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Contrary to the popular belief that pregnancy is a biologically protective and emotionally joyful time, women are actually quite vulnerable to a spectrum of psychiatric disorders throughout the perinatal period - the time around pregnancy and postpartum. This range of disorders, more commonly referred to under the umbrella term of “postpartum depression”, is more accurately reflected by the terms postpartum or perinatal mood and anxiety disorders (PMADs). In fact, 1 in 7 women who become pregnant will experience a mental health disorder during the course of their pregnancy or in the postpartum period, making PMADs the most common complication of childbirth. Additionally, 50% of women diagnosed with PMADs postpartum had an onset of their symptoms during pregnancy.
As we have all sadly heard in the news recently, a mother of two daughters is facing murder charges for tossing her 7-month-old son off the roof of a parking garage in Southern California. And it is suspected that Lashanda Armstrong, who drowned herself in her three kids by driving her van into the Hudson River in April, was battling postpartum depression. Additionally, who could forget Andrea Yates, of Houston Texas, who drowned her five children in her bathtub. All are examples of women suffering from Postpartum disorders.
Unfortunately, approximately one-third of all pregnancies will end in some form of loss such as miscarriage, stillbirth or termination. Even when a woman does not bring home a baby, falling hormone levels coupled with the emotional sequela of loss may trigger PMADs. Additionally, these biochemical changes can be responsible for high levels of anxiety for up to six months after a pregnancy loss and place a woman at increased risk for both OCD and PTSD. It is important to mention that men are also vulnerable to depression and anxiety. Moreover, when there are birth complications or when a child is born with a birth defect, prematurely, put in neonatal intensive care, or given up for adoption, the added stress places her at increased risk for PMADs.
These types of pregnancy outcomes often fall into the category of “disenfranchised grief”- grief that is not fully acknowledged by society and for which there are few support systems, traditions, or institutions to help. Understandably, this can complicate a woman’s ability to grieve and to grieve with others close to her. Special attention must be paid when a woman with these types of pregnancy outcomes becomes pregnant again, as she may re-experience her anxieties and fears, and experience complicated emotions such as feeling guilty for feeling happy to be pregnant again.
Many women suffer silently after the birth of a baby, due to stigma, shame and fear. Studies reveal that women avoid seeking mental health treatment because they feel like “a bad mother”, fear their babies might be taken away from them because they are “crazy” or feel defective because they cannot do what should come “instinctually”. In addition, when women do seek help, their requests are met all too often with well-intentioned but poorly informed responses from family, friends and health care providers.
Barriers to Identification and Care
One of the primary reasons women’s symptoms are missed, even when they are reported, is that they are dismissed as a normal and natural consequence of childbirth. PMADs symptoms hide in plain sight. Everybody knows that new mothers (and fathers) are sleep-deprived. However, it is critical to distinguish between interrupted sleep which is characteristic of this period, from an inability to sleep even when given the opportunity. Sleep disturbance alone can place a woman at risk for developing PMADs.
For example, one female professional in 2003 reported to her obstetrician in the weeks following the birth of her baby that she was unable to sleep. She was told that she was “just too Type A and needed to learn to relax.” Her chronic sleep deprivation caused her to develop serious suicidal intent and resulted in two inpatient hospitalizations before she received an appropriate diagnosis and treatment. Another normal occurrence of postpartum adjustment are the “Baby Blues”, which are experienced by approximately 80% of women. Many women report fluctuating moods, tearfulness, and mild sadness or anxiety, etc. The “Blues” typically resolve on their own. However, if the symptoms persist for more than two weeks, or become severe, a woman should be evaluated for PMADs. Postpartum psychosis, a serious and rare condition, also reveals itself early in the postpartum period. It is characterized by symptoms such as hallucinations, delusions, and extreme agitation. It is a true clinical emergency and requires immediate medical attention. Left untreated it can have tragic consequences.
Another factor contributing to the misdiagnosis of these disorders is that the term “postpartum depression” does not necessarily reflect the primary symptom experienced. Research shows depression ranks 10th on the list of presenting symptoms. More prominent are the symptoms of anxiety, insomnia, irritability, and feeling a “loss of self”. Some report feeling like they are “going crazy”, have serious regrets about having the baby, experience ego dystonic disturbing thoughts about harm coming to the baby, or become suicidal believing that their families would be better off without them. It is imperative to evaluate postpartum women seeking treatment for suicidal ideation.
Additionally problematic, is that the DSM-IV-TR offers a limited symptom list. According to the DSM, only a woman who meets the criteria for a Major Depressive Disorder and who is four weeks postpartum, meets the criteria for MDD with postpartum onset. Actually, women are at risk for PMADs anytime during their pregnancy and through the first postpartum year.
Why Identification and Treatment of PMADs is Important
PMADs can have serious consequences for mothers, infants, children and families regardless of socioeconomic status, race or ethnicity. Untreated PMADs increases the risk of preterm delivery, can interfere with the mother/infant attachment, and can result in social, emotional, and behavioral difficulties in children.
Although the causes of PMADs are not fully understood, they are generally considered to be due to a confluence of biological, social and psychiatric stressors. PMADs are not always preventable, but they are highly responsive to treatment. And while, some episodes of PMADs resolve on their own, others can become chronic affecting the quality of family life and significantly contributing to marital friction and divorce. With an improved level of understanding, screening and integrated physical and mental health care women and their families can benefit not only from preventative efforts but also from early intervention, which can dramatically improve the course, severity and outcome of PMADs when they occur.