Beatrice (not her real name), a single mother of an active toddler, admitted feeling overwhelmed. She felt like the household chores were too much and described a mountain of laundry on her couch that had been there for weeks. Unable to tackle what felt insurmountable to her, she spent hours each day watching reality TV and surfing the Internet. Despite living near a park, she never felt she had the time or energy to take her child there. She struggled with terrible feelings of guilt and inadequacy as a mother.

“Louise,” a new mom, felt no connection with her new baby. She described her daughter as “a thing” that had grown inside her. Although she had been married for several years, becoming pregnant was a surprise. She was not sure if she wanted to be a mother. When her baby cried, she sounded “like noise” to her.

Both these new mothers were unaware that they were suffering from postpartum depression, or PPD. (Details about their cases have been changed to protect their identities.) Feeling overwhelmed, ruminations of guilt and inadequacy, and inability to bond with their babies are common features of women suffering from PPD.

Within the first few days after giving birth many women experience a short period of tearfulness. This condition is frequently attributed to the rapid hormonal shifts that alter brain neurotransmitter regulation during this time. The postpartum blues pass quickly, usually within a week. In contrast, PPD has more severe symptoms and lasts more than two weeks. Approximately 10% of women giving birth experience PPD – this is not a rare phenomenon.

Often the symptoms of mood change begin in pregnancy causing many physicians to now use the term ‘perinatal depression’, meaning pregnancy-related depression. When depression occurs in pregnancy it can cause the stress hormone, cortisol, to rise. Elevated levels of cortisol are associated with diminished brain growth in the baby. It is therefore extremely important to diagnose and treat depression in pregnancy.

Many women have depression but don’t realize it. It is a common misconception to believe that someone with depression would feel sad or be crying frequently. This is not always the case. Depression is a state of muted or “depressed” emotions, not necessarily sadness. Severely depressed women often shed no tears at all. Signs that a person might have depression include sleep disturbances, decreased interest in pleasurable activities, feelings of guilt, low energy, difficulty concentrating, appetite changes, agitation, and thoughts of harming oneself. All but the last of these symptoms can also be inherent to the round-the-clock, sleep-depriving care required by a newborn. This can make diagnosis difficult and require the expertise of a trained medical provider or psychotherapist.

While each woman’s experience is unique, there are other common signs. Depression affects one’s mindset, making people highly self-critical and filled with self-doubt. Women wonder if they are “bad mothers”. They can become overwhelmed by recurring worries, such as the fear of accidently dropping their baby. Depressed mothers sometimes feel tremendous guilt over their difficulty in enjoying their new baby. This combination of self-doubt, criticism, and unworthiness leads to shame and secrecy. Unfortunately, mothers often don’t realize that PPD is what causes them to feel this way. Depression seeps in and integrates itself into a person’s way of being so innocuously that misery can seem normal.

Postpartum depression can also severely affect a mother’s relationship with her partner, as well as her bonding with her baby. Partners often feel rejected by the woman’s attempts to withdrawal and isolate herself. A depressed mother is also less likely to respond appropriately to her baby, resulting in poor attunement to the child. (Attunement is the foundation on which people develop emotional regulation, communication skills, and the ability to form relationships.) However, despite their concerns of not being a good enough mother, most women with PPD provide excellent care for their children. Of greatest concern is that women experiencing PPD or the more severe form – postpartum bipolar disorder – are at higher risk of suicide. Their feelings of worthlessness can be so profound that they can develop a distorted belief that their baby will be better off without them.

The exact cause of PPD remains undetermined. While the postpartum blues are frequently blamed on hormones, this scenario is unlikely to be the complete picture for PPD, since fathers and adoptive mothers also experience increased rates of postpartum depression. Risk factors for PPD include history of depression, lack of social support, history of infertility, undesired pregnancy, intimate partner violence, and history of trauma. It is important that physicians providing prenatal or newborn care should screen all mothers for signs of depression.

Much can be done to help women with perinatal depression. Often feeling better can begin with understanding the illness. Depression tricks people into thinking that they will feel better if they withdrawal from activities and interaction with others. However, isolation allows the depression to become more energy-consuming. To beat depression you have to fight it. Women with PPD need to force themselves to get out of bed every morning and care for themselves as they normally would. Finding the energy to get outside and take a walk with the baby can be very difficult, but this is exactly the type of activity that can begin to weaken the hold of depression.

Perhaps most important in alleviating PPD is getting adequate sleep. This is especially true for women with bipolar disorder. New moms can benefit from napping during the day while the baby naps. Women with partners can divide the night into two halves, with each partner taking a 3-5 hour shift of being responsible for childcare. This arrangement provides less interrupted sleep for the mother and increases the care-giving role of the partner.

Families and friends can support mothers to create family action plans. The main goals of a plan are to create a network of support. Since a baby requires nearly constant care, the mother has little time for herself. Simple things like showering, sleeping, eating regular meals contribute to one’s sense of well-being. When a baby arrives, many of these routines are dropped. Finding ways to reincorporate self-care back into the mother’s life can significantly improve her mood. Families and friends can band together to support the mother. Watching the baby so she can shower without worrying can give a new mother peace. Other ways of helping include doing laundry, grocery shopping, meal preparation, being a walking partner, or just being a good listener.

If you think you might have PPD talk with your physician. Together you can decide whether therapy, medications, or alternative treatments would be the best first step. Seeing a psychotherapist experienced in working with new mothers can make a tremendous difference. Counseling has been proven to be an effective treatment for depression and can bring the joy back to motherhood. Medication, such as antidepressants, can also be used to treat moderate to severe depression. Some antidepressants have been shown to be safe for women who are breast feeding. This is a personal decision and what might be right for one woman might not be for another. In addition, there are hotlines and websites listed in the side bar that can provide further information on perinatal mood disorders.

In summary, PPD is not a phase a woman must get through on her own or that her family or baby must endure; the suffering is unnecessary. Not only does PPD get in the way of enjoying some of the greatest moments in life, but lack of treatment can result in serious consequences for both the mother and family. The first step is asking for help.

Postpartum Depression (PPD) Resources

• Bay Area Postpartum Depression Stress Line. 888-773-7090. Available every day of the year from 9 a.m. to 9 p.m. Free and confidential telephone counseling provided by volunteers who are survivors of postpartum mood disorders.

• Postpartum Mom’s Line. 800-773-6667. For counseling services after 9 p.m.

• Postpartum Support International. www.postpartum.net. This website is particularly helpful for patients and also has information for partners helping spouses recover from PPD.

• Massachusetts General Hospital. www.womensmentalhealth.org. Extensive, up-to-date information for both patients and medical providers.

• CTIS website. www.ctispregnancy.org. Provides referenced fact sheets about many antidepressant medications commonly used in pregnancy and breast-feeding. Spanish also available.

Dr. Zechowy

Jill Zechowy, M.D., M.S. is a family physician with a master’s degree in counseling psychology who has a practice in Santa Rosa, California that specializes in women’s mental health. She is a member of Postpartum Support International. For questions or comments please call 707-515-6673. More information is also available at her website  www.WomensMentalHealthMD.com.