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Prepared for Postpartum

Understanding Postpartum Depression
By Kim Byrum Skinner

Dr. Cynthia Evans thought she understood the textbook ins and outs of postpartum depression. That is, until she became pregnant. A doctor and faculty member with The Ohio State University Medical Center's Department of Obstetrics and Gynecology, Dr. Evans playfully dismissed friends' postpartum warnings, believing, like most women, she could manage "life after baby" with a little mind-over-matter resolve, no prescriptions required. Well-informed as any new mother could be, she was, nonetheless, overwhelmed.

"The baby eats every two hours, literally around the clock, which means you're up, too, feeding the baby,” says Dr. Evans. “It's a real awakening. It's day after day without a break.”

Dr. Evans was confined to six months' bed rest with her daughter and later gave birth to a son prematurely. "I remember a good friend telling me that maternity leave was so much harder than being on call as a physician – lots tougher,” she says. “I laughed at her, too. But she was absolutely right.”

Dr. Evans found that the time after childbirth was much more difficult than she ever imagined. "It's such a misunderstood time,” she says. “There's this expectation that you have this bubbly little baby and should be happy, but the reality is, it's extremely hard work. The baby cries. It's completely needy. Your needs go to the bottom of the list. It gets trying, especially without any support. When people expect you to be happy all the time, that's hard. That's why, a lot of times, people don't admit this and just say they're doing fine."

A practicing physician for the past 13 years, Dr. Evans believes when it comes to PPD – a condition that affects roughly 10 to 30 percent of women – education and preparation are keys to a healthy transition. “People don't really talk about it, though,” she says. “People assume life is good. You've got this gorgeous baby. Everyone's approached you with, 'Isn't life wonderful?' But you haven't slept or showered in weeks. Your hormones have gone totally berserk, and you think you should be happy. People shouldn't be embarrassed to seek treatment. Ever."

Psychotherapist Kevin Malarkey, who launched his own Columbus, Ohio-based company, Life Strategies, couldn't agree more. After watching his wife, Beth, struggle with the birth of sons Alex and Aaron, Malarkey developed "Focus on the Parent," a two-part, informational course at Doctor's West Hospital. He also hit the lecture circuit with vigor and began penning workbooks and other educational materials to help a misinformed public steer clear. The couple's third child is on the way.

"Beth didn't even have postpartum depression, but I got to thinking about how hard it must be," he says. "My wife's real strong. She runs marathons – takes pain a lot better than I do. In fact, most women take pain a lot better than their husbands. That's not unique. But here she was, pregnant and sick. I saw how hard it was.”

Common PPD Myths
  • Anti-depressants passed through breast milk harm the baby. "There have been quite a number of published studies looking at mothers who breastfeed and take newer anti-depressants, and they offer encouraging results," says Dr. Steven Pariser, professor of clinical psychology and obstetrics and gynecology at The Ohio State University Medical Center. "Small quantities do pass on in the breast milk, but the conclusion can be reached that it's not a threatening or dangerous thing to do. Does that mean it's 100 percent safe to breastfeed and take anti-depressants? No. But a large number of women are doing so with no harm to their children. Each case needs to be looked at and discussed individually between a new mother and her physician."
  • Depression's all in your head. "People don't have the same acceptance of depressive illness as they have for diabetes, hypertension and hypothyroidism, and that's an unfortunate fact," Dr. Pariser explains.
  • It's safe to think, “I don't have PPD. This will pass.” "The leading misconceptions are: 1) that people don't have it or 2) that they have some kind of choice about having it," says psychotherapist Kevin Malarkey.
  • Parenting is natural – you should “just know” how to do it. "I had to do all kinds of things to learn how to drive a car but nothing to parent my child," Malarkey notes. "It's called 'parenting,' not 'childing.' The focus should be on the parent, but we put it on the kid. We sit around and analyze the kid when we should be analyzing ourselves."
  • PPD is under your control. "People think they're just 'having a problem or it's a sign they're a bad parent," Malarkey says. 'It's culturally unacceptable to feel bad after having a baby, and, yet, it's the most understandable thing in the world, given what the woman's been through."
  • Education and pre-screening can't help. "We tend not to pay to prevent things," Malarkey says. "We pay only when there's a mess to clean up. That's sad, and it's got to change."
  • Spouses can't really help. "It's wonderful if spouses help the new mother get help, not only professionally but at home," Dr. Pariser says. “That includes, when possible, attending visits to the treating physician. I've always welcomed partners who come in with a postpartum mother. I think it's very helpful for them to understand what's going on and be a part of the treatment – to avoid blame, be supportive and helpful with chores and ensure the new mother gets help."

According to Malarkey, women may feel particularly uncomfortable about PPD because of “conflicting cultural setups.”

A Treatable Condition
More severe than the transient, 10-day "baby blues," PPD can persist for months, even years. It's not only treatable, but common, exhibiting many of the same characteristics as clinical depression: prolonged sadness or irritability, loss of interest in usual activities, difficulty sleeping or sleeping too much, feelings of hopelessness, weight changes, fatigue and loss of concentration.

While PPD's specific triggers remain somewhat mysterious, many experts believe that dramatic hormonal shifts, genetics, prior history and increased stress are all major contributors. "Very little in terms of clinical, postpartum depression is the result of societal expectations," says Dr. Steven Pariser, professor of clinical psychology and obstetrics and gynecology at The Ohio State University Medical Center who directs both the Depression Research Program and Women's Depression Clinic. "At the same time, it's not helpful to a new mother to be feeling so poorly and have everyone around her dumbfounded by the fact that she isn't celebrating. Stress, financial or relationship issues, marital problems, job-related concerns – a lot of factors can make it worse, and we try to address them all."

So misinformed is the general public about this very common and treatable condition that Dr. Pariser fears the Andrea Yates case, in which the Texas woman was convicted of drowning her five children, pushed informational progress back at least a century. "She did not have postpartum depression," says Dr. Pariser. "She had something far worse – psychosis. With all the publicity surrounding that case, it makes it uncomfortable for women to step forward and get help … That's why the Yates case got so much attention, because it's so unusual. The important thing to remember is that any person who's having thoughts of harming someone else should talk about it with a mental health professional as soon as possible. "

Mothers at higher risk for PPD include those with a history of depression or mental illness or high levels of stress in their lives. Those diagnosed as being manic depressive, or bipolar, for example, are 25 to 45 percent more likely to experience either depression or mania after childbirth.

According to Malarkey, roughly 8 to 20 percent of postpartum mothers meet the standard diagnosis for depression, which, overall, runs twice as high in women as men.

While "baby blues" affect approximately 80 percent of new mothers, usually within the first two weeks of delivery, PPD typically develops during the first three months after childbirth, often reaching its peak between six and eight months. The good news is that women have more treatment choices than ever before such as new anti-depressants, seasonal light therapy, counseling, education and regular exercise (20-25 minutes, three or four times per week, has proven to be helpful).

"Addressing any other psycho-social issues – relationships and other co-morbid conditions that make it worse – is important," Dr. Pariser says. "Obsessive-compulsive behaviors, drugs or alcohol or marital misery can all compound (PPD).”

Partners play a critical role in helping women seek proper diagnosis and treatment, experts emphasize, and can often make or break a difficult situation. "I've been to postpartum support groups, and it almost killed me, as a male, to see them struggling – big-time," Malarkey says.

Malarkey says it isn't surprising that women internalize a superhuman ideal in a culture that heaps a bulk of its parenting on mothers and a majority of its focus on kids. "I don't think anyone initially sees themselves as a candidate for postpartum depression," he says. "Education is important. Letting women know, 'Hey, this happens, and it's OK.'”

Malarkey remains a firm believer in the power of modern-day anti-depressants but winces whenever knee-jerk prescriptions are written for individuals unlikely to also seek therapy. "Psychology made a huge mistake making everything medical," he says. "I mean, Prozac helps you feel better, but it doesn't fix problems. I don't know anyone who has a problem, and yet, everyone has a problem. Look around. The only difference between the people inside my office and outside my office is that the people inside my office chose to come in."

Malarkey's mission is to see some type of standardized counseling or parenting education become an accepted norm for new moms and dads. "We just need to be really open about it all," he says. "When my oldest son was born, I remember peeking into his room one night and thinking, in all seriousness, 'We've got to get Alex some parents.' I'm a psychotherapist and my wife's a stay-at-home mom. We're both fairly balanced and, well, we were scared to death. Parenting's a scary thing. Why can't we just say it?"

Red-flag Risk Factors for Developing Postpartum Depression

  • Birth complications
  • Previous miscarriage
  • Marital difficulties
  • Inadequate social support
  • Need for control
  • Negative attitude toward childbirth
  • Previous history of postpartum depression
  • Family depression or sexual abuse

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