LA JOLLA, CALIF. – More than 20 years ago Diana Lynn Barnes, Psy.D., then a new mom to a baby girl, found herself hospitalized four different times for stays that lasted 2-3 weeks each time.
"No one knew what was wrong with me," she told an audience at the annual conference of the Anxiety and Depression Association of America. "I had numerous treatments and saw many doctors, and yet the words ‘postpartum depression’ were never used. It was a full year after my daughter’s birth before I even heard the words postpartum depression."
Having endured a full year of illness before being diagnosed with depression, "I was in such a fragile state that I continued to relapse for the next 2 years, in and out of the hospital," said Dr. Barnes, a licensed psychotherapist at the Center for Postpartum Health in Sherman Oaks, Calif. "What should have been a very short course of treatment, probably 12-16 weeks, took 3 years out of my life."
Her own experience with postpartum depression illustrates how difficult it can be for clinicians to recognize the illness, which can present in many ways. "Despite the myths that pregnancy is blissful, that women have never felt better, that they’ve never looked better, about 10% to 15% of women are going to experience some kind of depression or anxiety during their pregnancies," Dr. Barnes said. "This is significant, because when it’s not treated, we know that those babies are at higher risk for low birth weight, prematurity, the possibility of organ malformation, the possibility of stillbirth, or placental abruption. There is a whole range of consequences when a mom has an untreated depression or anxiety during her pregnancy.
"We also know that the attachment relationship starts in utero. Stress hormones cross the placenta. That has an impact on the developing brain of the fetus."
She made a distinction between the so-called baby blues and postpartum depression. The baby blues, she explained, affects about three-quarters of new mothers and is characterized by symptoms that commonly occur during a menstrual cycle: tearfulness, anxiety, and mood swings. "We consider the baby blues a normal part of postpartum adjustment, but the symptoms are mild and they’re transient," she said. "They come up around the third or fourth day post partum, and they’re generally gone by about 2-3 weeks from the outset. They don’t generally require any intervention. With reassurance, enough support, and good self-care, women will get through this quite well."
Symptoms of postpartum depression lurk longer than those of the baby blues and can be more wide-ranging. Anxiety occurs in 15-20% of women with the illness and "can be paralyzing," Dr. Barnes said. "We’re now coming to think that the numbers are even greater. The anxiety really stops women in their tracks. It’s not that they don’t want to respond to their babies, it’s that they can’t. The anxiety impairs them in such a dramatic way that they are unable to function."
About 10% of women with postpartum depression will experience panic-related symptoms that range from waking out of sleep with their heart pounding to difficulty breathing, while 3%-5% will experience obsessive-compulsive symptoms. "There may be repetitive kinds of behaviors, so we will see women checking things or counting things repetitively," she said. "One of the other things we see is intruding images or thoughts about harm coming to self or, generally, the images and thoughts are about harm coming to the baby. It is very disturbing to many of these women."
Sometimes clinicians confuse intruding thoughts and images with postpartum psychosis. "But what we tend to see in women with obsessive-compulsive symptoms is that they are very disturbed by these thoughts," Dr. Barnes said. "In some cases they are embarrassed or ashamed by these thoughts. They’re saying to themselves, ‘What kind of a mom could I possibly be that I have these kinds of crazy thoughts?’ They don’t want to talk about them. In my practice, I often say, ‘It is very normal among women with postpartum depression to have intruding thoughts and images. Does that ever happen to you?’ Once I say it’s common, it normalizes the situation a little bit, enough to open the door so women feel safe talking about it. So often, women are afraid if they tell anyone that they’re really thinking that their children will be taken away from them."
One of the common intruding thoughts and images consists of a knife slipping, "either about what happens if the knife slips and it cuts their baby, or they will actually picture themselves with a knife," she said. "Another common thought is dropping the baby." Such thoughts "are caused by alterations in brain chemistry and are generally very responsive to medication, but it is not postpartum psychosis. In postpartum psychosis, when women have these intruding thoughts and images, it is part of their new reality. There is limited recognition that there is something wrong."