When a friend says postpartum depression is normal, I get disappointed.
When a psychologist says postpartum depression is normal, I get worried.
When a New York Times best selling author and former U.S. congressional candidate with hundreds of thousands of followers says that postpartum depression is normal, I get livid.
It's one thing to be misinformed about postpartum depression, it's quite another to be educated and yet still come to the wrong conclusion.
But then I take a deep breath, meditate, pray, practice some yoga, down my SSRI with a delicious blueberry smoothie and decide to cut them all some slack. I get to writing because I remember that postpartum depression isn't normal, it's complicated, and my keyboard is my greatest weapon.
That said, though it's getting better, the media isn't much help. We often only hear about extreme postpartum psychosis and infanticide cases. A research article published in Issues in Mental Health Nursing concluded that popular press magazines contained "contradictory information about the definition, prevalence, onset, duration, symptoms and treatment of postpartum mood disorders."
A Canadian study on community awareness of postpartum depression found that "awareness of the term postpartum depression does not necessarily imply awareness of its symptoms" and that "public education is needed to address this fact in order to provide social support and encourage treatment for symptomatic women and their families."
Yet another study points to primary health caregivers' lack of awareness of postpartum depression as a major problem.
"It's a societal issue," says Kate Kripke, a licensed clinical social worker and founder of the Postpartum Wellness Center of Boulder, Colorado.
That's why we need to keep talking about it. Mothers need to keep telling their stories. Researchers need to keep sharing their findings. Advocates need to keep fighting.
And I need to keep blogging.
We have to get the truth out about postpartum depression.
Because women and men are suffering.
And so are their children.
"There is no simple answer to this," says Kate. "It is so confusing even to those who specialize in the field of maternal mental health."
The confusion over postpartum depression is causing clashes between postpartum depression debunkers and retaliating warrior moms on the battlefield of social media instead of a safe haven for women and men to be able to share their experiences and obtain factual information as well as emotional support.
"I think this really unfortunate thing is happening where we're kind of at war with each other," says Kate. "It's this ongoing debate which is so sad because everyone is talking about the same thing."
In a statement following her comments which enraged the postpartum depression community, Marianne Williamson continued to defend her stance: "While not all would agree with my position, I would hope that we -- particularly women -- could honorably debate issues without excoriating someone's character over a difference of opinion."
"It's a dangerous statement," says Kate. "We are setting women up for months and sometimes years of illness which then can impact the health and safety of children. The more we can get real, educated information out there statements like hers become less problematic."
Kate started her center in an effort to bring "skilled and appropriate perinatal mental health support" to women and families around Boulder County. She travels to hospitals and trains obstetricians, pediatricians, doulas and nurses on the difference between normal postpartum adjustment and postpartum mood and anxiety disorders.
"Clinical depression and anxiety are not a normal part of the maternal process of the postpartum period," says Kate. "There are extreme hormonal shifts that impact brain chemistry and some women are more prone to those shifts in hormones affecting brain chemistry than others."
About 80 per cent of mothers feel sad, worried, irritable and anxious two to three weeks after giving birth. That's what's called having the "baby blues." It's when those feelings last longer that it could be a sign of postpartum depression.
But it's not that simple.
About 20 per cent of women will suffer from a diagnosable postpartum mood or anxiety disorder which comes in many forms.
And many mothers with postpartum depression aren't depressed at all.
"Postpartum mood and anxiety disorders include a range of mental health issues that can occur any time in the first 12 months postpartum," says Kate.
And they are:
- Postpartum Depression
- Postpartum anxiety
- Postpartum panic disorder
- Postpartum post-traumatic stress disorder
- Postpartum obsessive compulsive disorder; and
- Postpartum psychosis
And there's more.
Karen Kleiman, author of This Isn't What I Expected: Overcoming Postpartum Depression, coined the term "postpartum stress syndrome" (PSS). Adjustment disorder or PSS includes mothers who are struggling more than expected and who do not fit the criteria for a postpartum mood disorders.
PSS is most common in mothers who are experiencing high levels of external stress, such as those who have had a difficult birth, have relationship challenges or who are caring for a sick newborn.
"Without appropriate support, PSS will often lead to postpartum depression," says Kate.
For that reason and more including better screening techniques and treatment planning, it's vital to make the distinction between what's normal and not in the postpartum period.
But until there's a blood test that can clinically diagnose postpartum depression, health care providers must rely on a mother's interpretation of her own experience as to whether what she is experiencing is normal or not.
"What I really encourage women to do is just listen to themselves and to trust themselves, and if they are worried about how they're feeling, then speak up to a well-trained professional," says Kate. "Baby step by baby step we're getting there. But it's going to take an army."
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The sudden drop of estrogen and progesterone following labour may play a role in the onset of PPD. According to the authors of a 2012 Swedish study, “downregulation of endogenous hormon production in women with PPD history elicits depressive symptoms in more than 60% of cases.” Hypoestrogenism, as it’s called, has also been shown to cause depressive symptoms at other times of a woman’s life. However, there are other studies which challenge this concept and more research is needed.
A number of studies have shown that women with PPD have hypoactivation of the hypothalamic-pituitary-adrenal axis (HPA). The HPA axis controls your reaction to stress and women with PPD have have higher levels of corticotropin-releasing-hormone (CRH), better known as the cortisol, the stress hormone which is released by the HPA axis.
Though it’s not yet known why, research is showing that “failed or discontinued lactation” is associated with the onset of PPD symptoms and that it could have something to do with the feel good hormone, oxytocin, that’s released during milk let-down.
Women with PPD have been found to have lower tryptophan and serotonin levels. Tryptophan is an amino acid and serotonin is a neurotransmitter. Both work together to reduce anxiety and alleviate stress. It’s not known why women with PPD have lower levels of tryptophan and serotonin and researchers are looking into genetics as a possible reason.
Women with PPD reportedly have lower brain-derived neurotrophic factor (BDNF) levels. BDNF works with serotonin, the feel good neurotransmitter, also known to be low in women with PPD. Authors of a 2012 Swedish paper report that “PPD is likely to be the results of an interaction effect between hormonal changes and these brain neurotransmitter systems.”
Our circadian rhythm is our body clock which tells us when it’s time to sleep and when it's time to be awake and alert. Melatonin, the sleepy hormone, is involved in this process. While melatonin levels should be highest in the evening, it’s been shown that women with PPD have significantly higher melatonin levels in the morning suggesting their circadian rhythm is out of whack. Of course this makes sense as new mothers often go hand in hand with a lack of sleep as their care for their babies but researchers note that it’s important to consider that insomnia can also be the consequence as well as a cause of depression.
Many people with depression experience a worsening of their symptoms during the fall and winter months. This is known as Seasonal Affective Disorder (SAD) and is more common among women. Some studies have shown that women who give birth in the fall or winter have an increased rate of PPD than women who give birth in spring or summer. It’s also been reported that there’s a “significantly higher risk” for PPD symptoms to present themselves at six weeks or six months postpartum in women who have given birth in the months from September-December.
Lower vitamin D levels have been found in postpartum women compared with pregnant women and women with mood disorders have been shown to have a vitamin D deficiency. Researchers are wondering whether nutritional habits may play a role.
It’s thought that perhaps some women suffering from PPD are actually suffering from a psycho-neuro-immunological disorder in which their inflammatory response to labour has been exaggerated. Studies show that inflammation can produce anxious and depressive symptoms.
Women with the baby blues have been shown to have higher thyroid-stimulating-hormone (TSH) levels. Women with higher TSH levels tend to have higher depression scores at four weeks postpartum. Women in a study who reported PPD symptoms six months postpartum also had hypothyroidism at the time of delivery.