While this article was still germinating in my mind, I sat down in front of my computer to reach out via social media. I asked folks to share their experience with postpartum depression (PPD) in three words. What happened next was something I was not entirely prepared for or expecting. Immediately, the responses began to flood in; it was a wave of intensity and vulnerability. Here are some examples of what was shared:
Dark Deep Alone
Awake Vulnerable Sinking
Rage Powerless Foggy
Lonely Disconnected Consuming
Zombie Trapped Paranoid
Incompetent Jumpy Disappearing
Overwhelmed Agitated Guilty
Crushing Exhausting Unpredictable
Isolated Confusing Robbed
Shame Hopeless Immobilized
Drowning Frantic Terrified
Racing Irrational Panic
Suffocating Inadequate Numb
Please take some time to sit with these words, breathe deep with their meanings, feel them and move through them. Initially, the heaviness of these words was overwhelming but then as I sat with them, the process became beautiful and fulfilling. One overarching theme of postpartum depression is the lack of awareness regarding how the sufferer feels alone. What happened on my Facebook page was that a group of women stood up and spoke out, sharing and recognizing this side of motherhood. The sadness then transformed into something inspirational.
The power of our communities and our shared experiences can and should be uplifting. Putting the harsh reality of this experience into words, writing them out and then sharing them with others can be liberating. Reading and then knowing that you are not alone can be empowering. There is an unfortunate stigma around PPD in our mainstream culture; we need to rise above it, speak out and use our collective voices to support each other through this often misunderstood side of motherhood.
The term postpartum depression (PPD) can be misleading. It is perhaps an over-simplified and poor description of the array of experiences that postpartum women can have. The experience of PPD is much broader and can encompass much more than feelings of depression.
What Are Postpartum Mood Disorders?
The term postpartum depression (PPD) can be misleading. It is perhaps an over-simplified and poor description of the array of experiences that postpartum women can have. The experience of PPD is much broader and can encompass much more than feelings of depression. For some it acts and feels like postpartum anxiety (PPA) or for others like obsessive-compulsive disorder (PPOCD). There is also perinatal-related posttraumatic stress disorder (PTSD). For some, a postpartum mood disorder will include symptoms of all of these. In very rare cases—one to two out of every 1000 births—postpartum psychosis (PPP) can occur. In reality this experience is better described as postpartum mood disorder (PPMD) and many professionals and organizations have begun to apply this more comprehensive term. PPMDs can be experienced by any postpartum woman; first-time moms or those with four children, single women, partnered people, folks from high or low socioeconomic groups, women of any age group. Basically, PPMDs are equal opportunity attackers and all women should be screened for these conditions.
What Are the Symptoms of PPMD?
Up to 80% of postpartum women will experience “baby blues,” which are characterized by crying or weepiness for no apparent reason, insomnia, mood swings, restlessness, irritability and poor concentration. When I talk with clients about this, I point out that in the immediate postpartum period our hormones often take us on a roller-coaster ride as they re-settle after the pregnancy and birth. That journey, coupled with the lack of sleep and adjustment to the new baby is enough to make many people feel these baby blues in the first few weeks after birth. This process is normal and requires gentle support from care providers and family, assistance with household chores and meal prep, encouragement to sleep and rest, friendly visits to prevent feelings of isolation, etc. Many women will find that such feelings resolve and they can move through the experience with the necessary support and rest.
For 10–15% of women, the baby blues will progress to become a PPMD. Many of the symptoms of PPMD are similar to those associated with the baby blues. However, these feelings will persist past the first two to four weeks and will be more intense. They include:
- Loss of interest in activities previously enjoyed
- Overwhelming sadness
- Persistent anxiety or panic attacks
- Intrusive, repetitive or racing thoughts
- Excessive irritability, anger or agitation
- Extreme mood swings
- Disinterest in baby or family members
- Changes in dietary habits—eating much more or much less than usual for the individual
- Problems with concentration and memory
- Feelings of guilt or being unworthy
- Thoughts of harming self, baby or family members
People who experience these symptoms require the same gentle community support mentioned above and a more intensive, structured level of support. For midwives, it is critical to be aware of these symptoms and to actively screen our clients.
How and Whom
Do We Screen for PPMD?
As stated above, any person can experience PPMD, so we cannot assume that a particular person is immune. Due to the stigma associated with PPMD and potential fear of speaking out, having a protocol for routine screening of all clients is helpful. That way, you can explain that it is standard so an individual does not feel singled out in any way. For example, at my practice, we routinely screen all clients at 28 weeks gestation during the pregnancy and at six weeks postpartum. If we have concerns about a particular person based on observation or risk factors, we will screen more often.
Several tools are available to use for screening. The most well established and widely used is the Edinburgh Postnatal Depression Scale or EPDS. A free downloadable copy can be found at www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf. (Even though this tool specifically names “postpartum” depression, it has also been used during pregnancy.) Other tools are available, as well; the most important thing is to pick a tool and become familiar with how to use and score it. Also, be aware that numbers on a piece of paper are just that. Ideally, the tool should be used only as a jumping off point to open a dialogue.
Next, after screening, it is essential to have resources and intervention strategies available for those women who will benefit from them. We cannot simply screen and identify; we must take the next step to assist in healing and support. Additionally, it is critical to have a plan in place for immediate intervention if a client reports an active desire to harm herself or others. This will likely not happen often, however, when it does it cannot be ignored or brushed off. Know the resources in your area and develop a strong protocol for responding.
Interventions to Treat PPMD
After the overwhelming response to my social media call out for how PPMD made folks feel, I followed up with a request for what helped them move through these feelings. Here are some of the responses:
Time. Getting out of the house. Therapy. Sleep.
Community support. Family support. Time.
Love. Somatic therapy. Sleep. Eye Movement Desensitization and Reprocessing (EMDR).
Exercise. Fresh air and sunlight. Connecting.
Recognizing and acknowledging the problem. Love.
Time. Releasing unrealistic parenting expectations.
Vitamin D and Zoloft.
Love, time, sleep and support.
As you may have noticed, there were several common threads throughout all the responses: love, sleep, time and support. Love—for yourself and from your support team. Sleep—this is never to be underestimated as crucial for healing to be possible. Time—there is no quick-fix or one-size-fits-all approach. Support—these clients will need close monitoring and extra follow up past the usual six weeks post birth.
When sitting with a client to make a PPMD treatment plan, the first thing I always do is to reassure her that she is not alone. Then, I let her know that I am proud of her for being honest, open and vulnerable; this is critical, it takes courage to speak out and share these intimate emotions, especially when the dominant culture still shuns people with mental health issues. I also make sure she knows that our plan will not (except in rare cases of postpartum psychosis) involve separating her from her baby. Nor does it make her a bad mother; on the contrary, she is being an excellent mother by acknowledging this and reaching out for help!
Next, I will work with her to create a sleep plan to ensure that she has opportunity to have structured and planned time to sleep. This will clearly need to involve her partner, family and/or a postpartum doula. Then, I recommend vitamin D supplementation and regular exercise—particularly outdoors, if possible. For many, dedication to this plan, with regular check-ins from me and her support team, is all that will be needed. For others, we will need to do these things and more. Other options include:
Therapy with a practitioner trained in and familiar with PPMD, either in a one-on-one setting, a facilitated group or both. Have resources on various types of practitioners in your area at your fingertips. There is no “one right type” of therapy; each person as an individual will need options to find the right one for them. Get to know these practitioners and let them educate you further; they should be close collaborators.
Eye Movement and Desensitization Reprocessing (EMDR). This technique is done by a specially trained practitioner and in conjunction with therapy. It can be especially helpful to treat traumatic experiences and PTSD. You can learn more about this technique here: www
Pharmaceutical treatment. For some women, all of the other interventions may not be enough and the option of prescription medications should always remain in the toolbox. The most common class of medications used to treat PPMD is Selective Serotonin Reuptake Inhibitors or SSRIs. Of these, Zoloft (Sertraline) is the most commonly prescribed. If anxiety or OCD is a strong feature, another SSRI, Lexapro (Escitalopram), may be more beneficial. It is important to educate yourself regarding these medications, to not judge anyone who needs them and to have resources for women to obtain a prescription if you cannot prescribe. Medication is not a quick fix; it will still be necessary to practice other interventions and have close followup. Eventually, most women will be able to discontinue medication after a time—a process that requires management and supervision. Also, clarify that these medications are considered safe with breastfeeding; a woman should not have to choose between her mental health and nursing.
In closing, PPMD is a potentially devastating result of the postpartum period for many folks. It should never be underestimated or ignored. Never make an assumption about who is at risk and be vigilant about screening for PPMD and then intervening, when necessary. Know your local resources and be familiar with them. Reach out to them when they are not needed so you know who they are and can feel comfortable contacting them when needed.
Some online resources:
- Postpartum Support International at www.postpartum.net
- Postpartum Progress at www.postpartumprogress.com
- The Online PPMD Support Group at www.ppdsupportpage.com