My mother groaned!
My father wept.
Into the dangerous world I leapt:
Helpless, naked, piping loud;
Like a fiend hid in a cloud.

–William Blake, Infant Sorrow

Postpartum Depression

Just as the ordeals of pregnancy and labour are over – right when a mother expects joy and blissful repose – there is an illness that not only feels dreadful but also impairs her ability to be the happy, adept, and loving carer she hoped to be.

With mood low, energy gone and thinking foggy, normal tasks suddenly seem impossible, let alone providing the expected perfect welcome to a demanding new arrival. The last thing needed by the exhausted survivor of life’s most demanding experience is an intrusive house guest, yet here they are, making urgent and untimely demands, and with every intention of staying. And when the best laid plans go awry, the mother often blames herself and feels like a failure, which only nourishes the tendrils of despair.

The Baby Blues

Postpartum depression is not the passing emotional disturbance commonly known as the Baby Blues. Starting a couple of days after childbirth, the Baby Blues shares many features of postpartum depression but with lower intensity. The new mother may feel sad, anxious, irritable, or overwhelmed, with frequent crying, poor concentration and little appetite, but the feelings are tolerable and resolve in a few weeks.

While the Baby Blues lie within the normal experience of childbirth, postpartum depression (PPD) is an entirely separate disorder. While PPD usually begins within four weeks of delivery, it may also appear up to a year afterwards, or even during the pregnancy itself. A clinician makes the diagnosis after identifying a clinically depressed mood and at least four of the following:

  • Anhedonia (lost pleasure or interest)
  • Insomnia (or hypersomnia)
  • Weight loss
  • Exhaustion
  • Agitation (or inertia)
  • Self-reproach (feeling worthless or overly guilty)
  • Impaired concentration and decision making
  • Thoughts of death or suicide

You might like to remember this by the acronym Waited Sad:

Weight
Anhedonia
Insomnia
Thoughts (morbid)
Exhaustion
Distraction
Self-reproach
Agitation
Depression

Simple observation of a mother and her baby often confirms the diagnosis, as well as pointing to its fallout. A depressed mother is emotionally shutdown and less attuned to her child’s attempts to communicate. Babies of depressed mothers eventually give up and sit in silence, or when distressed, resist efforts to soothe them. Friendly gestures from strangers also receive little response. Researchers have noticed that these babies resemble the animals in learned helplessness experiments which no longer make any effort to save themselves.

A Tight Psychological Unit

Mother and baby form a tight psychological unit where what affects one necessarily affects the other, thus postpartum depression strikes not only one person, but two. The timing could hardly be worse because the first few months are not only laden with exhaustion and long-nurtured hopes, but crucial for a child’s emotional development.

The brain has a narrow window when it forms the mental structures through which it will experience the world from that time on. When a mother is too depressed to provide close emotional interaction, this absence tends to become frozen into the adult personality – like the proverbial scowl staying in place when the wind changes. The child enters the world with no sense of self distinct from the wider world: instead, everything is a bewildering soup of sensation. Interaction with others, experiencing needs and having them satisfied, crying and receiving comfort, all these experience gradually crystallise the early tumult into mental models of self and other.

Without positive interaction, these internal schema can become infused with pain and anxiety, or more severely, have failed to fully form by the time the window closes. The result is a personality bent out of shape like a stunted tree, and healing only becomes more difficult with time. The suffering of depression is reason enough for action, but the danger of lifelong problems for the child makes it critical.

When Should I See a Doctor?

Postpartum depression may be picked up by maternal health nurses who are well-trained to spot it. If not, there are some signs that a mother can discern on her own:

  1. Symptoms worsening or lasting beyond two weeks
  2. Symptoms preventing baby care or everyday tasks
  3. Thoughts of harming herself or her baby

Number 3 especially calls for a prompt assessment.

A related condition that also needs urgent attention is postpartum psychosis. Rare but crucial not to miss, postpartum psychosis typically develops in the first week after delivery but may also emerge from severe postpartum depression.

The key features are typical psychotic symptoms such as paranoia, hallucinations, and delusions. Specific to the postpartum variety are intrusive morbid thoughts about the baby. These demand urgent care as they have been known to escalate to violence.

What Causes Postpartum Depression?

The association with childbirth indicates biological changes, yet varying rates between countries suggests that there is more to the story. Singapore reports PPD in 3% of mothers; while at the other of the scale is Chile, with 38%. The United States has a rate of around 10%, which is only slightly higher than depression before pregnancy (9%) or during (7%). The overall pattern suggests that pregnancy entails a buffer that disappears after birth, and the most likely element is hormonal change.

During pregnancy, blood levels of estrogen and progesterone surge around 50 times higher, which then plummet after childbirth. Just as menstrual hormonal fluctuations affect a woman’s moods, so too do these – but much more. Drastic hormonal changes help explain the Baby Blues, and why some mothers can become suddenly depressed even despite everything seeming to go so well.

Personal life factors are also involved. Along with the hormonal rollercoaster come more life duties, interrupted sleep, and a new reality which is not just another person, but the loss of a former life, even an identity. All new mothers face these challenges, but different genetics and personalities make some more vulnerable than others. Research studies have identified several elements that suggest where PPD may strike.

Postpartum Depression Predictors

Since the best predictor of the present is the past, major risk factors are previous PPD, another mood disorder, or a family history. Also implicated are pregnancy complications – including twins – and problems breast feeding. Then come external factors such as grief, relationship problems or financial worries.

As with any mental disorder, these risk factors tend to interact and amplify each other. For example, studies show that women with previous depression are more affected by hormone fluctuations. Throw in stress and poor sleep and defences may crumble, whereupon the illness takes on a life of its own. Yet we should keep in mind that risk factors offer no guarantee either way. Some mothers will have them all and be fine, others will suffer PPD like a bolt from the blue. Such are the vagaries of probability.

The vast gulf in cases between Chile and Singapore also indicate that cultural differences play a role. In fact, culture is such a profound influence that the illness can appear in a variety of unique ways depending on the setting. Some are so striking that debate continues over whether they should be considered the same illness at all.

One example is the Ugandan postpartum illness of “Amakiro”. Some features resemble the Western version, others are quite different, e.g. the traditional risk factor of maternal promiscuity during pregnancy, or the symptom of wanting to eat the baby.

Other colourful variations appear across regions where Western medicine is yet to take hold. The overall lesson is that postpartum depression is likely everywhere in different guises, with attempts to understand it interwoven with the surrounding culture.

Treatment of Postpartum Depression

Postpartum depression was known as far back Hippocrates, but treatment advanced little in the following 23 centuries. Bloodletting and opium were popular in the 19th century, and until recently doctors recommended separating the mother and her infant.

Charlotte Gillman’s short story, The Yellow Wallpaper, depicts a disturbed new mother secluded in a holiday house – the treatment of the time – who becomes ever more delusional as the story unfolds.

Treatment even went backwards in the years following Freud as doctors pursued theories such as frigid personalities, unresolved incestuous longings, and schizoid traits. After World War II, hospitals in Britain and Australia opened dedicated mother-and-baby units which are now the preferred therapeutic arena. Shortly afterwards came the pharmacological revolution headed by medications such as Prozac. For severe cases, especially when psychosis is involved, excellent results have achieved with electroconvulsive therapy.

Getting Help

Mothers with PPD can be caught in a toxic bind where even recognising the problem can feel like failure. Brooke Shields captured the problem in her autobiography:

Once upon a time, there was a little girl who dreamed of being a mommy. She wanted, more than anything, to have a child … one day, finally, she became pregnant. She was thrilled beyond belief. She had a wonderful pregnancy and a perfect baby girl. At long last, her dream of being a mommy had come true. But instead of being relieved and happy, all she could do was cry.

Making matters worse is the knowledge that early bonding is so important for the child’s development. Then there are fears that treatment could do more than good, such as by medications passing into breast milk, or needing to avoid breast feeding altogether.

Fortunately, treatment has vastly improved over time with several new options now available.