Health Talk: Postpartum Depression
Hosted by Craig Stoltz
Washington Post Health Editor
Tuesday, March 14, 2 p.m. EST
For more than a century, physicians have debated whether postpartum depression is a unique illness or an episode of standard depression that is triggered by childbirth.
Jane Honikman, president of Postpartum Support International, and Dr. Robert Daly, from the National Institute of Mental Health, were our guests for "Health Talk" with host Craig Stoltz. Ms. Honikman and Dr. Daly discussed the issues raised in this week's Health cover story.
Please read the transcript below.
Good afternoon, everyone, and welcome to our Tuesday afternoon session of Health Talk. This week we're taking up the issue addressed in the cover story of our Parent & Child issue, postpartum depression. We're happy to have (a Health Talk first!) a pair of guests joining us today: Jane Honikman is head of a group that offers support and services to women with PPD, and Dr. Daly of NIMH here in Washington is conducting important research into PPD. So feel free to ask questions of either a medical or support-seeking nature. And please, everyone should feel free to share their own experiences with PPD, regardless of whether you have a question or not.
Let's start with a question for Jane Honikman. My guess is that a lot of people come to your group, and similar groups, only after they've received minimizing or otherwise unsatisfactory responses from their internist or ob/gyn regarding PPD. Is it your observation that a lot of MDs on the front line don't recognize it or take it seriously?
Jane Honikman: My experience has been that it depends upon the community and the doctor. I have seen an increased sensitivity by the professionals, however, they often do not know what to do next. It is variable and perhaps related to the doctor's own experiences and/or training.
Dr. Daly, can you tell us briefly about the research you're conducting on PPD at NIMH? I understand it has to do with hormone levels after giving birth, and some womens' unusual reactivity those hormones?
Dr. Robert Daly:
We are examining the effects of hormone withdrawal on mood in women with and those without a past history of postpartum depression. We employ a "scaled down" model of the hormone changes in pregnancy and the postpartum. We have observed that women with postpartum depression, but not those without postpartum depression, experience sadness, irritability and anxiety after hormones are withdrawn in this study.
A few comments...
It's great that this area is coming to light...Though its been 15 years since the birth of my daugher, I remember the feelings of hopelessness I felt when I awoke at 5AM with my daugher; watched my husband leave for work at 7AM knowing he wasn't returning for 12 hours; and thinking, as a former professional working mother, what do I do for 12 hours with this baby? I watched others looking seemingly happy, and I truly thought there's something wrong with me. Having had a mother who died at age 46 when I was only 14, I had many unrealisic views about what I should be able to handle. I hated people who told me "Sleep when the baby sleeps" because that was my time to get the things done I use to be able get done. I hated a sloppy house and even more, a sloppy me. I wasn't happy when I was at home...and I wasn't happy when I went back to work three months later. I began not being able to sleep, and finally, thanks to my husband's pleadings, sought psychiatric help. Fearing that I'd become addicted to sleeping pills -like my stepmother did-, I begrudingly took them while continuing my therapy to overcome my "supermom" thoughts. At age 35, this was very scary. But finally, through the help of my wonderful therapist, I began seeing the more sunny side of motherhood and began not feeling guilty to want to be by myself.
Thank you for sharing your experience 15 years ago. One never really forgets those intense moments when our expectations do not match realtity. We now have books to read and support groups but there is much to do. The postpartum movement has a universal message which states 1) you are not alone, 2) you are not to blame and 3) you will be well, this is treatable. I believe it is essental that we convey this message to all pregnant and postpartum families.
I was relieved to read the article by Gerhardt! I was terribly depressed DURING pregnancy and thought there was some sort of conspiracy among women who had children not to reveal to those of us who did not that pregnancy was indeed scary and depressing. I, too, mourned the loss of my "old self." I was amazed at the power pregnancy hormones exert over the body and mind. A psychiatrist friend told me that dealing with the hormones of pregnancy is like being "a very small rider on a very big horse!"
My pregnancy ended in disaster. My pregnancy-induced depression was compounded with post-partum depression. I have a good therapist but she was hesitant to combine an anti-depressant with the hormone activity of my body. Can you comment on this? I have heard that ECT has become the treatment of choice for severe post-partum depression.
Dr. Robert Daly: The changes in levels of the female hormones
estrogen and progesterone that occur during pregnancy may represent a great physiological stress. There is clinical evidence, supported by our study, which demonstrates that adverse mood symptoms may actually begin at the end of the pregnancy in some women (as with you). Treatment for postpartum depression should be comprehensive and usually includes psychotherapy, support and medication. ECT may indeed be used (usually in more serious cases), and can certainly be effective.
This article really hit a nerve with me. After the birth of my son 2 years ago, I would sit on the stairs and cry while literally counting the minutes until my husband came home from work to rescue me from the overwhelming and lonely feelings I was having. I felt like the author said she did; that between nursing and caring for a baby, I was in prison and had made a horrible mistake. I never told any other family members because I was embarrassed and kept thinking the feelings would go away, which they finally did. Do I have a high chance of having these feelings again after the birth of our next child?
Yes, one of the risks of experiencing postpartum depression is a previous postpartum depression. It is very important that you find a nonjudgemental forum where you can share your feelings about what happened to you two years ago. I call it "secret keeping". There is an excellent book available called When Words Are Not Enough by V. Raskin, MD which has a chapter about having another baby. I believe in having families design a "plan of action" during pregnancy in anticipation for the next postpartum period. Prevention is possible and there are many many success stories! I hope this helps you.
Falls Church, VA:
No questions, just a great big THANK YOU to Pamela for sharing her story. Our situations paralleled one another. I began my journey through PPD two years ago, shortly after my daughter was born. It was a long haul, and to my surprise, there were no support groups in the D.C. area. I am certain there are many new moms out there today who are breathing a sigh of relief after reading Pam's story.
Jane, what can you recommend for someone looking for support and services in the Washington metropolitan area?
Jane Honikman: I agree that we owe Pamela a great big thanks for sharing her story. The media in general has been helping the postpartum social support movement increase awareness about emotional responses to motherhood. The organization I founded, Postpartum Support International (PSI) has developed a worldwide network of members who help families in need. For example, in the Washington, DC metropolitan area, Karen Peterson is available to offer emotional support and referrals to professionals and support groups. She can be reached online at firstname.lastname@example.org. PSI is always looking for more volunteers to assist others. If you are ready or know of others who want to "spread the word", please let me know!
This is a great topic that needs more awareness.
A few years ago when trying to get pregnant, I discovered that I had hypothyroidism, meaning my thyroid worked slower than normal. My symptoms were sluggishness, weight gain and irregular menstral periods. At the time, my doctor also told me that there was some research into undetected hypothyroidism contributing or causing postpartum depression in new moms. Since then I now have a two year old and a four month old. I have not heard anything more about this link but I can say that if I miss my synthroid dose, I often feel tired and overwhelmed. What is the current state of linking postpartum depression with hypothyroidism? Thanks.
Dr. Robert Daly:
Normal thyroid function is challenged during pregnancy by a number of factors, including changes in iodine levels and serum proteins. Although a subgroup of women may suffer thyroid dysfunction after childbirth, no clear relationship between thyroid dysfunction and postpartum depression exists.Although thyroid dysfunction may certainly contribute to postpartum mood disorders in some women, other factors would appear to play more defining roles in the development of the condition. However, all women with postpartum mood complaints should have their thyroid function checked- thyroid dysfunction is usually easily treated when present, with a resultant improvement in mood symptoms.
I'm four months pregnant now, and I read with interest the cover article on postpartum depression. Although I have no family history of depression or mental illness, I think I may have some of the risk factors identified in the article. I'll be over 25 when I deliver our first child in August and, more importantly, in June we will be moving across the country. We have no family or friends in the new area, I won't be working outside the home initially, and my husband will be in a job where he won't be able to be home before 9 or 10 p.m. Although we're of course looking forward to the baby, I'm apprehensive that I'll feel lonely or isolated, which I understand can contribute to depression. Is there anything I can do ahead of time to lessen this risk? Should I alert my healthcare provider in my new city to my situation? I don't want to seem overly anxious if the risk isn't that high, but I also don't want to get in a situation where I have a problem that goes untreated or unrecognized. Thanks.
I'm glad that you are asking about being proactive regarding your postpartum vulnerability. Yes, social isolation is a big factor in any circumstance and when you are starting your new family you will want to be surrounded by others. We believe in "mothering the mother". In other words, when you arrive in your new community you will most definitely want to seek out the birthing and postpartum communities. Yes, speak with your care providers about what is available. Perhaps I can be of assistance since the PSI organization has members in many locations. You are welcome to write me directly at email@example.com.
This is Judith McCrosky, LCSW and Barbara Eckman, LCSW with In Step, PC. We are part of a private mental health therapy practice located in Fairfax, Va. We would like to let you know about a resource that we offer. Judith and Barbara are co-therapists for a on-going therapy group which offers support to women suffering from post-partum depression. We can be reached by calling 703-876-8480 or you can visit our web site at www.insteppc.com.
I gave birth to twins three weeks ago via C-section -after 24 hours of induced labor-. Although I thought I was very prepared for the birth by reading and asking my OB lots of questions, it turned out that everything that happened was completely unexpected -like severe swelling from Stedol & Pitocen, not being shown one of the babies until I was in the recovery room, not being told what was happening during the C-section, to name a few-. As my doula said, the whole process started out bad and went from bad to worse. I started feeling depressed the day after the C-section. I was wondering if you have noticed an increased incidence of post partum depression in women who have had a more traumatic birth experience? I almost wonder if I am going through post-traumatic stress instead of post partum depression. -BTW, both babies are healthy & well.-
Jane Honikman and Dr. Robert Daly: Congratulations on the birth of your twins! You certainly did have a traumatic birth experience and I'm sorry to hear about it. The word postpartum is an adjective that describes the first year after a pregnancy. A woman's body needs time to heal and recovery from even the "perfect" delivery. It is important that you be assessed by a professional familiar with postpartum depression so that you receive the appropriate care during your recovery. We need to know how you are sleeping, eating and enjoying life to determine your options for care. Please remember that you are not alone, even though it may feel like that. I certainly hope you are getting lots of help with the twins and being "mothered". You deserve it! Jane
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Thank you so much for doing this very timely discussion.
I have wrestled with estrogen-linked depression and mood disorder since I was about 12-13 and am just now trying to get to the bottom of things and see a psychiatrist. She told me that I would also be susceptible to post-partum depression if I ever have kids. This just frightens me to death. Even tho I have never experienced PPD -I"ve never had kids-, I could totally relate to the experiences of the woman who wrote today's article. It is so frightening to feel out of control and locked behind these chains of sadness, anxiety, and disgust.
MY QUESTION FOR YOU TODAY IS: Do you have any experience with estrogen-linked depression-anxiety generally, and does this touch on any of your studies with PPD? Can you suggest any sources I can go to for more information? Any specialists in the DC area whom you might recommend?
Dr. Robert Daly:
There are a number of reproductive hormone-related mood disorders, including postpartum depression, premenstrual syndrome and midlife or menopause-related depression. Research indicates that women suffering these conditions may be have a differential sensitivity to normal hormonal changes at different times during their reproductive life. We conduct studies here at NIMH in Bethesda,MD, on these questions concerning the relationship between reproductive hormones and mood symptoms. We are interested in having women participate in our studies, with and without mood symptoms. Our telephone number is 301-496-9576. Also, I can be contacted
by email concerning such questions at firstname.lastname@example.org
This is a comment. I was excited to see that there was an article on postpartum depression. What I was not excited with was the comment made by Jessica Berger-Weiss. She said, "The fact is depression-prone women sigh with relief when they find out they can't breast-feed...." I can tell you that I did not sigh with relief. I was glad that my depression was discovered, but I agonized on whether to continue breast feeding or take depression medication. I chose to not take the medication because of the unknown effects the medication might have on my child. Breasting is something that I have truly cherished with all of my children and something that I felt I could not give up.
The decision to continue breastfeeding when being on antidepressants is a complex topic, emotionally and medically. We have women who have decided not to breastfeed as you did and others breastfeeding on medications all around the world. My concern is that we support the woman's decision no matter what it may be and provide her with accurate information for her to make an informed choice. Again, my focus is on the mother and her mental well-being and the need to give her emotional support during this difficult time.
This note just came in from a reader in Potomac, Maryland. Thanks, Potomac, and thanks for the tip on PACE.
In 1985 I gave birth to my first child at age 41 and while I was extremely happy to become a mother, the "culture shock" of being at home all day with an infant as opposed to working in an office was quite difficult to adjust to. In addition, my friends at that time were filling out college applications with their children and were not very interested in discussing my "clogged ducts" from breast feeding. I struggled along alone for a few weeks and finally located a wonderful support group for new mothers called Parent and Community Education-PACE-. While they are not specifically geared to treat post-partum depression, they provide a wonderful opportunity to discuss the emotional aspects of becoming a parent and they are able to make referrals to therapists when necessary. After finding my way through the emotional maze of mothrhood and subsequently having another child at 44, I resumed my career as a Clinical Social Worker and, as part of my private practice, I began to facilitate groups for PACE. I currently run therapy groups for new mothers who are attempting to balance family and career responsibilities. As a mother and therapist I feel very strongly that women and families be given recognition for the complexities of parenting today as well as support services.
If doctors can measure the amount of CRH in postpartum women, why can't they measure this is non-postpartum women? It would be an objective way to find out if a person is depressed. The HMO's would love it- a blood test to assess depression. Is work on this being done at NIMH?
Dr. Robert Daly:
Much research effort is being focussed on identifying "biological markers" of psychiatric illness. Such markers (often through blood tests) may indicate a susceptibility to developing illness. It is important to know that no hormonal abnormality during pregnancy or postpartum has been consistently identified that would distinguish a woman with postpartum depression from a woman without postpartum depression. This is also true for other hormone-related mood disorders. Our work is also examining this area, one example is genetic research.
How can you tell the difference between postpartum depression and the feelings that sometimes normally accompany such a huge life change? Feelings like wondering if you made the right choice, sadness over your lost freedom, inadequacy of caring for a small baby - some of these seem like they could be normal.
Everyone experiences the adjustment to parenthood but what you are asking is the critical piece. We want to educate society about the signs of depression so that families can help distinguish when "normal" crosses over the line into "not ok". Ask yourself the following questions; can I sleep when given the opportunity to sleep? do I have an appetite? Am I getting pleasure from living the way I used to before my life as a parent? Sometimes the expression "I just don't feel like myself" is all that it takes to help you take stock of your personal health. Mental health is physical health. All of our functions begin in the brain. If we cannot sleep or eat properly, the body begins to rebel. Being a parent is so demanding and stressful, even under ideal circumstances that we MUST recognize the signs when it is important to be assessed for depression.
This addition from Potomac, Maryland:
Potomac, MD: I would like to give the phone number for PACE - 301-983-9133 and I am Anne Cohn, LCSW and can be reached at Annekoco@aol.com or 301-299-8510.
How long does the average PPD last? I'm taking Paxil which has helped my moods, but I am still having trouble sleeping at night. Any suggestions?
The answer to your question about how long does PPD last is not a very scienfic one but the rule is "the earlier you get help, the sooner you'll be well". I'm glad to hear that the Paxil is helping your moods but if you are not sleeping well, please inform your doctor to discuss dosage and perhaps ways to augment the medication. There are self-help ways and psychotherapies that can assist the medications. Good sleep hygiene is what it is commonly called. Ask your doctor and good luck.
Tracy's Landing, MD:
Today's article contained a sidebar that asserts that options for treatment of PPD are "depressingly few." This is not true, and may be very upsetting for sufferers of PPD. I speak from personal experience. I also do not think that taking antidepressant medication is necessarily incompatible with breastfeeding. I'd appreciate your comments. Thank you.
Dr. Robert Daly: Thankfully there are now a range of treaments available for postpartum depression. The
therapeutic approach should be balanced and address biological, psychological and social issues as appropriate.
Regarding breastfeeding, relatively little is known about
the excretion of antidepressants into breastmilk or the effects of this on the nursing infant. The long term effects of trace amounts of medication that may pass to the infant are unknown. In psychiatric practice, many physicians advocate the use of the selective serotonin reuptake inhibitors (eg Prozac, Paxil, Zoloft)during the postpartum period for women with depression who are breastfeeding. The decision about treatment must consider such factors as the psychological and physical benefits of breastfeeding, the severity of symptoms, and possible effects on the infant.
Silver Spring, MD:
I was very distressed by Pamela Gerhardt's seeming to blame breastfeeding, in part, for her postpartum depression. As a mother of two grown children, and a former breast-feeding counselor, I think she does a diservice to women who wish to breastfeed. It has been my experience that the relaxing effects of prolactin during nursing may actually help MILD postpartum depression. I have known some women, with severe depression to take medication and continue to breastfeed. What are you advocating in this regard?
I advocate for the woman, whatever she wishes to do. Women are intelligent and able to make personal decisions but they need accurate information and an opportunity to discuss her options. Each woman's postpartum recovery is unique, as is her pregnancy and birth experience. We cannot rush to judgement and therefore must remain objective and support. The more the professionals discuss what the research is showing us and convey this information accurately to the consumers the closer we get to healthy mothers and babies.
What a great article! I felt as though I was the only women who had ever suffered from PPD. When I would ask friends about the way I was feeling, I always walked away feeling like a horrible mother.
Now that my first child is one, my husband and I look forward to having another child. I just don't want to go through PPD again. It lasted for about four months and was such a dark time in my life. Is there anyway to prepare for my next birth experience?
Absolutely, prevention is possible but if symptoms were to return you would know what to do the second time around. We call this early intervention. I recommend designing a "Plan of Action" during pregnancy and there are many books available to assist you. This includes lining up your professional and social support teams prior to delivery. I mentioned previously a book called When Words Are Not Enough by V. Rakin, MD. It is the sequel to This Isn't What I Expected. Education is the first line of prevention! Read, learn, talk, share, prepare and let me know how you do.
I currently take welbutrin, and I was wondering if it is considered safe to take this medication while pregnant or nursing? Since I am prone to depression, I am nervious about going off it when approaching motherhood.
Ames, IA: What's this about not taking antidepressants while you're breastfeeding? I took Prozac through my entire pregnancy, and I'm still taking it 7 months later, and still breastfeeding and I have a happy, health, developmentally sound daughter - no problems, and no one ever suggested there might be.
[I've put these two questions about taking depressants while pregnant and while breastfeeding together.]
Dr. Robert Daly: As with many situations in medicine, the question of using antidepressants during pregnancy and while breastfeeding needs careful consideration on a case by case basis. According to its manufacturer's , there are no adequate or well controlled studies in humans on Wellbutriin's use in pregnancy (this is the case for most antidepressants). However the possibility of depressive relapse during or after childbirth has significant risks of its own which enter into the clinical decision around treatment.
Regarding the second question, this lady's experience
reflects successful and appropriate intervention.
Well we're out of time for today, but I'd like to thank everyone--questioners, commentors, and especially Jane Honikman and Dr. Daly for joining us. It's rare to get two people with expertise in both medical and support issues together, and we're awfully glad we were able to make it happen today. People with additional questions and comments, feel free to check out our message board, where the conversation can continue, 24 hours a day, 7 days a week.
Thanks again, and we'll see you next Tuesday at 2 p.m.
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