Perinatal Mood Disorders

I suggested we start with breastfeeding, and after getting mom comfortable and the baby latched we began to talk. Her husband offered her food but she refused, saying she was too tired to eat, not having slept enough. I started getting the feeling of things not being right with Liz, a familiar feeling in the course of my doula work, and asked her how she felt emotionally. The tears began to roll down her cheeks and she confessed that she just felt overwhelmed with all of it, the breastfeeding, the baby crying, worrying that she couldn't take care of herself, let alone her baby, and worst of all feeling guilty for being sad when she had so much to be thankful for. She said she was about ready to give up on the breastfeeding but felt, at the same time, that this was all she had to offer her baby in her state of "inadequacy". Nothing I suggested made her feel adequate or capable.

I recognized from experience that she had probably more than one form of perinatal mood disorder. She was too anxious to know when things were ok and too depressed to follow up on any suggestions when they were not and sleep deprivation intensified all of it. She had no appetite and felt guilty for being sad at all. I explained that as a doula I couldnt diagnose but I gave her the name of an excellent counselor who specialized in postpartum recovery. I gave her handouts, some practical tips for calming baby and mother self care, and my own wording of the PSI motto: You're Not Alone, You're Not to Blame, You Will Recover.

Twenty percent of all newly delivered mothers will develop postpartum depression and anxiety, but about one third of my postpartum clients have it, because they (or their families) are the ones most likely to reach out for doula help.

Everyone knows these women are out there suffering, and often alone, but few have known how to help until recently as more light is shed on this topic due to celebrities coming forward with their own challenges with PMD and news stories of women with postpartum psychosis. As professionals acquire information it is probably inevitable that there will be some errors in treatment such as over zealous use of drugs without careful evaluation and counseling by specialists, and using drugs too early, when it can be difficult to recognize the difference between PMD and normal baby blues that can last one to three weeks. Evaluation is necessary to make sure she is on the right combination of drugs to treat more than one coinciding illness.

SSRIs have been promoted to treat PMD and have been helpful but they are not without drawbacks, so it is prudent to make sure a mom wouldn't do alright just with a good counselor who specializes in PMD. ACOG published this in a May, 2007 news release: "Selective serotonin reuptake inhibitors (SSRIs) are the most commonly prescribed class of antidepressants because they are effective, well tolerated, and have adverse effects that are less severe than those of older antidepressants. However, recent studies have indicated that exposure to SSRIs late in pregnancy has been associated with short-term complications in newborns, including mild respiratory distress, irritability, feeding problems, jitteriness, and seizures. Individuals taking SSRIs may experience other side effects, including nausea, drowsiness or fatigue, decreased sex drive, headaches, weight gain or loss, and agitation. ACOG also advises that paroxetine (Paxil®), a longer-acting SSRI, be avoided when possible by pregnant women or women planning to become pregnant due to the potential risk of fetal heart defects, newborn persistent pulmonary hypertension, and other negative effects."
It is always advisable to first check mom's thyroid and physical health status.

Here are some facts to help sort out the confusion:

Depression and Anxiety During Pregnancy	10% of all women	Depressed and anxious
"Baby Blues" in first three weeks	80% of all women	Sleep deprived, hormonal, crying over everything. Overwhelmed, but can sleep given chance.
Postpartum Depression and Anxiety	20% of all women	Sad, guilty, cant sleep, too much worrying. Chronic if untreated.
Obsessive/Compulsive Disorder	5% of all women	Repetitive intrusive thoughts, abhorrent to the woman re: hurting the baby, feeling guilty. Irrational behavior (hiding knives).
Postpartum Panic Disorder	10% of all women	Extreme anxiety and worry. Physical sensations, dizzy, palpitations, cant breathe, cant sleep.
Postpartum Post Traumatic Stress Disorder	10% of all women	Triggered by traumatic event. Flashbacks, intrusive images of event, hyper vigilant, jumpy. Depression and anxiety can concur. Traumatic birth, rape.
Postpartum Psychosis	2 in 1000 women	Need hospitalization, early onset, three days to three months hallucinations, mood instability, suspicious, may be in denial of the birth.

Regarding postpartum psychosis, there have been newspaper stories about women who did horrific things while in a state of psychosis, leading women to believe they could do such things themselves. It needs to be noted that psychosis is a different illness than depression, and depression does not turn into psychosis. The first symptoms of psychosis typically begin in the first two weeks, and involve delusional beliefs; there would be no doubt in the family's mind that she needs to go to the hospital right away. It will be a good thing when journalists themselves learn to differentiate between the two before frightening so many pregnant women with their stories.

There are many hypotheses regarding the cause of PMD but few real facts. Fluctuations in hormones and brain chemical imbalances play a part in ways not yet understood. We do know there are risk factors and prevention techniques that can help. There is strong evidence that birthing at a hospital increases the risk of PMD because the liability-based thinking there leads to many harsh interventions from the beginning of labor that affect the mothers moods and feelings of control and capability. Unnecessary C-section is the worst but only one of many harsh forms of treatment to both mom and baby. Often the conflicting advice regarding breastfeeding of two to three shifts of nurses is enough in itself to have the mother crying at home at our first postpartum doula visit. Over-testing and monitoring often leads to comments from staff to indicate that baby might have this problem or that. Sometimes one test that shows an abnormal reading is enough to cause mom to feel her baby might not be ok even if another test shows her baby to be normal, thus affecting her willingness to bond for some time (with "a baby that might not make it" in her subconscious). There is some evidence that Omega-3s can prevent depression and fatigue. Women also need good health care, resources when she is beginning to stress, preparation for parenthood, a social network rather than isolation, a good support system at home, arrangements for some way to get necessary sleep and be aware of past history predisposing her to PMD.

Most of us aren't trained professionals, yet there is much we can do. We can validate our sister's suffering rather than tell her to pick herself up by her bootstraps. We can reassure her that we will be there to help when she needs us, and we can carry the hope that she'll recover. She has so little hope while in the crisis state; it is the biggest thing you can provide. Tell her she is not alone, not to blame and she will recover. Find handouts for her, prepare good food for her and do whatever it takes to enable her to get some sleep. Then most importantly of all, follow up with a plan.

If you are a birth professional you can listen without judgment and don't diagnose. Be with the mom; educate yourself and be comfortable with mental illness, rather than be fearful yourself. Support her family; they are frightened and confused as well. Refer her to help that may take one or more of three forms. There are medications that can be prescribed by her OB, GP, nurse practitioner, and psychiatrist. Most of them can be taken while breastfeeding but check with Thomas Hale's Medications and Mothers Milk. She needs good counseling that can come from social workers, psychologists, or family counselors. She will always need social support (not advice) from peer support groups, church, phone support, family and friends, and doulas. Doulas generally are educated and informed about PMD and one of the best sources of woman-to-woman support. The birth professional's role is to give mom a plan and follow up with it at least through phone calls.

Postpartum Support International is an international organization that has been helping women for years to find information and resources.

There are many good books now that can shed a little light on this often-dark disease. The Baby Blues Connection web site has an excellent page containing most of the best reading material for these families and much other helpful information, founded by Wendy Davis, Ph.D. an Oregon PMD expert.