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, breath 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 very fulfilling. One overarching theme of postpartum depression is the lack of awareness and how folks feel alone. What happened on my Facebook page was a group of women, standing up and speaking out, sharing together and recognizing this side of Motherhood. The sadness then transformed into something inspirational. The power of our communities, of 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, speak out and use our collective voices to support each other through this often misunderstood side of Motherhood.
What are Postpartum Mood Disorders?
So, what is Postpartum Depression? 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) and there is also perinatal related Post Traumatic Stress Disorder (PTSD). For some, it will include symptoms of all of these. In very rare cases, 1-2 out of every 1,000 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. PPMD’s can be experienced by any postpartum person; first time Mom’s or ones with 4 children, single women, partnered people, folks from high or low socio-economic groups, women of any age group. Basically, PPMD’s are equal opportunity attackers and all folks should be screened for these conditions.
What are the symptoms of PPMD?
The commonly referred to “Baby Blues” can be experienced by up to 80% of postpartum folks, this is 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 are often taking us on a roller coaster ride as they re-settle after the pregnancy and birth. That journey, coupled with the potential lack of sleep and adjusting to the new baby is enough to make many people feel these Baby Blues in the first few weeks after baby. 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. For many women, these feelings will resolve and they will 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 2-4 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 this 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 will 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 who do we screen for PPMD?
As stated above, any person can experience PPMD so we cannot assume that any particular person is immune. Due to the stigma associated with PPMD and potential fear of speaking out, it can be helpful to have a protocol for routine screening of all clients. This way, you can explain that it is standard and individuals will 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 6 weeks postpartum. If we have concerns for a particular person based on observation or risk factors, we will screen more often.
There are several tools available to use for screening. The most well established and most widely used is the Edinburgh Postnatal Depression Scale or EPDS. A free downloadable copy can be found here. (Even though this tool specifically names ‘postpartum’ depression, it has also been used during pregnancy.) There are other tools 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 only be used as a jumping off point to open a dialogue and start a conversation.
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 themselves 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 call out 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. 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 any 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 plan to treat PPMD, the first thing I always do is to re-assure them that they are 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 about mental health issues. I will also be sure they know 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 them to create a sleep plan to ensure that they have opportunity to have structured and planned time to sleep. This will clearly need to involve the 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, will be all that is 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 for various practitioners, who practice with various styles, 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 fir for them. Get to know these practitioners, 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 is done in conjunction with therapy. It can be especially helpful to treat traumatic experiences and work with PTSD. You can learn more about this technique here.
- 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 tool box. The most common class of medications used to treat PPMD is Selective Serotonin Reuptake Inhibitors or SSRI’s, 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 on these medications, to not have judgement about some people requiring them and to have resources for clients to access them if you cannot prescribe them. Medication is not a quick fix, it will still be necessary to practice other interventions and have close follow up. Eventually, most women will be able to wean off medications after a time and that process will require management and supervision. Also, be clear with her 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. Assumptions about who is at risk should never be made and we should 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:
This article originally appeared in Midwifery Today, Issue #121, Spring 2017 which can be purchased here. I highly recommend getting the whole magazine as it is full of great information.
Image credit Aubre Tompkins, CNM