as a result of her depression. Interestingly, most men who find themselves caring for a partner with a postpartum mood disorder are not strangers to depression themselves. History-taking frequently reveals their personal knowledge of depressive illness, either because they have suffered from depression themselves or have experience with a family member who was challenged by some type of mood disorder. Their earlier experience often heightens their emotional reactivity to the current situation.
Whereas traditional treatment identified the woman as the patient, more recent practice recognizes that the birth of a baby reverberates throughout the family system and treatment goals must address the experience of the entire family, particularly that of the marital couple. As family members struggle with their own unspoken expectations of how things should be, guilt and fear often interfere with a family’s comfort in talking about the ambivalent feelings that are absolutely normal and appropriate during this time.
Instability in the marital relationship is one of the key risk factors in the onset of a postpartum depression. Therefore, the initial therapeutic work should strive to normalize the reactions of both partners and their individual feelings of frustration, uncertainty, anger, and sadness that may create distance between them. As MFTs assist the family in this reorganization of roles, it may also be significant to explore with them ways in which they have dealt with change and loss in the past as this will have a bearing on their current behavior.
Transition to Motherhood
Pregnancy and delivery gives rise to a psychological process as many women struggle with their notions of what constitutes a “good mother.” The advent of motherhood also reconnects women with their earliest memories and sensations of their experiences as daughters, and the birth of a child rekindles those images. Inevitably, the quality of a woman’s past relationship with her own mother has an enormous impact on her current responses to her baby as she takes on this new role of ”Mommy.”
Most women rely on their knowledge of their own mothers as a role model for motherhood. A woman’s previously unsatisfactory relationship with her own mother may create ambivalence about the maternal role and leave the new mother feeling isolated and inadequate about her coping skills. Women with postpartum depression tend to question their ability to develop a strong attachment to their infant and a genuine concern that they may not have the emotional stamina to be appropriately responsive, adequately attuned, and sufficiently nurturing to meet the ongoing demands of their newborn.
Treatment consists of helping women after birth and even during pregnancy to gain emotional access to some of the negative and confusing beliefs that influence their behavior, thoughts, and feelings. Failure to manage the psychological tasks of the postpartum period, an inherent part of the transition to motherhood, is implicated in the downward spiral of cognitive and emotional processes that result in maternal depression.
For women at high risk of developing a major depression with postpartum onset, much of the treatment can begin during the third trimester of pregnancy with a preventive program that entails starting psychotherapy several months before the due date and then adding an antidepressant in the first weeks. It is also vital that families use this time to put an adequate support plan in place. In this way, the new mother will be assured of receiving enough help with household responsibilities and infant care in the weeks and months following delivery. This plan ensures sufficient rest for the new mother and reduces feelings of overwhelm, a common experience of the postpartum mother. In addition, a good social support network might even include some kind of weekly psychotherapy group to lessen a new mother’s feelings of isolation.
A variety of antidepressant drugs are used to treat postpartum depression. These include the tricyclics like Norpramin (desipramine) and Pamelor (nortriptyline), as well as the SSRIs, of which the most commonly used are Prozac and Zoloft. More recently, effexor and celexa, two other drugs in the SSRI family of antidepressant medications, are being prescribed. The most frequent side effects associated with SSRIs are headache, anxiety, insomnia, nausea, and sexual dysfunction. Patients who use TCAs often complain about dry mouth and blurred vision. Less commonly used because of their deleterious side effects, but nonetheless effective in treatment resistant depressions, are the MAO inhibitors (i.e., Nardil and Parnate).
The most dangerous side effect of the MAOs is a hypertensive reaction, which although reversible with medication, can be life threatening. This reaction is caused by an interactive effect between the drug and the absorption of large amounts of tyramine, a substance found in certain foods. Consequently, patients who take MAOs must follow a tyramine-restricted diet and avoid foods such as aged meats and cheeses, wine, and beer. Another disadvantage of MAO inhibitors is harmful interactions with other drugs such as Demerol, nasal decongestants, and certain asthma inhalers.
Mothers who begin a trial of an antidepressant need to be informed that it may take between three to six weeks before they begin to feel better so that they don’t become quickly discouraged and quit taking their medication if they don’t feel more immediate results. Women also should know that individual body chemistry and sensitivity to medication affects the type and combination of drug choices. No single medication is effective for all women.
Because anxiety and agitation are often a component of postpartum depression, antianxiety drugs such as Ativan or Xanax may be used in conjunction with an antidepressant to provide added symptom relief. In cases of more severe depression or a postpartum psychosis, lithium is sometimes given to counteract the uncomfortable effects of rapid mood cycling. Thyroid medication also seems to alleviate depressive symptoms in women with an underactive thyroid. Subsequently, therapists should encourage clients to have a medical evaluation so that organic causes for her emotional state are ruled out.
One of the most controversial issues facing breastfeeding mothers receiving treatment for postpartum depression is the safety of medication for their nursing infant. Recent studies endorse Zoloft (sertraline) and Paxil (paroxetine) as top choices for breastfeeding moms with little or no medication detected in infants (Moline, et al., 2001). Celexa (citalopram) and Prozac (fluoxetine) do enter breast milk in small amounts but are considered acceptable choices when mothers are not responding to Zoloft or Paxil. Although some of the older tricyclic medications may cause more side effects in the mother than the SSRIs, drugs like Tofranil (Imipramine) or Pamelor (Nortriptyline) may be more effective for some mothers and are recommended as alternatives.
For severe depressions with psychotic features, it is often necessary to combine an antidepressant with an antipsychotic like Haldol or a mood regulator like lithium (a drug that is contraindicated for breastfeeding moms). Haldol, a widely used antipsychotic medication, is usually chosen over some of the newer drugs like Risperdal or Zyprexa primarily because as of date, the latter two have not been tested enough in breastfeeding mothers and their babies.
POSTPARTUM DEPRESSION AND ITS REPERCUSSIONS ON THE FAMILY SYSTEM
A systems approach offers the view that the functioning of one person in the family cannot be understood out of context of the people closely involved. Although women with postpartum that were formerly perceived as the ”identified patient” current thinking acknowledges the birth of a baby creates a dynamic reaction throughout the family system.
Bowenian theory takes the perspective that individuals usually marry at the same level of differentiation, which directly affects the level of emotional reactivity and anxiety in the marital dyad. The case example in the chart above indicates that both individuals have a history of depression and significant loss in their respective families. As their roles shift from couple to parents, there is a parallel process regarding the feelings of loss in response to the enormous changes after childbirth. Although the mother with postpartum depression is the ”presented patient,” it is clear that both spouses are reacting with intensity to the changes in their lives. For the father in this case example, his current feelings of fear, anger, helplessness, and confusion may be a restimulation of his earliest experience of fear, anger, loss, and powerlessness.
Systemic treatment helps to reestablish emotional intimacy within the relationship by looking at the family as “patient,” and exploring the emotional experience of everyone involved. Family treatment opens communication channels and enables partners to respond to each other more objectively and not reactively.
Diana Lynn Barnes, Psy.D., LMFT, specializes in women’s health concerns and life cycle changes, particularly those involving issues of pregnancy and birth. Dr. Barnes is a frequently interviewed trainer and international presenter on the subject of postpartum mood disorders. She has received acclaim as the consultant for MSNBC’s ”A Mother’s Confession” and Discovery Health Channel’s “Medical Diary.” Dr. Barnes has appeared on CNN, Fox News, and Lifetime Television, and is a frequent consultant for the print media. She serves on the Board of Postpartum Support International, is a Clinical Member of the AAMFT, Depression After Delivery, and Postpartum Health Alliance, and is the director of the Center for Postpartum Health in Woodland Hills, California (www.postpartumhealth.com).
The sources cited throughout the text, and the references listed below, include clinical books and research that should be helpful when undertaking treatment for postpartum depression.
MOLINE M. L., et al (March 2001).
Postpartum depression: a guide for patients and families. Expert consensus guideline series. White Plains: Expert Knowledge Systems.
MURRAY, L., & Cooper, P. J. (Eds.) (1997). Postpartum depression and child development. New York: Guilford Press.
O’HARA, M. W., & Stuart, S. (1999). Pregnancy and postpartum. In R. C. Robinson and W.
R. Yates (Eds.), Psychiatric treatment of the medically ill. New York: Marcel Dekker.
BECK, C. (1998). A checklist to identify women at risk for developing postpartum depression. Journal of Obstetric, Gynecological, & Neonatal Nursing, 27(1) 39—46.
COX, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression: Development of the 10-item Edinburgh postnatal depression scale. British journal of Psychiatry, 150, 782—786.
POSNER, N., et at. (1997). Screening for postpartum depression: An antepartum questionnaire. Journal of Reproductive Medicine, 42, 207—215.
RESOURCES FOR PRACTITIONERS
In addition to the preceding books:
BURT, V.K. & Hendrick, V.C. (1997), Concise guide to women’s health. Washington, DC: American Psychiatric Press. A thorough guide to assessing and managing psychiatric conditions in women with an emphasis on the biological, psychological and sociocultural factors that influence a woman’s mental health.
DUNMEWOLD, A., & Sanford, D.G. (1995). Postpartum survival guide. Oakland: New Harbinger Publications. A practical and comprehensive guide that addresses the range of postpartum adjustment problems. Good choice for clients, as well.
HAMILTON, J. A., & Harberger, P. N. (Eds.) (1992). Postpartum psychiatric illness: A picture puzzle. Philadelphia: University of Pennsylvania Press. One of the foremost works towards a understanding of postpartum mood disorders, this hook presents research and treatment considerations with an emphasis on the organic components of postpartum illness.
KLEIMAN, K. (2000). The postpartum husband: Practical solutions for living with postpartum depression. Xlibris Corporation. Contains information and specific recommendations to help partners cope with the impact of depression after the birth of a baby.
MILLER, L. J., (Ed.) (1999).Postpartum mood disorders. Washington, DC: American Psychiatric Press. This is a comprehensive, well-organized, and recent overview of all aspects of postpartum mood disorders, including the effects of postpartum disorders on child-rearing.
STERN, D. (1998). The birth of a mother. New York: Basic Books. An in-depth and sensitive look at the psychological processes involved as women move towards motherhood.
POSTPARTUM SUPPORT INTERNATIONAL
927 N. Kellogg Avenue
Santa Barbara, CA 93111
The purpose of the organization is to increase awareness among public and professional communities about the emotional changes that women often experience during pregnancy and after the birth of a baby.
DEPRESSION AFTER DELIVERY, INC.
91 East Somerset Street
Raritan, NJ 08869
Depression After Delivery, Inc. is a national, nonprofit organization that provides support for women with ante and postpartum depression. Its focus includes education, information, support groups, telephone support, and referral for women and families coping with mental health issues associated with childbearing, both during pregnancy and postpartum.