http://www.postpartum.net/Have you recently given birth? Are you feeling exhausted, anxious, depressed, or just not yourself? If you are?you are not alone. Many women are not prepared for the wide range of emotions they may experience after the birth of a child. They often feel sadness, anger, anxiety, or a sense of inadequacy.
These feelings may vary in frequency and intensity, but are collectively known as postpartum mood disorders. Help and support is an important part of getting back to feeling like yourself again.
The important thing to remember is that the symptoms are temporary and treatable with skilled professional care and social support. Whether you think you are depressed or just want more information, Postpartum Support International (PSI) is here to help.
http://www.postpartum.net/brief.htmlBeyond The Blues?A Guide to Understanding and
Treating Prenatal and Postpartum Depression
by Shoshana S. Bennett, Ph.D. and Pec Indman, Ed.D., MFT
Moodswings Press, 2003
Pregnancy and Postpartum Psychiatric Illness
Perinatal (during pregnancy and postpartum) mood disorders are caused primarily by hormonal changes which then affect the neurotransmitters (brain chemicals). Life stressors, such as moving, illness, poor partner support, financial problems, and social isolation are certainly also important and will negatively affect the woman?s mental state. Conversely, strong emotional, social, and physical support will greatly facilitate her recovery.
Any of the five postpartum mood disorders discussed in this chapter can also occur during pregnancy. These perinatal mood disorders behave quite differently from other mood disorders because the hormones are fluctuating. A woman with a perinatal mood disorder often feels as if she?s ?losing it,? since she can never predict how she will feel at any given moment. For instance, at 8:00 A.M., she may be gripped with anxiety, at 10:00 A.M. feel almost normal, and at 10:30 A.M. become depressed and lethargic.
Our clients who have had personal histories of depression tell us that postpartum depression feels very different (and usually much worse) than depressions at other times in their lives. One of Shoshana?s postpartum clients is a survivor of breast cancer. At a support group, she eloquently explained:
When I had cancer, I thought that was the worst experience I could ever have. I was wrong ? this is. With cancer, I allowed myself to ask for and receive help, and expected to be depressed. My friends and family rallied around me, bringing me meals, cleaning my house, and giving me lots of emotional support. Now, during postpartum depression, I feel guilty asking for help and ashamed of my depression. Everyone expects me to feel happy and doesn?t accept that this illness is just as real as cancer.
Women who experience these symptoms need to speak up and be persistent in getting proper care. In the past, these illnesses have been trivialized and even dismissed. Research has shown how important it is to treat perinatal mood disorders for the health and well-being of the mother, baby, and entire family.
The Psychiatric Issues of Pregnancy
Contrary to popular mythology, pregnancy is not always a happy, glowing experience! Approximately 15-20 percent of pregnant women experience depression. Of these, about 15 percent are so severely depressed that they attempt suicide.
It can be confusing that normal pregnancy experiences such as fatigue, appetite changes, and poor sleep are similar to symptoms of mood disorders. It is easy to make a blanket dismissal of these symptoms as just part of pregnancy. However, for that 10 percent, it is essential that the proper questions are asked and intervention is given when symptoms Pregnancy and Postpartum Psychiatric Illness 31 are outside the normal realm.
When symptoms of depression or other mood disorders cause limitations in the client?s ability to function on a day-today basis, intervention is necessary. This may include traditional (counseling and medication) or nontraditional modalities (such as Yoga or acupressure), or any combination thereof. The goal is to use whatever the individual woman needs in order to feel like herself again.
Depression during pregnancy has been associated with low birth weight (less than 2,500 grams) and preterm delivery (less than 37 weeks). Severe anxiety during pregnancy may cause harm to a growing fetus due to constriction of the placental blood vessels and higher cortisol levels.
Some women become pregnant while taking psychotropic medications for depression, anxiety, and other mood problems. Many of these medications are considered acceptable during pregnancy. A practitioner who is familiar with the current research about the safety of taking medications during pregnancy should be consulted. Often it is safer to continue a medication than risk a relapse.
The rate of relapse for a major depressive disorder (MDD) in women who discontinue their medication before conception is between 50-75 percent. The rate of relapse for MDD in those who discontinue medications at conception or in early pregnancy is 75 percent, with up to 60 percent relapsing in the first trimester. In one study, 42 percent of women who discontinued medications at conception resumed medications at some time during their pregnancy. Resources listed in the back of this manual provide helpful guidelines regarding the use of medications.
Mood Disorders
There are five postpartum mood disorders. This list details each of the principal disorders, some of their most common symptoms, and risk factors. It is important to note that symptoms and their severity can change over the course of an illness.
?Baby Blues? ? Not Considered a Disorder
This is not considered a disorder since the majority of mothers experience it.
? Occurs in about 80 percent of mothers
? Usual onset within first week postpartum
? Symptoms may persist up to three weeks
Symptoms
? Mood instability
? Weepiness
? Sadness
? Anxiety
? Lack of concentration
? Feelings of dependency
Etiology
? Rapid hormonal changes
? Physical and emotional stress of birthing
? Physical discomforts
? Emotional letdown after pregnancy and birth
? Awareness and anxiety about increased responsibility
? Fatigue and sleep deprivation
? Disappointments including the birth, spousal support, nursing, and the baby
Deborah?s story:
For about a week and a half after my baby was born I would cry for no reason at all. Sometimes I would feel overwhelmed, especially when I was up at night with my son. Once I even thought that I had made a big mistake having a child. I felt resentment toward my husband since his life stayed pretty much the same and mine was turned upside down. When I started going to the mother?s club at two weeks, I felt so relieved that all these other moms felt the same way.
Deborah?s treatment:
Since Deborah was experiencing normal postpartum adjustment, she did not require any formal treatment. Her hormones were balancing out by themselves. All she needed in order to enjoy her new life was a combination of socializing with other moms, taking time to care for herself, and working out a plan of sharing child and household responsibilities with her husband.
Depression and/or Anxiety
? Occurs in 15 to 20 percent of mothers
? Onset is usually gradual, but it can be rapid and begin any time in the first year
? Excessive worry or anxiety
? Irritability or short temper
? Feeling overwhelmed, difficulty making decisions
? Sad mood, feelings of guilt, phobias
? Hopelessness
? Sleep problems (often the woman cannot sleep or sleeps too much), fatigue
? Physical symptoms or complaints without apparent physical cause
? Discomfort around the baby or a lack of feeling toward the baby
? Loss of focus and concentration (may miss appointments, for example)
? Loss of interest or pleasure, decreased libido
? Changes in appetite; significant weight loss or gain
Risk factors
? 50 to 80 percent risk if previous postpartum depression
? Depression or anxiety during pregnancy
? Personal or family history of depression/anxiety
? Abrupt weaning
? Social isolation or poor support
? History of premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD)
? Mood changes while taking birth control pill or fertility medication, such as Clomid
? Thyroid dysfunction
Lori?s story:
I was so excited about having our baby girl. My pregnancy had gone smoothly. I had been warned about the ?Blues,? but I just couldn?t shake the tears and sadness that seemed to get deeper and darker every day. My appetite was non-existent, although I forced myself to eat because I was nursing. I lost about 30 pounds the first month. At night I was having trouble sleeping. My husband and baby would be asleep but I would have one worry after another going through my head. I was exhausted. I felt like my brain had been kidnapped. I couldn?t make decisions, couldn?t focus, and didn?t want to be left alone with the baby.
I wanted to run away. I withdrew from friends and felt guilty about not returning phone calls. I couldn?t understand why I felt so bad; I had the greatest, most supportive husband, a house I loved, and the beautiful baby I had always wanted. At times I felt close to her, but at other times I felt like I was just going through the motions ? she could have been someone else?s child. I thought I was the worst mother and wife on the face of the earth.
Lori?s treatment:
Lori began psychotherapy and also saw a psychiatrist for medication. She was started on an antidepressant and the dosage was gradually increased. Initially she took medication to help her sleep as well. She began taking regular breaks to take care of herself. She also started attending a postpartum depression support group and met other moms with similar stories. After several months she felt like herself.
Obsessive-Compulsive Disorder
? 3 to 5 percent of new mothers develop obsessive symptoms
Symptoms
? Intrusive, repetitive, and persistent thoughts or mental pictures
? Thoughts often are about hurting or killing the baby
? Tremendous sense of horror and disgust about these thoughts (ego-alien)
? Thoughts may be accompanied by behaviors to reduce the anxiety (for example, hiding knives)
? Counting, checking, cleaning or other repetitive behaviors
Risk factors
? Personal or family history of obsessive-compulsive disorder
Tanya?s story:
Each time I went near the balcony I would clutch my baby tightly until I was in a room with the door closed. Only then did I know he was safe one more time from me dropping him over. The bloody scenes I would envision horrified me. Passing the steak knives in the kitchen triggered images of my stabbing the baby, so I asked my husband to hide the knives. I never bathed my baby alone since I was afraid I might drown him.
Although I didn?t think I would ever really hurt by baby son, I never trusted myself alone with him. I was terrified I would ?snap? and actually carry out one of these scary thoughts. If my baby got sick it would be all my fault, so I would clean and clean to make sure there were no germs. Although I had always been more careful than other people, now I would check the locks on the windows and doors many times a day.
Tanya?s treatment:
After meeting with Tanya twice individually, her therapist suggested that her husband join her in the next session. Tanya needed reassurance that her husband knew she wasn?t ?crazy? and would never really harm the baby. She did not want to tell him the specific graphic thoughts, so she referred to them generally as ?scary thoughts.? After being educated, her husband?s aggravation with her being ?nervous all the time? subsided.
Tanya started taking an antidepressant and within two weeks the scary thoughts were occurring far less frequently. Her therapist suggested that she wait another few weeks to join a support group since she was still too vulnerable to hear about the anxieties of others. In the meantime, she was given the names and numbers of a few women to connect with who had survived this disorder.
Panic Disorder
? Occurs in about 10 percent of postpartum women
Symptoms
? Episodes of extreme anxiety
? Shortness of breath, chest pain, sensations of choking or smothering, dizziness
? Hot or cold flashes, trembling, palpitations, numbness or tingling sensations
? Restlessness, agitation, or irritability
? During attack the woman may fear she is going crazy, dying, or losing control
? Panic attack may wake her up
? Often no identifiable trigger for panic
? Excessive worry or fears (including fear of more panic attacks)
Risk factors
? Personal or family history of anxiety or panic disorder
? Thyroid dysfunction
Chris?s story:
At about three weeks postpartum I stopped leaving my house at all except for pediatrician appointments. I was afraid I might have a panic attack in the store and not be able to take care of my baby. I never knew when that wave would begin washing over me and I would ?lose it.? The windows had to be open all the time or else I thought I would suffocate if I had an attack.
The first time I had a panic attack I thought I was having a major heart attack. A friend drove me to the emergency room and the doctor on call told me it was only stress. He gave me some medicine but I was too afraid to take it. I went home feeling stupid, like I had made a big deal out of nothing.
Everyone told me that breastfeeding would relax me, but it did just the opposite. I never knew how much milk my baby was getting and that really worried me. Sometimes when my milk would let down I would get a panic attack. The first therapist I saw told me I must have had issues bonding with my own mother, but I knew that wasn?t true and I didn?t see that therapist again. On many nights I woke up in a sweat, with my heart beating so fast and hard. My head was racing with anxious thoughts about who would take care of the baby when I die. I thought I was going crazy. I was so scared.
Chris?s treatment:
Chris had her first therapy appointment over the telephone since she felt she could not go outside. Her therapist talked her through taking a bit of the medication her MD prescribed, so Chris would know she had something that would help in an emergency.
Driving was too scary for her, especially in tunnels and over bridges. Her husband drove her to her next session, following a route that avoided those obstacles. Chris needed to sit near the door during the appointment just in case she felt the need to run outside for some air. Her therapist urged her to sleep for at least half the night, every night. Chris?s husband began taking care of his baby for the first half of the night on a regular basis. Chris noticed immediately how sleep lowered her stress level. She attended a stress management class which also helped. P
Psychosis
? Occurs in one to two per thousand
? Onset usually two to three days postpartum
? This disorder has a 5 percent suicide and 4 percent infanticide rate
Symptoms
? Visual or auditory hallucinations
? Delusional thinking (for example, about infant?s death, denial of birth, or need to kill baby)
? Delirium and/or mania
Risk factors
? Personal or family history of psychosis, bipolar disorder, or schizophrenia
? Previous postpartum psychotic or bipolar episode
Mike?s story:
My wife, Gloria, had a great pregnancy and a long labor. We were thrilled to have our first child, a son. But within days of his birth my wife began to withdraw into her own world. She became less and less communicative and she became more and more confused and suspicious. I almost had to carry her into the therapist?s office; by that time she could hardly speak or answer questions, nor write her name on the forms her therapist gave us. I was told to take her to the hospital immediately.
When we arrived at the hospital, she became fearful and then violent. She ended up in restraints. Fortunately, she responded pretty quickly to the anti-psychotic medication, and was able to come home after about a week. She continued to improve, and when she was back to herself again, she slowly weaned off all the medications.
We had always wanted two kids, so we consulted with our therapist and psychiatrist. With careful planning, we now have our second child with a very different story to tell.
Gloria?s treatment:
After being released from the hospital, Gloria continued therapy and saw the psychiatrist, who carefully monitored her medication. She worked to understand and process what had happened to her. Eventually she joined a postpartum support group which was quite helpful. Since there were no other moms present in the group who had experienced a postpartum psychosis, the group leader gave her the names and numbers of women who had ?been there? and who wanted to help.
Postpartum Psychiatric Illness Posttraumatic Stress Disorder
? There is no available data regarding the prevalence or onset
Symptoms
? Recurrent nightmares
? Extreme anxiety
? Reliving past traumatic events (for example, sexual, physical, emotional, and childbirth)
Risk factors
? Past traumatic events
Jennifer?s story:
During the delivery it all came flooding back. I felt terrorized and vulnerable. I thought I had already dealt with the abuse in my childhood. It seemed that all the years of therapy were a waste of time and money. I was so embarrassed for losing control during labor. I was angry that what happened to me as a kid was still affecting me after all this time.
My therapist told me the nightmares and flashbacks would go away but I just didn?t know. It was so real ? like the abuse was happening again over and over. I couldn?t even leave my poor husband alone with my baby. I got the sick feeling that I couldn?t even trust him. I was so messed up. I thought maybe I?d never be a normal mother.
Jennifer?s treatment:
Jennifer hired a postpartum doula who took care of her and the baby for two months. Having this trusted female companion with her almost everywhere she went gave Jennifer comfort. She began weekly therapy sessions and eventually joined a support group. She and her therapist agreed that she did not need medication at this point.
Consequences of Untreated Mood Disorders
Maternal depression was placed at the top of the list entitled, ?Most significant mental health issues impeding children?s readiness for school? (Mental Health Policy Panel, Department of Health Services, 2002). There is a tremendous amount of data regarding the profoundly negative impact of untreated maternal depression on infants, toddlers, preschoolers, school age children and adolescents. There is an increased incidence of childhood psychiatric disturbance, behavior problems, poor social functioning, and impaired cognitive and language development. When a depressed mother goes untreated, every member of the family and all the relationships within the family are affected. The quicker the mother is treated, the better the prognosis for the entire family.
Perinatal Loss
No matter how a pregnancy is terminated, whether by nature or by choice, depression and anxiety commonly follow. Not only should grief be addressed through counseling, but medications may also be useful in reducing symptoms due to loss and hormonal changes. When a stillbirth or neonatal death occurs, depression is, of course, to be expected. Counseling for the couple will be helpful, and medications may be needed to treat anxiety and depression. These women need to be monitored carefully for emotional symptoms in subsequent pregnancies and the postpartum period.
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