Postpartum Mood Disorders

Myths of Motherhood

Modern American society has fostered many “myths of motherhood” that play a major role in the development of Postpartum Mood Disorders (PPMD). These myths greatly influence a woman’s expectations of having a baby and how she will fulfill her role as a mother.

These myths include:
- The myth of “happy motherhood,” which indicates that mothers should feel happy when a new
baby arrives.
- The myth of having an intuitive mothering capability immediately after the baby is born.
- The myth of unremitting motherly love for the new child.
- The myth of the “perfect baby.”
- The myth that fathers will be equally involved in parenting the child.
- The myth of the “perfect mother.”

For many women, after the baby is born these expectations are met with feelings of depression or anxiety that can lead to extreme feelings of guilt and shame.

The Postpartum Period

In pregnancy, reproductive hormone levels in a woman’s body are 20-30 times greater than normal. At delivery, hormone levels drop abruptly, along with changes in amino acids, neurotransmitters, and thyroid hormones. The sudden drop in estrogen, progesterone, endorphins, and other hormones may trigger depression the same way moodiness may be triggered by premenstrual changes in these hormones.

Thyroid levels may also drop sharply after birth. A new mother may develop a thyroid deficiency that can produce symptoms that mimic depression. (It is always recommended that a woman have a thorough physical examination for this reason).

Many women feel exhausted after labor and delivery and may need a long time to fully recover. Cesarean births require an even longer recovery. New mothers rarely get adequate rest. In the hospital, they are awakened by nurses and the baby’s feedings. At home, feedings continue every 2-4 hours, around the clock, along with usual household tasks.

This extreme lack of sleep continues for weeks and months and can be a major reason for depression. Babies who are born prematurely or with a birth defect may present the new mother with even more stress and the overwhelming realization that her baby is not the “perfect” being she had envisioned.

Other tasks which may pose a stress on a new mother include:
- establishing successful breast/bottle-feeding
- coping with sleep deprivation
- forming an attachment to the child
- re-negotiating family relationships and responsibilities
- giving up the fantasy of what the baby would look like or be like
- facing whether or not one is an adequate parent
- one must also effectively integrate all these new experiences.

Feelings of loss are very common after childbirth. These “losses” include:
- loss of freedom
- feeling tied down
- loss of an old identity
- loss of control
- loss of a slim figure
- loss of a sense of attractiveness

Since motherhood is typically viewed as a “happy time” and childbirth is seen as an event from which a woman should “bounce back” within a few days, many women experience a lack of understanding and/or support from those around them. Mothers need significant coping skills to deal with so many new challenges.

Four aspects of the postpartum period which demand significant coping abilities are:
1) the physical adjustment
2) initial insecurities about one’s ability to parent
3) relying on support systems for tasks that one feels she “should” do
4) loss of a previous identity as one who is taken care of and the birth of a new identity as the
caretaker.

The “Baby Blues"

- Occurs in 75-80% of new mothers.
- The “Baby Blues” is described as mild depression interspersed with happier feelings, or as some women state, it is “an emotional roller-coaster.”
- Onset is usually 2-3 days postpartum, with a peak around 7-10 days.
- Symptoms may include:
- Fatigue/Exhaustion
- Feelings of sadness
- Crying spells
- Anxiety
- Mood swings/Irritability
- Confusion
- Feeling overwhelmed
- Inability to cope
- Feelings of loneliness
- Causes of the “Baby Blues”: include biological factors (drop in hormone levels), social/environmental factors (marital stress, lack of support system, low SES), stress, and sleep deprivation, in addition to the physical aftermath of labor and delivery. First-time moms are at a higher risk of experiencing the “Baby Blues.” The “Baby Blues” typically does not require professional treatment and should subside within two weeks after delivery.
- Treatments include: validation of the existence of the phenomenon, labeling it as real but a normal adjustment reaction, assistance with self/infant care, and family support.

Postpartum Depression

- If the “Baby Blues” persist for two weeks or longer and/or if symptoms of the blues intensify, it is then considered to be a “Postpartum Depression” (PPD).
- 10-20% of postpartum women will experience PPD.
- Onset of PPD can be anytime during the first year after delivery, with the highest incidence of onset between 4 and 8 weeks postpartum.
- PPD may last from 3 to 14 months or longer, if left untreated.
- Though most women recover within a year, the condition may become chronic if it goes untreated. Chronic depression may have significant effects on mother-baby attachment and bonding.
- Symptoms of PPD include:
- Sadness
- Frequent crying
- Insomnia
- Appetite changes
- Difficulty concentrating/making decisions
- Feelings of worthlessness
- Racing thoughts
- Agitation and/or persistent anxiety
- Anger, fear, and/or feelings of guilt
- Obsessive thoughts of inadequacy as a person/parent
- Lack of interest in usual activities
- Feeling a loss of control
- Feeling disconnected from the baby
- Possible suicidal thoughts
- Although most symptoms of PPD are similar to those in a Major Depressive Disorder, many symtoms are unique to PPD, including feelings of anger, fear, or extreme feelings of guilt, obsessive thoughts of inadequacy as a parent, extreme exhaustion yet difficulty sleeping, agitation, feelings of disconnection from the baby, and feeling a loss of control over one’s life.
- Risk factors for PPD include: 1) First-time motherhood, 2) ambivalence about keeping the pregnancy, 3) history of PPD, bipolar, or another mood disorder, 4) lack of social support, 5) lack of stable relationship with partner and/or parents, 6) woman’s dissatisfaction with herself, 7) history of infertility, 8) unrealistic expectations of parenthood, 9) recent stressful event, 10) previous aversive reaction to oral contraceptives or severe PMS.
- Causes of PPD include: 1) Biological/physiological factors (genetic predisposition, hormone-related, severity of physical damage from labor and delivery), 2) environmental factors (stress, feeling alone, lack of support), 3) psychological factors (things that affect a woman’s self-esteem and the way she copes with stress), or 4) infant-related factors (infants with difficult temperament or colic, infants born with problems). **Most likely it is a combination of all of these.**
- Treatments include: 1) individual and/or couple’s therapy, 2) group therapy or support groups, 3) psychotropic medications, 4) practical assistance with child care/other demands of daily life.
- If a woman experiences PPD, her chances of PPD with subsequent children are 10-50%.

Postpartum Anxiety Disorders

- Postpartum Anxiety Disorders are common, yet are diagnosed far less than the others because of the belief that new mothers are just naturally anxious.
- There are two forms of Postpartum Anxiety Disorders.

Postpartum Panic Disorder

- Occurs in up to 10% of postpartum women.
- Symptoms include: feelings of extreme anxiety and recurring panic attacks, including shortness of breath, chest pain, heart palpitations, agitation, and excessive worry or fears.
- Three common fears experienced by women with a Postpartum Panic Disorder are: 1) fear of dying, 2) fear of losing control, and/or 3) fear that one is going crazy.
- 2 significant risk factors: 1) a previous history of anxiety or panic disorder, and 2) thyroid dysfunction.

Postpartum Obsessive-Compulsive Disorder

- Occurs in up to 10% of postpartum women.
- Symptoms include: presence of both repetitive obsessions (intrusive and persistent thoughts or mental images) and compulsions (repetitive behaviors performed with the intention of reducing the obsessions), as well as a sense of horror about these thoughts.
- The most common obsession is thoughts or mental images of harming or even killing one’s own baby. - The most frequent compulsion is bathing the baby often or changing the child’s clothes.
- Postpartum Obsessive-Compulsive Disorder is the most under-reported and under-treated disorder of childbirth, since these symptoms are horrifying or embarrassing to the mother and she may fear that others will think she is a risk to her child.
- It is important to note that, unlike Postpartum Psychosis, these mothers know their thoughts are bizarre and are highly unlikely to ever indulge in the imagined behaviors.
- Risk factors include: history of Obsessive-Compulsive Disorder and/or negative feelings about motherhood resulting from unrealistic expectations.
- Treatments for both Postpartum Panic and Obsessive-Compulsive Disorders include: 1) individual therapy (cognitive-behavioral is recommended) with, 2) psychotropic medications, also 3) couple’s therapy, 4) group therapy/support groups, and 5) practical assistance with child care and/or demands of life.

Postpartum Psychosis

- Occurs in 1-2 of every 1,000 births.
- Onset is usually within the first two weeks-three months.
- Symptoms include:
- Acute onset of psychotic symptoms including
- Delusions and/or hallucinations
- Extreme agitation
- Hyperactivity
- Insomnia
- Mood lability
- Confusion/poor judgment
- Irrationality
- Difficulty remembering/concentrating
- Risk factors include:
1) previous postpartum psychosis;
2) manic-depressive (bipolar) history;
3) prenatal stressors (lack of supportive partner, social support, low socioeconomic status)
4) obsessive personality traits;
5) family history of mood disorder.
- Treatments include: 1) hospitalization with 2) antipsychotic medication (lithium, when indicated) and 3) temporary removal of infant from mother’s care, also 4) sedatives, 5) electroconvulsive therapy, 6) psychotherapy, and 7) social support.
- There is a 10% rate of suicide/infanticide associated with this disorder. Thus, immediate treatment is imperative.
- Women are 20-30 times more likely to be hospitalized for a psychotic episode in the first 30 days after delivery than at any other time in their life.
- Women with a history of bipolar illness have a 40% chance of developing Postpartum Psychosis after their first child is born.
- Almost all women with previous episodes of Postpartum Psychosis will experience repeat episodes in subsequent pregnancies. Preparing for this ahead of time is key.

Effects of Postpartum Mood Disorders on the Couple’s Relationship

When a woman has a Postpartum Mood Disorder (PPMD), she, her partner, and the entire family system may suffer. Due to the extreme stress of having a baby, the first year postpartum has the highest rate of divorce than at any other time during a marriage. Conversely, the most cited non-biological cause of PPMD is marital/relationship problems.

Typically the woman feels very overwhelmed and may feel that her partner is not very helpful, even if he is trying his best to be understanding and/or helpful. Because PPMD can have such a debilitating effect on the woman, the man is often left with the burden of caring for his new baby, his wife, the household, and himself.

When Your Wife/Partner Has a PPMD

What He May Be Feeling
- He may feel:
- “Pulled” between the demands of work and home
- He can’t do anything right
- His efforts go unnoticed by her
- He is taking on the role of the “mother”
- He may fear his wife will never be the same
- He may feel angry that his wife is not “pulling her weight” at home
- He wants to “fix” this problem and is frustrated because there is no apparent solution

What Can He Do?
- Take time to learn all you can about postpartum mood disorders in order to understand what she is experiencing.
- Let her know that you recognize that she is not making up her symptoms and that this is not her fault.
- Let her know that you love her, support her, and are there for her.
- Help with the care of the baby as much as you are able, allowing time for your wife to take naps or sleep during the night.
- Enlist family, friends, and/or the community to help with care of the baby, household, other children, and/or meals in order to provide your wife with time to care for herself.
- Let her know that you understand she may not be interested in sex and that you love her and enjoy holding her.
- Be sure to take some time for yourself and encourage your wife to do the same.
- Help her monitor her symptoms and seek out professional help when needed.
- Remember that this is 100% treatable and she will be well.

Advice For New Mothers

- Postpartum Support International lists three important messages that new mothers who are experiencing a postpartum mood disorder need to hear.

They are:
1) You are not alone.
2) You are not to blame.
3) You will be well (this is treatable).

What Can You Do?
- Rest is extremely important. Sleep when the baby sleeps, or get someone to help care for the baby while you nap.
- Give yourself permission to do less. Allow others to help with household chores and other daily tasks. Don’t try to overdo it.
- Shower and dress each day. This will help keep your spirits up.
- Get out of the house or take some “me” time each day. This is extremely important in helping you keep yourself mentall well.
- Be sure to monitor your nutrition habits and water intake in order to keep your body healthy and full of energy.
- Exercise (after your doctor gives you the “ok”) is an extremely important tool in helping you feel healthier and stronger both physically and emotionally. Even going for a short walk can help.
- Talk about your feelings with your partner, a friend, or family member. Find others who have experienced motherhood and use them as a support system.
- Join a postpartum support group or mother’s group where you can talk with others who are sympathetic to your situation.
- Be specific about how your husband and/or others can help you. Assign specific tasks and don’t allow yourself to feel guilty.
- Remember that your husband and other loved ones are going through this too. Try to appreciate the efforts they are making.
- If your “baby blues” don’t go away within two weeks, if your symptoms are intensifying, or if you are having suicidal thoughts, seek professional help in order to obtain therapy and medications when needed.
- Remember that becoming a mother is a life-altering event that takes time to completely understand and get used to. Don’t give up!

Resources

Postpartum Support International (PSI):
- National hotline, with referrals in your area and resources available.
6706 SW 54th Avenue, Portland, Oregon 97219, USA
Hotline: (800) 944-4773
Text: (503) 894-9453
Website: www.postpartum.net

Postpartum Support - Arizona (PSAz):
- Local chapter of PSI, Warmline with referrals and resources in the state of Arizona.
Warmline: (888) 434-6667
Email: azwarmline@gmail.com

National Suicide Prevention Hotline:
Telephone: (800) 273-8255

Recommended Reading:
- Kleiman, K.R., & Raskin, V.D. (1994). This Isn’t What I Expected: Overcoming Postpartum Depression. New York, NY: Bantam Books.
- Kleiman, K. (2000). The Postpartum Husband: Practical Solutions for Living with Postpartum Depression. Xlibiris Corporation.
- Sebastian, L. (1998). Overcoming Postpartum Depression and Anxiety. Omaha, Nebraska: Addicus Books.

**Information for this handout was obtained from training seminars by Postpartum Health Alliance as well as from the doctoral dissertation research of the author.