Postpartum Mood Disorders:
Risk Factors, Symptoms & Treatment

By
Shelley P. Ash, MPH
Secretary, Postpartum Health Alliance of Northern California
Co-founder, Bay Area Postpartum Hotline

DISCLAIMERS

1. The following document, although based fully on a current literature search, personal experience of the author, and anecdotal evidence from hundreds of women, does NOT replace the expertise of a medical doctor. This document is for general health education purposes only. Therefore, this Forum’s directors and the author of this document shall remain free of any legal liabilities.

2. The author wishes to acknowledge, in advance, that references are listed at the end of the document, going against standard practice of citing references immediately following a statement. The author has done this for the sake of readability. The author apologizes if this offends any health care provider or agency.

OVERVIEW

For most women, especially first-time moms, the postpartum period is another in a continuing series of normal developmental steps requiring a set of new adaptations. Who will adjust with minimal disruption to emotional integrity and who will get into psychological trouble after childbirth have been baffling questions since earliest medical history.

Postpartum depressive disorders have engaged physicians’ speculation beginning with Hippocrates in 400 B.C. The search for etiological and predictive factors has ranged through a wide variety of physical, genetic, psychosocial, biologic, superstitious, and esoteric factors.

In modern times, particularly from the 1970s onward, researchers have repeatedly found that far more women (21 percent) versus men (13 percent) will endure major depressive disorder (MDD) during their lifetimes. It is not surprising then, that the prevalence of MDD in women increases during their reproductive years. In other words, women are more likely to suffer from mood and anxiety disorders following childbirth than at any other time in their lives.

Why? The powerful influence of hormones and the tremendous life change that arrives with a new baby are just two of many reasons.

The postpartum mood and anxiety disorders—baby blues, depression, psychosis, obsessive-compulsive disorder, and panic disorder—are thought to affect as few as 10 percent and as many as 80 percent of new mothers around the world, representing all shapes, sizes, ages, cultures, religions, socio-economic positions, educational achievements, and health status levels.

While prevalence statistics are difficult to ascertain due to stigmas, cultural issues, fear, reporting practices, etc., we know for sure that these conditions are fully treatable. Keys to successful intervention include early detection and proper diagnosis, patient education, social support, psychotherapy, and sometimes medication.

The goal of this document is to educate the public about the many risk factors and symptoms for each of the postpartum mood disorders, as well as discuss treatment options (in general terms) and give the latest views regarding medications and breastfeeding.

MYTHS:

PREGNANCY AND PARENTHOOD

The stigmas surrounding mental health conditions are many, and the multiple motherhood myths further perpetuate the lack of detection and recognition of personal psychological problems. Parenthood myths include but are not limited to the following:

Babies keep partners together; baby will solidify a marriage
Motherhood is mandatory
Extended family members will help out
Grandparents will provide dutiful support
Pregnancy is wonderful
Pregnancy “glow”
“Natural” birth, and birth plan
Madonna images of an instant bond with baby
Sustained blissful happiness
Love of baby at first sight
“Sleeping like a baby”
Babies are beautiful
Motherhood is instinctive
Breastfeeding will come naturally
Routines will not change
One’s social structure will not change
“Supermom” syndrome (we try to be everything to everyone and do it perfectly)
Change to being a stay-at-home mom is easy
Father will share infant care equally with mother
Father is clueless, has no instincts
After 6-week checkup, everything should be smooth sailing

There are also cultural opinions about mental illness that add to the problem of stigma. These contribute to the inability to be accurately assessed, receive recognition of the problem, be properly referred to appropriate professionals, and receive proper treatment. Some of these myths include, but are not limited to:

Self-reliance values
Abhorrence of dependency
Double standard of physical versus mental illness
Fear of addiction to medications
Financial and insurance restrictions

Further complicating the situation is that women’s health, baby, and parenting magazines are replete with articles (these were real headlines!) such as, “10 steps to a perfect birth,” “20 steps to locking in a high IQ for your baby,” or “30 ways to enrich your sex life in the postpartum period,” titles which give a false impression of the parenthood process!

The results of the perpetuation of motherhood myths include:

A woman’s shame for the feelings she is having
Fear of being judged a bad person
Fear of having the baby taken away
Being seen as having a weak character
Being thought of as “out of control”

These feelings become magnified when healthcare professionals do not acknowledge that a woman is experiencing a REAL problem.

Healthcare providers should possess the skills to allay new mothers’ and fathers’ fears by putting the situation into context. They should be able to, in a culturally relevant way, acknowledge that childbirth is a major event and the transition from “couple” to “family” can be challenging physically, emotionally, and socially. Unfortunately, many health professionals have not had intensive training on the subject of postpartum mood disorders, and often simply attest the mood disruptions to “hormones.” While this is some of the scenario, it is by no means the only trigger.

It has been documented that patients will tolerate depression for several weeks before they recognize that something is wrong and overcome a natural reluctance to admit to psychiatric complaints. But, we know that the sooner a woman receives treatment for her condition(s) the sooner and more fully she will recover, the less severe her side-effects will be, and the better for her baby’s health.

Baby “Blues”

“The blues” is a mild and transient period of tension that affects up to 80 percent of all new mothers with onset usually between day 3 and 14 postpartum. Symptoms may persist from several days to a few weeks.

Due to a sudden drop in hormones and other dramatic changes in her body, a woman may feel any range or combination of emotions:

weepy (most common)
happy
sad
excited
frustrated
joyful
exhausted
anxious
tense

She may also experience a lack of concentration, energy to carry out simple tasks, and have feelings of dependency and inadequacy. Additional factors include:

Induced labor (due to the hormone flood)
Emotional letdown after pregnancy and childbirth
Physical aches and pains from childbirth
Fatigue and sleep deprivation
Eating difficulties/problems with appetite
A colicy baby
Difficulty with breastfeeding
A frenzied feeding schedule (mom and baby)
Single parenthood
Marital instability
Social or geographic isolation from one’s family
Adult Child of an Alcoholic (ACOA)
The realization that parenthood is a huge responsibility

Thankfully, “the blues” generally subside within two weeks. And it’s typical to have good days and bad days in terms of emotional ups and downs. What are some simple things you can do to get started down a more stable path? Focus on the basic, primal needs first—-eat, sleep, and personal hygiene. Start each day on the right foot by eating breakfast: toast, OJ, a piece of fruit, cereal. Then throughout the day, drink adequate fluids and eat healthfully. You need good-quality fuel going in to help you heal physically and emotionally, and to produce breastmilk. Continue taking prenatal (or multi) vitamins. Rather than eat three large meals, graze during the day to keep your energy up. Fresh fruits and vegetables, dairy products, lean meats, rice, pasta and potatoes). Avoid products with caffeine and excess sugar, especially if you are prone to the jitters and/or are having difficulty getting sleep at night. Get plenty of rest! Sleep when the baby does. If you can’t sleep, REST! Put your feet up and read a magazine, listen to music, or watch TV (but no shock-talk programs!). The dishes and laundry can wait!

Take a warm bath or shower every day. Not only is it important for personal hygiene, but it’s a great way to soothe one’s soul. Babies generally love the water, and it’s a great idea to bathe with baby.

Go potty! Regularly. Don’t hold it. You may think you don’t have time, but you do. Last thing you need right now is a bladder infection, and this CAN happen. In the early months, if this is all you and baby do in a day, you’ve accomplished a lot! Pat yourself on the back!!

Here are the next steps:

Accept offerings of help from friends and family members. These people can watch the baby while you take a shower or nap, cook meals (and stock the freezer with food in containers that don’t have to be returned), and answer the telephone (better yet, turn the ringer off!).

Encourage your husband/partner to help with baby care and take over some household chores. In addition to diapering baby and cuddle time, it’s helpful for you to get a break from doing dishes and laundry, and going to the grocery store. (Yes he can learn to do the laundry!)

Remind each other about the fact that in the early weeks, you both may find you can’t get as much done as you did previously. Pare your daily “to do” lists way down.

When you’re ready, get outside for sunshine and a gentle walk. Exercise is a good thing. Carry baby in a sling, snuggle sack, or like carrier rather than a stroller. This way baby can be close to you and not jolted by bumps in the sidewalk.

Avoid social isolation. Participate in a hospital-based new mothers support group, get to know other moms in the neighborhood, join a neighborhood playgroup, or look into activities for new mothers offered by the County or your City recreation department.

Say daily affirmations: “My emotional distress is temporary, I am not to blame, and I will feel better soon.” Write this on bright paper and post it on the fridge.

Try massage. One’s coping abilities are significantly improved when stress and muscle tension is reduced.

Avoid getting caught up in the frenzy of toy marketing. The only stimulation that baby requires in these early weeks and months is hearing your soothing voice, seeing your smiling face, feeling your gentle touch, and experiencing the hum of your household.

If you live in the San Francisco Bay Area, call the Postpartum Hotline at (888) 773-7090. This hotline, staffed by seven women volunteers—all survivors of postpartum blues or depression—operates from 9 a.m. to 9 p.m. seven days a week. It is a collaborative project of the Postpartum Health Alliance of Northern California and Family Service Mid-Peninsula (a United Way agency). Please though, only No. Calif. callers because we do not have funding for long-distance calls.

There are many resources available to you around the world! The best place I know to begin your search is Postpartum Support International, whose Web site is www.postpartum.net.

Postpartum Depression

In general, depression can be defined as the loss of pleasure or negative mood combined with a set of symptoms (at least four) which lasts more than two weeks and causes impairment in some or several areas of life. Past and present studies consistently find that depression is far more common among females than males.

In terms of postpartum depression (PPD), which affects upwards of 25 percent of new mothers (20 percent of those with postpartum blues develop PPD), this condition is much more than the baby blues.

A woman suffering PPD may experience gradual or rapid onset of any combination of the following:

Chronic crying (deep, like grieving)
Panic attacks (more about this in the later section about panic disorder)
Overall anxiety (ditto)
Excessive worry
Mild to severe sadness
Mood swings
Compulsive or ritualistic (scheduled) behaviors or actions (more about this in the later section about OCD)
Eating problems and appetite changes
Rapid weight loss or gain
Obsession with “getting my body back”
Sleeping problems and/or insomnia
Physical symptoms or complaints without physical cause (ie. you have an earache but a doctor’s exam finds nothing wrong)
Phobias
Marked fear of criticism of mothering skills (no matter what anyone says to you, even positive remarks, and you take it as all negative)
Excessive concern about the baby’s health or well-being
Loss of focus and concentration, and memory
Loss of interest in activities that once brought pleasure
Feelings of isolation
Feelings of hopelessness
Detachment/disinterest in the baby
Feelings of regret about having a baby
Frightening thoughts or fantasies (more about this in the later section about OCD)

Infant’s failure to thrive

Postpartum depression may occur immediately after birth or many months later. Weaning from breastfeeding can trigger PPD. It can happen after giving birth to any child, not just the first. (But if a woman had PPD after a previous pregnancy, there’s a 50 to 80 percent chance of recurrence.)

In terms of etiology, any of the risk indicators related to the “blues”—myths, hormones, childbirth experience, adjustment to parenting—apply to postpartum depression. But there are other factors that deserve attention, such as your history of:

PMS
Previous psychiatric disturbance (self of family members)
Depression or anxiety during pregnancy
Previous pregnancy, birth or postpartum difficulties (mental and physical)
Thyroid disorders/imbalance
Sexual abuse or trauma
Domestic violence
Anorexia/bulimia
Fertility problems
Losses (miscarriage, neonatal, early childhood)
Use or abuse of tobacco, alcohol and/or hard drugs
Growing up in an angry, stressful or unstable household
Chronic illness (physical: heart disease, diabetes, asthma, pain; mental: eating disorders, post-traumatic stress disorder)
Use or over-use of prescription or over-the-counter medications
Difficult life events (divorce, financial problems, recent move, recent loss of a loved one)
Whether this was a planned pregnancy

PPD is very traumatic, for new mothers and their partners. It causes overwhelming feelings of guilt and shame, and often women feel compelled to keep silent. Family members often don’t know what to say or how to help. Left untreated, however, PPD can continue for many months and negatively impact the health of a woman and her baby. A women suffering PPD cannot “will” herself better. Suicide and infanticide are real threats!

The sooner a woman receives treatment the faster she will recover in the short term and the better to prevent long-term repercussions such as chronic depression in the mother, failure to thrive in the infant, and the marriage ending in divorce.

Treatment takes a four-fold approach—education, social support, psychotherapy, and (sometimes) medication—and with proper treatment most women recover within one year.

What do do? Start by working through the coping steps as listed under the “baby blues.” Doing so can significantly reduce anxiety by gaining a sense of control over your body and environment. Then:

Read up on the subject of postpartum mood disorders. Jane Honikman, founder of Postpartum Support International (PSI), recommends the following books as they are geared for the consumer and made easy to read:

This Isn’t What I Expected (1994) by Karen Kleiman, MSW, and Valerie Raskin, M.D. (Bantam Books)
Postpartum Survival Guide (1994) by Anne Dunnewold, Ph.D., and Diane Sanford, Ph.D. (New Harbinger Publications)
Shouldn’t I Be Happy: Emotional Problems of Pregnant and Postpartum Women (1995) by Shaila Misri, M.D. (Simon and Schuster)
When Words Are Not Enough: The Women’s Prescription for Depression and Anxiety (1997) by Valerie Raskin, M.D. (Broadway Books)
Overcoming Postpartum Depression & Anxiety (1998) by Linda Sebastian (Addicus Books)

Of course there are many more books available on postpartum mood disorders, hormones, thyroid conditions, coping with dysthymia or depression, etc. For more information or to make purchases, look up PSI’s Web site, www.postpartum.net.

Make an appointment to see a psychiatrist (an M.D.) who specializes in women’s health and can conduct a thorough investigation into your personal and family’s mental and physical health history. Not only can this person determine whether anti-depressant medication is warranted, but can educate about personal risk factors for depression and how to manage them.

Further, this person can order a blood test to check your thyroid function (free T4, TSH, anti-TPO, and anti-thyroglobulin). Thyroiditis occurs in 10 percent of postpartum women, and can be treated. (Tests suggested by Richard Cherlin, M.D., endocrinologist.)

Locate a support group that addresses issues specifically about adjustment to parenthood and coping with mood disorders. New mothers’ support groups, run by most hospitals with labor/delivery departments, are great places to learn about baby care, self care, and parenting.

Obtain individual or couple psychotherapy. It’s very helpful, coming from a professional with expertise in postpartum mood disorders.

Keep the faith! If prayer and meditation helped calm your soul in the past, you may derive comfort from these activities now (as will your significant other). Speak kind thoughts to yourself, out loud! “I am a GOOD mom. I will get better. And I am doing the best that I can with what I know now.”

One Dad’s Advice to Other Dads

Know that your wife WILL get better.
PPD is treatable.
Try not to resent your wife, baby, and the situation.
Positive attitude is a huge component in your wife getting better and the baby being happy.
Don’t be sorry for yourself. You need to be the strong one right now.
You must provide a supportive and loving environment.
Realize that your anger is really a fear of the unknown.
If your wife is on medications, pay close attention to her physical and emotional reactions, give feedback to her psychiatrist, and participate in her check-up appointments.
Allow your wife to get out without baby.
Help arrange a family member or close friend to stay a few nights: keep mom company, give her breaks, and help with household chores.
Expect sexual/intimate relations to be on hold for a while.
Don’t buy in to someone else’s opinion about depression. Get the facts!
You can’t fix this in a hurry. Healing will come with time.

Helpful books:

The Expectant Father: Facts, Tips and Advice (1995) by Armin Brott (Abbeville Press)
The New Father’s Panic Book: Everything a Dad Needs to Know to Welcome His Bundle of Joy (1997) by Gene Williams (Avon Books)
Pregnant Fathers: Entering Parenthood Together (1995) by Jack Heinowitz (biracial and multiethnic concerns also addressed)
This Isn’t What I Expected: Recognizing and Recovering from Depression and Anxiety After Childbirth (1994) by Karen Kleiman, MSW, and Valerie Raskin, M.D. (Bantam Books) (Chapter 10, “Will my wife ever be the same?: When your wife has postpartum depression”, is particularly helpful.)

Postpartum Psychosis

Once thought “extremely rare” but finally receiving its due attention, one to two in 1,000 new mothers will suffer a far more serious disorder known as postpartum psychosis(PPP).

The onset of PPP usually begins about day 3 postpartum, however, it can happen very soon after birth or a week or two later. Symptoms of the blues and depression will present with any combination of the following:

Severe or rapid mood swings
Extreme fatigue
Chronic crying
Hyperactivity
Agitation
Confusion
Incoherent statements
Inability to care for self or baby
Thoughts of harming self or baby
Losing touch with reality
Hallucinations and/or irrational thoughts
Confusion, suspiciousness, and obsessive concern about the baby
Delusional thinking (infant death, denial of birth, need to kill baby, “voice of God telling you to put baby in the trash”)

Postpartum psychosis is “mercurial” in nature. This means that the mother’s condition can change back and forth rapidly. One moment, things may seem normal, and the next moment, the mother is not acting like her normal self. This condition requires immediate, urgent care!! There is a suicide rate of 5 percent and infanticide rate of 4 percent.

Once medically stabilized, and some weeks down the road, the mom may want to consider attending support group meetings in addition to individual psychotherapy and taking medication.

Risk factors can include any combination of those previously described for blues and depression. In research, additional factors that seem to show significance include:

Personal history of psychosis or bipolar disorder
Previous psychiatric disturbance (self of family members)
Particularly difficult/complicated labor
Primigravida (first-time mom)
Advanced maternal age
Previous miscarriage
Premature delivery and low birthweight baby
Being an unmarried mother combined with social or geographic isolation

It is very important to be clear: Yes ... this is very scary, but it’s not a life sentence. You will get well! It just takes patience and perseverance. The key is to get immediate medical attention!!

Panic Disorder

In panic disorder, brief episodes of intense fear are accompanied by multiple physical symptoms (such as heart palpitations and dizziness) that occur repeatedly and unexpectedly in the absence of any external threat. These “panic attacks,” which are the hallmark of panic disorder, are believed to occur when the brain’s normal mechanisms for reacting to a threat—the so-called “fight or flight” response—becomes inappropriately aroused.

Most people with panic disorder also feel anxious about the possibility of having another panic attack and try to avoid situations in which they believe these attacks are likely to occur. Anxiety about another attack, and the avoidance it causes, can lead to disability in panic disorder.

Who has panic disorder?

In the United States, between 3 and 6 million people will have panic disorder at some time in their lives. The disorder typically begins in young adulthood, but older people and children can be affected. Women are affected twice as frequently as men. While people of all races and social classes can have panic disorder, there appear to be cultural differences in how individual symptoms are expressed.

Symptomatology

Typically, a first panic attack seems to come “out of the blue,” occurring while a person is engaged in some ordinary activity like driving a car, going to the mall, or walking in the neighborhood. Suddenly, the person is struck by a barrage of frightening and uncomfortable symptoms. These symptoms often include:

Terror—a sense that something unimaginably horrible is about to happen, and one is powerless to prevent it
Racing or pounding heartbeat
Chest pains
Dizziness, lightheadedness, nausea
Difficulty breathing/shortness of breath
Tingling or numbness in the hands
Shaking
Hot or cold flashes
Sense of unreality
Fear of losing control, going “crazy,” or doing something embarrassing
Fear of dying

This barrage of symptoms usually lasts several seconds, but may continue for several minutes. The symptoms gradually fade over the course of about an hour, and can leave its victim completely exhausted. People who have experienced a panic attack can attest to the extreme discomfort they felt and to their fear that they had been stricken with some terrible, life-threatening disease or were “going crazy.” Often people who are having a panic attack seek help at a hospital emergency room, thinking it’s an actual heart attack.

Initial attacks

Initial panic attacks may occur when people are under considerable stress such as from an overload of work, recent move, from the loss of a family member or close friend, post-surgery or serious accident, or after a major life change (having a baby!).

Excessive consumption of caffeine or use of cocaine or other stimulant drugs or medicines, such as stimulants used in treating asthma, can also trigger panic attacks.

Nevertheless, panic attacks usually take a person completely by surprise. This unpredictability is one reason why they are so devastating. Sometimes people who have never had a panic attack assume that panic is just a matter of feeling nervous or anxious—the sort of feelings with which most everyone is familiar. However, some people who have one panic attack, or an occasional attack, never develop a problem serious enough to affect their lives. For others, however, the attacks continue and cause much suffering.

Panic disorder

In panic disorder, panic attacks recur and the person develops an intense apprehension of having another attack. This fear—called anticipatory anxiety or fear of fear—can be present most of the time and seriously interfere with the person’s life even when a panic attack is not in progress.

In addition, the person may develop irrational fears, or phobias, about situations where a panic attack has occurred. For example, someone who has had a panic attack while driving may be afraid to get behind the wheel again, even to drive to the grocery store. If the trigger is job-related, she or he may become chronically late to work and/or avoid certain projects or co-workers. Sleep may be disturbed because of panic attacks that occur at night, causing the person to awaken in a state of terror. The experience is so harrowing that some people who have nocturnal panic attacks become afraid to go to sleep and suffer from exhaustion. Even if there are no nocturnal panic attacks, sleep may be disturbed because of chronic, panic-related anxiety.

Agoraphobia

Panic disorder may progress to a move advanced stage in which the person becomes afraid of being in any place or situation where escape might be difficult or help unavailable in the event of a panic attack. This condition is called agoraphobia. It affects about a third of all people with panic disorder. Typically, people with agoraphobia fear being in crowds, standing in line, entering shopping malls, and riding in cars or public transportation (airplanes, especially). Often these people restrict themselves to a “zone of safety” that may include only the home or the immediate neighborhood. Any movement behond the edges of this zone creates mounting anxiety.

Sometimes a person with agoraphobia is unable to leave home alone, but can travel if accompanied by a particular family member or friend. Even when they restrict themselves to “safe” situations, most people with agoraphobia continue to have panic attacks at least a few times a month.

Due to their reliance on others to function, and their inability to leave the “safety zone,” people with agoraphobia typically lead lives of extreme dependency as well as great discomfort. Left untreated, depression often sets in.

What about postpartum-induced panic?

Women who suffered from anxiety and/or panic attacks before becoming pregnant are significantly at risk of having such events occur during pregnancy and particularly during the postpartum period. Limited studies in this area have found that panic disorder may occur in up to 10 percent of postpartum women. In addition to the list of symptoms listed above, a postpartum woman may also experience:

Extreme anxiety
Sensations of choking or smothering
Restlessness, agitation, or irritability
Excessive or obsessive worry or fear(s)
Constant crying

Further complicating the situation is that a woman, who may be alone in the home, must care for a newborn while coping with these physically and emotionally draining symptoms. Severe enough, these symptoms can be disabling and often render a woman completely unable to care for herself or her baby.

What about risk factors?

Research by the National Institute of Mental Health is ongoing. For sure, a woman who experienced episodes of anxiety and/or panic before pregnancy is at risk for postpartum panic disorder. Thyroid dysfunction is another contributing factor.

Regarding genetics, we know that panic disorder runs in families. One study found that if one twin in a genetically identical pair has panic disorder, it is likely that the other twin will also. Scientists are studying families in which several individuals have panic disorder; the aim is to identify the specific gene or genes involved in the condition.

In terms of brain and biochemical abnormalities, one line of evidence suggests that panic disorder may be associated with increased activity in the hippocampus and locus ceruleus, portions of the brain that monitor external and internal stimuli and control the brain’s responses to them. Also, it has been shown that panic disorder patients have increased activity in a portion of the nervous system called the adrenergic system, which regulates such physiological functions as heart rate and body temperature. However, it is not clear whether these increases reflect the anxiety symptoms or whether they cause them.

Other studies (some with animals) are looking into environmental factors (noise, sudden movement, etc.), while other research programs are investigating the basic thought processes and emotions that come into play during a panic attack and those that contribute to the development and persistence of agoraphobia.

Treatment

Treatment can bring significant relief to 70 to 90 percent of people with panic disorder, and early treatment can help keep the disease from progressing to the later stages where agoraphobia develops.

Before undergoing any treatment for panic disorder, a person should undergo a thorough medical examination to rule out other possible causes of the distressing symptoms. This is necessary because a number of other conditions, such as excessive levels of thyroid hormone, certain types of epilepsy, or cardiac arrhythmias, can cause symptoms resembling those of panic disorder.

Further, coexisting conditions such as specific or social phobias, depression, OCD, alcohol abuse, drug abuse, suicidal tendencies, irritable bowel syndrome, and mitral valve prolapse, need to be identified.

Once other causes are ruled out or addressed, treatment is generally a combination of:

Cognitive-behavioral therapy (to modify or eliminate negative thought and behavior patterns, learn breathing exercises, and work through phobias) Medications (anxiolytics, SSRIs, MAOIs, and tricyclics) Support group (also a great place for family members to learn how to help)

Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD), one of the anxiety disorders, is a potentially disabling condition that can persist throughout a person’s life. The individual who suffers from OCD becomes trapped in a pattern of repetitive thoughts (obsessions) and behaviors (compulsions) that are senseless and distressing but extremely difficult to overcome.

OCD occurs in a spectrum from mild to severe, but if severe and left untreated, can destroy a person’s capacity to function at work, in school, and at home. For many years, mental health professionals thought of OCD as a rare disease because only a small minority of their patients had the condition. The disorder often went unrecognized because many of those afflicted with OCD, in efforts to keep their repetitive throughts and behaviors secret, failed to seek treatment. This led to underestimates of the number of people with the illness. However, a survey conducted in the early 1980s by the National Institute of Mental Health provided new knowledge about the prevalence of OCD. The NIMH survey showed that OCD affects more than 2 percent of the population, meaning that OCD is more common than such severe mental illnesses as schizophrenia, biopolar disorder, or panic disorder.

OCD strikes people of all ethnic groups. Males and females are equally affected.

Obsessions

These are unwanted ideas or impulses that repeatedly well up in the mind of a person with OCD. Persistent fears that harm may come to self or a loved one, an unreasonable concern with becoming contaminated, or an excessive need to do things correctly or perfectly, are common.

Again and again, the individual experiences a disturbing thought, such as, “My hands may be contaminated—I must wash them”; “I may have left the garage door open”; or, “I am going to injure my baby.” These thoughts are intrusive, unpleasant, and produce a high degree of anxiety. Sometimes the obsessions are of a violent or a sexual nature, or concern illness.

Compulsions

In response to their obsessions, most people with OCD resort to repetitive behaviors. The most common of these are washing and checking. Other compulsive behaviors include counting (often while performing another compulsive action such as hand washing), repeating, hoarding, and endlessly rearranging objects trying to keep them in precise alignment with each other.

Mental problems, such as mentally repeating phrases, listmaking, or checking are also common. These behaviors generally are intended to ward off harm to the person with OCD or others. Some people with OCD have regimented rituals while others have rituals that are complex and changing. Performing rituals may give the person with OCD some relief from anxiety, but it is only temporary.

What causes OCD?

The old belief that OCD was the result of life experiences has been weakened before the growing evidence that biological factors are a primary contributor to the disorder. The fact that OCD patients respond well to specific medications that affect the neurotransmitter serotonin suggests the disorder has a neurobiological basis. For that reason, OCD is no longer attributed only to attitudes a client learned in childhood—for example, an inordinate emphasis on cleanliness, or a belief that certain thoughts are dangerous or unacceptable. Instead, the search for causes now focuses on the interaction of neurobiological factors and environmental influences, as well as cognitive processes.

OCD is sometimes accompanied by depression, eating disorders, substance abuse, a personality disorder, attention deficit disorder, or another of the anxiety disorders. Co-existing disorders can make OCD more difficult both to diagnose and to treat.

What about postpartum-onset OCD?

Estimates are that 3 to 5 percent of new mothers develop this disorder, exemplified by:

Intrusive repetitive and persistent thoughts or mental pictures (“sees” the baby on fire)
A drive to repeat tasks (pack and re-pack the diaper bag)
Avoidance behaviors to reduce the anxiety (hiding knives, “testing” oneself, avoiding the baby)
Thoughts often about hurting or killing the baby (pushing baby out the window)
Tremendous sense of horror and disgust about these thoughts (ego alien)
A strong visceral sensation (ie. butterflies)

Risk factors include a history of OCD (in milder forms known as a “Type A” personality), and, negative feelings resulting from unrealistic expectations.

Treatment:

Psychotherapy
Anti-depressant medication
May need to medicate anxiety symptoms separately

Breastfeeding and Medications

There is no question, breastfeeding offers an unmatched beginning for children, providing the perfect mix of nutrients and antibodies necessary for each baby to thrive, which formula can only attempt to match. Further, breastfeeding has a protective effect on mothers, decreasing their risks for osteoporosis and certain cancers. Therefore, it isn’t surprising that the American Academy of Pediatrics (among others) now recommends breastfeeding for at least one year. However, if a new mother is suffering from postpartum depression, psychosis, panic disorder, OCD, or combination thereof, circumstances may warrant that she not breastfeed based on the contraindications of certain psychotropic medications.

This is NOT an easy decision! The new mom, her partner, and her doctor(s) must weigh the many benefits of breastfeeding against the severity of her symptoms and the risks associated with delaying treatment. Two issues further complicate the situation:

There are different schools of thought among OBs, midwives, pediatricians, psychiatrists, and lactation consultants: a) continue nursing only (and delay meds), b) quit nursing all together (and take the meds), and c) take meds and continue nursing (“pump and dump”).

In addition, the IQ debate rages on! This HAS to stop! Militant breastfeeding advocates insist that breastfed infants grow up to have higher IQs, but repeatedly studies have shown that formula-fed children as well as those who were nursed while their moms were on anti-depressant drugs have grown up to be perfectly normal, healthy, and intelligent adults!

We know that infants require consistency, stability, and responsiveness on the part of their parents. The greatest period of brain development is during the first 18 months of life—that life experience will be stored in actual changes to the physical and chemical structure of the brain. Therefore, the single most important factor in child emotional well-being is the parent emotional well-being.

Bottom line: The decision to breastfeed, formula-feed, take meds or a combination thereof depends on the woman and her family, and what will work to promote the health of the mother and her infant. This is a very individual decision, with no right or wrong answers.

Here’s what two experts in this field have said:

“In my opinion, the data for sertraline and nortriptyline do not warrant depriving babies of breastmilk IF it is the woman’s choice to breastfeed.” - Katherine L. Wisner, M.D., University Hospitals of Cleveland

“There are no good data to support any particular drug being safer than another in women who breastfeed while being treated with psychotropics (lithium being the exception). Treat with an agent that maximizes the likelihood of quickest recovery.” - Lee S. Cohen, M.D., Massachusetts General Hospital

For those who decide to breastfeed and take medications

According to psychiatrist Dennis Plesons, M.D., there is much to consider, including the woman’s specific symptoms, her personal and family’s health history, what psychotropics worked for her in the past (if applicable), what prescription and over-the-counter medications she presently takes (inclucing “the pill”), her support system(s), any thyroid dysfunction, and her wishes regarding breastfeeding.

Additional factors are the many variables that determine drug concentration in milk and potential exposure in the infant. These include dose and compliance, bioavailability, maternal pharmaocokinetics, time since drug intake, time of feeding, volume of milk intake, maturation of liver and renal function of the neonate, among others.

The milk-plasma ratio is the concentration of drug in milk, compared with concentration of the drug in the maternal plasma. This varies as to which portion of the milk is studied, fore versus hind. Drug concentrations tend to increase from the initial portions of breast milk to the latter portions. When medicating a nursing mother, it becomes necessary to obtain a baseline pediatric assessment of the infant before starting the medication and follow-up with routine checks for reassurance of normal development.

All medications pass from mother’s milk to the baby. The amount varies substantially. General guidelines are to use the minimal effective doses, prefer short-acting medications (Luvox or Zoloft), use monotherapy if possible, consider past response of the individual or family members with the same condition, and nurse (if possible) prior to the time of dosing of the medication.

One thing many women do, with the help of their doctor, is to calculate when the medication will be of the highest concentration in their system. So if a woman takes her medications in the morning, for instance, she might calculate # hours later as the “pump and dump” feeding. For this breastfeeding time, she would pump her milk and discard it, and give expressed breastmilk from another time of day or give formula—just for that feeding. She can nurse the rest of the day and/or night. This type of schedule CAN be worked out with the help of the doctor, and thus preserve the breastfeeding relationship!

If there are concerns about adverse effects to the nursing infant, obtain infant serum levels of the medication and metabolites. Difficulties commonly arise when the nursing infant becomes ill or dehydrated, leading to an increased infant serum concentration of the medication. Also particular attention must be paid in drugs with central nervous system effects, particularly concerning apnea, lethargy, and sedation.

Healthcare providers cannot rule out long-term effects. There is inadequate data in this regard. (In other words, there is no such thing as “safe” and we must be cautious in using this word!) To date, no such indication exists. Again, a risk versus benefit analysis is necessary. In the vast majority of case reports of nursing infants exposed to medications prescribed to the mother, no evidence of treatment emergent adverse effects is reported. One thing we know for sure: Lithium should not be used while breastfeeding. Anticonvulsive drugs such as carbomazepine may be an alternative because of its rapid metabolism.

Finally, there are early reports of women with postpartum psychosis improving rapidly with sublingual estradiol therapy and reports of bright light therapy being effective in some cases of postpartum depression.

Herbal supplements and breastfeeding

This discussion wouldn’t be complete without a few words about St. John’s Wort, Kira, Kava Kava, and other over-the-counter herbal “remedies” for unstable mood. Bottom Line: CONSULT YOUR DOCTOR BEFORE TAKING THEM. Avoid self-diagnosing any of the postpartum mood disorders yourself and seek professional advice. These items, available over-the-counter, act as an monoamine oxidase inhibitor (MAOI) in your brain, in other words, these substances are anti-depressants. Research is ongoing around the world as to safety and efficacy, but nothing has been satisfactorily researched to FDA standards with regard to safe use for breastfeeding mothers. Remember, everything you ingest you share with baby. It’s not worth the risk, baby may not be able to metabolize the compounds and can have an allergic or toxic reaction.

Furthermore, potency can vary from manufacturer to manufacturer as can the filler ingredients, which themselves can cause negative side-effects. Last, these compounds can react with other medications you may be taking, and, are known to affect blood pressure.

Consult a medical professional before taking these herbs.

For those who decide to wean

According to La Leche League International, breastfeeding is not a physiologic contributor to postpartum depression. In fact, one study from Australia found a lower rate of postpartum depression in breastfeeding women (Astbury 1994). The hormonal changes after birth occur more gradually when a mother breastfeeds. However, should the mother and her doctor decide she should discontinue breastfeeding, La Leche’s position (and that of the psychiatric community) is that weaning should be carefully managed as there are physical, hormonal, and emotional changes that take place during weaning that can affect the mother’s depression. Stopping “cold turkey” can cause a host of problems, including engorgement and possible mastitis, and a severe hormone fluctuation further exacerbating the depressive symptoms.

Additionally, the mother may have, for many weeks, feelings of guilt and loss over having to give up nursing. The mother experiencing these emotions, although to be expected, may need counseling to address her many concerns and feelings. She may also need education regarding the types of bottles and formulas on the market, in addition to positive words and encouragement that she and her baby will be fine.

In Summary ...

Why treat postpartum mood disorders? Because there’s too much at stake if we don’t! There’s no reason for a new mother and her family to suffer. Furthermore, we want to curb the incidences of childhood psychological disturbances, impaired cognitive and language development, the potential for child abuse and failure to thrive, the negative impact on marital and family relationships, chronic illness in the mother; and at its worst, maternal suicide and infanticide!

Babies of depressed mothers

Lower birth weights
Lower growth weights
Elevated stress hormones
Less responsive to others, show little facial expression
Loss of appetite
More negative interactions with a friendly stranger than other children

Toddlers and children of depressed mothers

Lower levels of symbolic play (cognitive development not as great)
Heightened emotionality
Behavioral problems
Learning difficulties
Accidents
Depressive symptoms or diagnosable depression
Headaches and stomach aches
Greater risk of depression

Babies are affected at young ages

10-week-old infants react to maternal facial and vocal displays of anger with anger (Lelwica and Haviland, 1983)
3-month-old infants’ emotional states reflect their mothers’ emotional state (Hamilton, 1989)
7-month-old infants of the most disengaged mothers show the greatest amounts of protest, infants of the most intrusive mothers look away the most, and the infants of the most positive mothers display more positive behaviors with more positive content (Tronick, 1990)

In the words of Jane Honikman, founder of Postpartum Support International, as public health officials we must convey to suffering new mothers: You are not alone, you are not to blame, and you can feel better! The key is to obtain professional help, ASAP.



ABOUT THE AUTHOR

Infanticide. Suicide.

It’s jolting to see those words together. But for about 25 percent of new mothers, killing themselves and/or their babies is a very common thought. In fact, it looks pretty darn good. This is depression.

These women believe that having a baby has ruined their lives and feel trapped because there’s no going back. Sleep deprivation and no appetite zap all energy. Rampant anxiety and postpartum raging hormones strangle any sense of reality. Friends and family members, who are scared, don’t know what to say or how to help. Without support, this can turn into a life-and-death situation. For me, life after my son was born was a living hell. People told me, “Buck up, you have a beautiful baby. You should be happy.” But I couldn’t control the crying, I hated being a mother, and I found no enjoyment in anything. Besides, I was caring for a very sick infant who almost didn’t make it. So I tried everything to be happy: positive self-talk, exercise, prayer, sunshine. Nothing worked. I just wanted the pain to go away.

At nine weeks postpartum I contemplated suicide with a bottle of Vicodin in hand. On the phone our midwife told my husband to take me to Good Samaritan Hospital, where, in the emergency room, a psyche nurse said I was suffering from postpartum depression (PPD). I was admitted to the mental health department and stayed there for three days and nights, among drug addicts and schizophrenics, and sadly, away from my baby.

My new doctor, a psychiatrist, became my best friend and my worst enemy at the same time. I was relieved to know that anti-depressant medication would help me feel better, but I could not come to terms with needing a “shrink.” Besides, how could a man understand how I was feeling? Well ... the education ensued. From him I learned about perinatal body chemistry, genetics and family history, social and environmental factors, the value of talk therapy support groups, and that there’s no reason to fear psychotropic drugs. I learned that depression is a multi-faceted illness that requires combination treatment. Perhaps most important, I learned that I did nothing to cause my PPD, and that it is a temporary condition.

It took a while for all of this to sink in, but when it did, I knew I had to speak openly about my experience and attempt to do some public education. My goal, albeit challenging: Quash the stigma surrounding postpartum depression and demystify the illness.

Having been a newspaper reporter and editor for nearly 10 years, I knew that tapping the press was a great place to start. In September 1997, I published a first-person account of what I experienced in Bay Area Baby magazine. In December 1997, I was a source for a cover story on PPD in the Cupertino Courier and Sunnyvale Sun weeklies.

Additionally, I have been a guest speaker at three conferences on the subject and continue to co-facilitate PPD support group meetings. In 1997, I became a member of Postpartum Support International to keep informed of PPD research around the world. In 2001, I became the President for the Northern California chapter of the Postpartum Health Alliance (PHA), which aims to educate health professionals and laypersons and promote support mechanisms on local levels. In March 1999, I and another PHA officer, with Family Service Mid-Peninsula, co-launched the Bay Area Postpartum Hotline, a telephone support program specifically for postpartum mood disorders. I am among the hotline volunteers, and I am proud to say that we’ve helped dozens of women and their partners cope with this emotional trauma and get a proper referral.

In Fall 1999, I began my graduate studies at San José State University, pursuing a Master of Public Health (MPH) degree with specialization in postpartum mood disorders. After graduation, I hope to continue my efforts to educate the public and healthcare providers alike, from conducting workshops to facilitating online support via Yahoo.

Thanks for reading!

Shelley P. Ash



References

BOOKS

Dunnewold, A. & Sanford, D. (1994). Postpartum Survival Guide. New Harbinger Publications, Oakland, Calif.
Dunnewold, A. (1997). Evaluation and Treatment of Postpartum Emotional Disorders. Steerforth Press, South Royalton, Vt.
Katon, W. (1994). Panic Disorder in the Medical Setting. National Institute of Mental Health, NIH publication no. 94-3482.
Kleiman, K. & Raskin, V. (1994). This Isn’t What I Expected. Bantam Books. La Leche League International. The Breastfeeding Answer Book: Revised Edition.
National Institute of Mental Health (1995). The Neuroscience of Mental Health II: A Report on Neuroscience Research. Status and Potential for Mental Health and Mental Illness. NIH publication no. 95-4000.
Misri, S. (1995). Shouldn’t I Be Happy: Emotional Problems of Pregnant and Postpartum Women. Simon and Schuster.
Raskin, V. (1997). When Words Are Not Enough: The Women’s Prescription for Depression and Anxiety. Broadway Books.
Roan, S. (1997). Postpartum Depression: Every Woman’s Guide to Diagnosis, Treatment and Prevention.
Sebastian, L. (1998). Overcoming Postpartum Depression & Anxiety. Addicus Books.
Todd, L. (1987). Labor & Birth: A Guide for You. International Childbirth Education Association (ICEA).

VIDEOS

Driscoll, J. (1993). “Fragile Beginnings: Postpartum Mood and Anxiety Disorders.” InJoy Productions, 1-800-326-2082.

BOOKLETS, BROCHURES AND PAMPHLETS

Agency for Health Care Policy and Research (1993). “Depression Is A Treatable Illness: A Patient’s Guide” patient education booklet/publication no. AHCPR 93-0553.
American College of Obstetricians and Gynecologists. “Postpartum Depression” patient education pamphlet AP091.
American Massage Therapy Association. “Enhancing Your Health With Therapeutic Massage” patient education pamphlet 40030/30M698.
The Learning Curve (1996). “Breaking the Silence, Depression After Childbirth,” 1-800-795-9295.
MBL Communications and SmithKline Beechman Pharmaceuticals (1998) “Psychotropic Drug Interactions,” pocket reference for healthcare professionals, Vol. 5, No. 9.
National Institute of Mental Health (1996). “Medications” patient education booklet, NIH publication no. 95-3929.
National Institute of Mental Health (1996). “Obsessive-Compulsive Disorder” patient education booklet/NIH publication no. 96-3755.
National Institute of Mental Health (1995). “Panic Disorder” patient education brochure/NIH publication no. 95-3508.
National Institute of Mental Health (1996). “Understanding Panic Disorder” patient education booklet/NIH publication no. 95-3508.
National Institute of Mental Health. “Getting Treatment for Panic Disorder” patient education brochure/NIH publication no. 94-3641.
National Mental Health Association. “Depression: What You Need to Know,” a patient education booklet.

CONFERENCES

Postpartum Health Alliance of Northern California (July 2000), “Postpartum Mood Disorders: Assessment and Treatment,” Walnut Creek, Calif. Featured speakers: Shoshana Bennett, Ph.D., MFT; Jane Honikman, M.S.; Pec Indman, Ed.D., MFT; and Dennis Plesons, M.D.
Parenting Project of the Napa Valley (Sept. 1997), “Beyond Baby Blues: Postpartum Depression & Other Mood Disorders,” Napa, Calif. Featured speakers: Jeanne Watson Driscoll, M.S., R.N., C.S.; Deborah Sichel, M.D.; Edward Tronick, PhD.; and Jane Honikman, M.S.

JOURNAL ARTICLES

Affonso, D. “Postpartum depression: A nursing perspective on women’s health and behaviors,” IMAGE: Journal of Nursing Scholarship, Vol. 24, No. 3, Fall 1992.
Affonso, D., Lovett, S., Paul, S. & Sheptak, S. “A standardized interview that differentiates pregnancy and postpartum symptoms from perinatal clinical depression,” Birth, Vol. 17, No. 3, September 1990.
Associated Press, “Brain ‘pacemaker’ found to fight depression,” San Francisco Chronicle, Oct. 12, 1999, page A2.
Beck, C. “The lived experience of postpartum depression: A phenomenological study,” Nursing Research, Vol. 41., No. 3, May/June 1992.
Beck, C. “A checklist to identify women at risk for developing postpartum depression,” JOGNN, Vol. 27, January/February 1998.
Cahill, C. “Differences in cortisol, a stress hormone, in women with turmoil-type premenstrual symptoms,” Nursing Research, Vol. 47, No. 5, September/October 1998.
Cooper, P.J. et al. “Post-partum depression and the mother-infant relationship in a South African peri-urban settlement,” British Journal of Psychiatry, Vol. 175, December 1999.
Cox, J., Murray, D. & Chapman, G. “A controlled study of the onset, duration, and prevalence of postnatal depression,” British Journal of Psychiatry, Vol. 163, 1993.
Cox, J., Holden, J.M. & Sagovsky, R. “Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale,” British Journal of Psychiatry, Vol. 150, 1987.
Duckett, L., Henly, S., Avery, M. et al. “A theory of planned behavior-based structural model for breast-feeding,” Nursing Research, Vol. 47, No. 6, November/December 1998.
Gennaro, S., Fehder, W., York, R. & Douglas, S. “Weight, nutrition, and immune status in postpartal women,” Nursing Research, Vol. 46, No. 1, January/February 1997.
Hall, L., Sachs, B. & Rayens, M. “Mothers’ potential for child abuse: The roles of childhood abuse and social resources,” Nursing Research, Vol. 47, No. 2, March/April 1998.
Lamberg, L. “Safety of antidepressant use in pregnant and nursing women,” JAMA, Vol. 282, No. 3, July 21, 1999.
Martell, L. “Postpartum depression as a family problem,” MCN (American Journal of Maternal/Child Nursing), Vol. 15, March/April 1990.
McIntosh, J. “Postpartum depression: Women’s help-seeking behaviour and perceptions of cause,” Journal of Advanced Nursing, Vol. 18, 1993.
NICHD Early Child Care Research Network “Chronicity of maternal depressive symptoms, maternal sensitivity, and child functioning at 36 months,” Developmental Psychology, Vol. 35, No. 5, March 1999.
Nicolson, P. “Understanding postnatal depression: A mother-centred approach,” Journal of Advanced Nursing, Vol. 15, 1990.
OBGYN.net (1999) “The Female Patient: Postpartum Depression,” www.obgyn.net/english/pubs/features/tfp/leopold.htm.
Pearce, P. “Postpartum depression: More than “the blues,” Canadian Journal of CME, February 1997.
Pearlstein, T. “Hormones and depression: What are the facts about premenstrual syndrome, menopause, and hormone replacement therapy?” American Journal of Obstetrics and Gynecology, Vol. 173, No. 2, August 1995.
Pearlstein, T., Rosen, K. & Stone, A. “Mood disorders and Menopause,” Endocrinology and Metabolism Clinics of North America, Vol. 26, No. 2, June 1997.
Riordan, J. “Predicting breastfeeding problems,” AWHONN Lifelines, Vol. 2, Issue 6, December 1998.
Rothschild, A. “Advances in the management of depression: Implications for the obstetrician/gynecologist,” American Journal of Obstetrics and Gynecology, Vol. 173, No. 2, August 1995.
Ryan, J. & King, M. “Scanning for violence: Educational strategies for helping abused women,” AWHONN Lifelines, Vol. 2, Issue 3, June 1998.
Sichel, D., Cohen, L. & Robertson, L. et al. “Prophylactic estrogen in recurrent postpartum affective disorder,” Biological Psychiatry, Vol. 38, 1995.
Sichel, D., Cohen, L. Rosenbaum, J. & Driscoll, J. “Postpartum onset of obsessive-compulsive disorder,” Psychosomatics, Vol. 34, No. 3, May/June 1993.
Stowe, Z. & Nemeroff, C. “Women and depression: Who is at risk?” and “Women at risk for postpartum-onset major depression,” recap of the ACOG symposium held May 10, 1994 in Orlando, Fla., American Journal of Obstetrics and Gynecology, Vol. 173, No. 2, August 1995.
Suri, R. & Burt, V. “Coping with postpartum depression,” Journal of Practicing Psychiatry and Behavioral Health, March 1997.
Susman, V. & Katz, J. “Weaning and depression: Another postpartum complication,” American Journal of Psychiatry, Vol. 145, No. 4, April 1988.
Unterman, R., Posner, N. & Williams, K. “Postpartum depressive disorders: Changing trends,” Birth, Vol. 17, No. 3, September 1990.
Wood, A., Thomas, S., Droppleman, P. & Meighan, M. “The downward spiral of postpartum depression,” MCN (American Journal of Maternal/Child Nursing), Vol. 22, November/December 1997.
Zuckerman, B. & Beardslee, W. “Maternal depression: A concern for pediatricians,” Pediatrics, Vol. 79, No. 1, January 1987.

PEOPLE

Shoshana Bennett, Ph.D., MFT: (San Ramon, Calif.)
Nancy Facher, LCSW, MPH: (Fremont, Calif.)
Christine Hagion Rzepka, CHES: (San Jose, Calif.)
Jane Honikman, M.S.: (Santa Barbara, Calif.)
Pec Indman, Ed.D., MFT: (San Jose, Calif.)
Dennis Plesons, M.D.: (Santa Barbara, Calif.)
Jay Tanenbaum, M.D.: (Milpitas, Calif.)
Shirley VanLieu, Ph.D.: (Pebble Beach, Calif.)

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