By Ruth L. Formosa Ventura, Systemic Psychotherapist and Couple & Familly Therapist, member of the WBP Executive Committee
Fact: Did you know that 1 in 10 women suffer with postnatal depression? Prevalence varies from 4.5 % to 28 % in onset, duration, and severity of symptoms mainly because of the range of measurement scales used, timing of intervention and follow-up.
Some support and solutions exist. These range from talking therapies to courses, self-help groups, yoga, meditation, and even some pharmaceutical treatments.
In this article – published today in honor of Maternal Mental Health Awareness Week, the focus is to facilitate a conversation on post-partum depression in the hope of making it easier for women to talk about such experiences. It brings into awareness women’s symptoms and challenges as well as provides alternative treatments and ways forward.
Postnatal Depression can happen to anyone
Symptoms: The most common symptoms of postnatal depression include a general lack of enthusiasm, sustained crying and intensive sadness, continuous self-doubt and guilt around not being able to show love to ones’ baby, anxiety about coping with this new role, lethargy, lack of sleep and loss of appetite, and a general sense that life is not worth living.
Postnatal mental health difficulties range from the manifestation of a variety of the above symptoms to depression, anxiety, psychosis and post-traumatic stress disorder. Postnatal anxiety and postnatal depression often co-exist. The average prevalence rate of postpartum depression is of 13%. Psychotic disorders during the postnatal period may be associated with previously experienced mental health issues.
Suffering in silence. Many mothers are unable to talk about the reality they are facing. Some are not even aware of what is happening, as it is something that invades them without any notice. Others are aware that something is changing, yet they find it extremely difficult to put words to their thoughts and feelings as they are supposedly experiencing a time where joy and happiness abounds. This is what women are socially constructed to believe: everyone expects them to be happy and to embrace the new life they created.
“I love my baby. My fear is that I do not have what it takes to show him that.”
In their review of qualitative studies with mothers experiencing postpartum depression, Knudson-Martin and Silversteinfound that the feeling of failing to be a “good mother” was a central experience reported in all studies.
“People think I do not love her. That is not true, I love her… I am afraid that I am going to harm her.”
Mothers who are already suffering from depression and anxiety tend to experience an increased intensity of symptoms, which is not necessarily detectable, and puts their mental health at higher risks.
Relating to their pain. Women walking out of hospitals or baby clinics with their new-born do so as mothers. This marks the beginning of a new phase. Mothers need help to take on this role and to grow into it. No course certifies an adequate parent. Parenting requires conscious effort and practice.
New mothers have to look after a baby whilst constantly doubting themselves and their actions. Everything they knew about themselves is changing fast. They cannot eat when they want to. They cannot rest when they want to, or be on their own if they feel it. A little creature depends on them day and night.
The baby becomes more important to them than looking after themselves. They do not realize they can take a time out or ask for help, partly because they believe they should be able to cope on their own. They feel overwhelmed with the constant fear and anxiety they carry around. Some mothers describe this as ‘a feeling of suffocation’.
To make it worse, they need to adjust to parents, relatives, and friends visiting, implying that they need to have energy for them too. Feelings of guilt, of not being able to feel or show gratitude for these people, might haunt them. The perfect, often unrealistic images of mothers with their babies in the media may add to the pressure they feel.
For women already parenting other children, the ´looking after oneself´ will be even more challenging.
How easy is it for mothers to ask for help?
Women feeling mentally vulnerable during and after pregnancy need to be listened to and given the relevant guidance and encouragement. Most women are not aware that they are going through low cycles of mood swings or that they have signs and symptoms of postpartum depression.
Mothers often share that they were given the opportunity to receive help and support, but they declined it. They felt they were already struggling to deal with “too much”. The idea that they have to find room to receive therapy or counselling sounds overwhelming.
We must inform and educate mothers about the possibility of mood swings, depressive tendencies, the overwhelming feeling that might accompany the arrival of a new-born at home, the self-doubt, and insecurity. Information about postpartum depression should be available for the whole family, especially partners and other close family members who may be the ones to identify the first signs of postpartum depression and encourage the new mother to get the support she needs.
This should come hand in hand with normalizing the act of reaching out for help or receiving counselling as part of the postpartum adjustment. Challenging the stigma related to postpartum depression will enable mothers to access support a bit more willingly when the need arises.
Who can help?
Midwives, perinatal nurses, consultant perinatal psychiatrists, midwife counsellors, doulas, psychotherapists, and family therapists as well as supportive partners, family, and friends are essential to the mother’s proper transition into this new lifecycle. In other words, we need a systemic approach to address postpartum mental health. Such a model understands and treats mother´s mental health in its totality – through the biological, physiological, psychological, and social components.
In their recommended approach to treatment decision making for postpartum depression Sit and Wisner conclude: “Effective decision making for the treatment of postpartum depression ideally occurs in a context that values a woman’s life experiences and her psychosocial environment, and must be a collaborative process between each patient and provider to be as successful as possible.”
Courses and self-help groups are also available, bringing mothers together to share their common experiences, offering guidance and tips on how to manage daily challenges. Other people’s stories about their own struggles are powerful human tools to access resources as well as in communicating understanding and compassion.
Today, mothers report finding yoga classes and meditation such as mindfulness practices very beneficial. These should not be underestimated, especially when we know that body and mind are interconnected.
There is actually a drug for postpartum depression. The story of its clinical development is an eye-opener, as they came up with a drug that works in women* just by studying the biology behind postpartum depression (which is sex specific) and its hormonal changes. As with other forms of depression, it is not a silver bullet, but it can help get a patient back on track.
Addressing pre-existing mental illness during and after pregnancy
Some mothers are already suffering from some kind of mental illness before they get pregnant. What happens when they have to stop medication because of pregnancy? What if they already struggle with self-confidence, self-efficacy, and adjusting to change? This puts an extra strain on their mental health. These risks need to be tended to and considered in their maternity adjustment plan.
Gynaecologists must work with the patient’s psychiatrists/psychologist/psychotherapist to jointly devise a treatment plan that caters both for the monitoring of the biological changes in the baby and mother as well as the psychological/therapeutic interventions needed to keep the mother, as much as possible, in a stable mental state.
Further research is needed
Postnatal health continues to be a relatively neglected as a topic for research and study. A survey conducted by the UK’s National Childbirth Trust showed that only half of the mothers thought they received adequate support and one quarter of the women reported no emotional support at all.
We must acknowledge the gap between evidence, policy, and practice if we want the care offered to pregnant women and new mothers to enhance their health and well-being.
WBP recognises that this topic is of major significance to women’s mental health. At their upcoming International Forum on Women´s Brain and Mental Health, a panel will be dedicated to this topic and will address different aspects of perinatal mental health including postnatal depression.
“I am a mother and I am vulnerable but I am capable
And I am doing the best that I can…”
*Comment by WBP: This drug was discovered because doctors focused on women and their specific biology during pregnancy. They noticed that a certain hormone (allopregnanolone) would be super-high in the last week of pregnancy, but drop dramatically after birth. Then they saw that the levels of this hormone inversely correlated with depression scores, and that mothers who got postpartum depression had the lowest levels. So, they manufactured a drug that mimics the action of this hormone to “rebalance” its levels. And it works (though it isn’t an absolute solution). It’s a wonderful example of how taking into consideration the exquisite female biology can result in sex specific drugs.