Oscar-winner Gwyneth Paltrow suffered from it. “Friends” and “Cougar Town” star Courteney Cox did too. Brook Shields and Marie Osmond both penned memoirs about their experiences with it. “Nashville” star Hayden Panettiere openly admitted seeking treatment for it in real time in the hopes of helping other sufferers.
Just as Asperger syndrom falls within an autism spectrum, postpartum depression (PPD) falls within a perinatal depression spectrum – a wide range of mood disorders that can affect women during pregnancy and for as long as the first 12 months after giving birth.
“Postpartum depression is a common problem we deal with in our practice,” said Peter Gearhart, MD, of Penn Ob/Gyn and Midwifery at Pennsylvania Hospital and a clinical assistant professor of Obstetrics and Gynecology. Studies vary but a conservative estimate is that about 15 percent of patients will experience postpartum depression. Additionally, molder forms of depression and anxiety can also significant'y impact a new mother's ability to function.l
“To put it into perspective, it’s important to note that the percentage of patients who experience postpartum depression is much higher than the number of patients who are diagnosed with gestational diabetes, which is between two and 10 percent,” Gearhart said.
While the term PPD is a fairly modern one, the disorder is nothing of the sort. It was recognized that some women experienced mental illness after giving birth long before the condition had a name – like way back in 460 B.C., when Hippocrates was writing about “puerperal fever” which produced “agitation, delirium and attacks of mania.”
“PPD is usually an anxious depression such that ‘scary’ or obsessive thoughts are common,” said Deborah Kim, MD, the chief of the division of Perinatal Psychiatry at the Penn Center for Women's Behavioral Wellness, and an assistant professor of Psychiatry. “They can range from fear of dropping baby to actual thoughts of harming baby. Actress Brooke Shields wrote about this in her memoir. These women feel guilty and bad about these thoughts and tend to avoid the baby when they have them – avoidance being the behavioral correlate of anxiety.”
Actress Panettiere who, in a twist of irony portrays a television character also suffering from PPD, opened up about her condition to talk show hosts Kelly Ripa and Michael Strahan about a month before voluntarily checking herself in for treatment. "I've never ever had those feelings,[of self-harming] and some women do. But you don't realize what broad of a spectrum you can really experience that on. And it's something I think that needs to be talked about and women need to know that they're not alone and that it does heal."
Kim thinks it’s helpful when celebrities share their experiences in the hopes that they will help other women seek the help they need. “Women are afraid of being shamed and judged so they will not discuss their PPD and upsetting anxious thoughts,” Kim said. “They are so afraid we will take their child or hospitalize them but most of the time that's not necessary, especially with proper and timely diagnoses and early intervention. Women are so relieved to hear these scary thoughts are common – and that there’s help.”
It’s important to note here that postpartum depression and anxiety are not the same as experiencing the “baby blues.” Many women experience feeling sad, stressed, tired, anxious, weepy and lonely – that is what is characterized as “baby blues” after giving birth. Unlike the baby blues, PPD does not go away on its own. “It can appear a few days or even months after giving birth and if untreated, it can last for many weeks or even months,” Kim said. The most serious of all in the perinatal depression spectrum, postpartum psychosis can cause delusions or hallucinations, and while it may garner the most headlines, it is very rare — approximately 0.2 percent of births.
PPD can make difficult, if not impossible, for a woman to take care of her baby or herself. PPD does not discriminate. It affects women who have had easy pregnancies as well as difficult pregnancies, first-time mothers, and third-time moms, regardless of age, race, ethnicity, education and income.
“It takes a team to manage postpartum depression,” Gearhart said. “Starting with the very first prenatal visit, we screen patients for risk factors and encourage them to initiate therapy during their pregnancy either prophylactically if they have a lot of potential to develop depression or if they begin to have depression. After delivery, screening continues in the hospital on postpartum day one. “
Risk factors include: history of previous pregnancy with postpartum depression; history of depression or anxiety; relationship difficulties; fertility difficulties; multiple gestation (twins, triplets); domestic violence, difficult birth experience, infant health issues; and lack of social support after delivery.
According to Gearhart, a four-step approach can be deployed to provide proper, timely and effective diagnosis for women suffering from PPD.
"Normalize" don't Stigmatize
The first step is to acknowledge the problem and engage the patient and ideally her partner as well, in a discussion of the problem. Explaining the multifactorial roots of the problem involves equal parts of sleep deprivation, hormonal shifts and self-perception changes of the tremendous new responsibility new parents are given. “I usually try to include personal experience,” Gearhart said. “I am one of the four to eight percent of fathers who had a mild form of postpartum depression after the birth of my second child. I think it’s helpful for patients to see that I am not afraid to admit my experience and it gives them some perspective,”
Encourage patients (and their partners) to meet with a therapist specializing in PPD for a few sessions if symptoms are not abating. “Sometimes, a patient may just need to learn some coping strategies, such as how to use cognitive behavioral changes to get through this generally transient condition,” Gearhart said. Sometimes, patients will need longer treatment and or medication, but relief is a reality with proper, timely intervention. It’s critical for those at risk for continued depression or postpartum psychosis to get a mental health expert involved early, especially those already suffering from or diagnosed with depression. Women on properly supervised medication for depression during pregnancy are less likely to develop PPD after.
Antidepressant medications definitely have a necessary role for some PPD patients, but medication alone is not as effective as when used in combination with therapy. It is not uncommon for an obstetrician to write the initial prescription for an antidepressant. “Strict oversight here is key,” Gearhart said.
Being prepared and having a plan of action is essential. “Women must always be engaged and encouraged to talk about the risk of worsening symptoms – especially progression towards suicidal tendencies or worse.” Gearhart said. “If they ever begin to think about these things, they must promise to call a defined person or place – their OB, health care provider, the Emergency Department of their local hospital, a therapist – a specific professional care provider who can safely and effectively intervene.”
Beyond the clinical setting, Kim is conducting research for new ways to treat perinatal depression, including a National Institute of Mental Health-funded study focusing on the use of a novel non-pharmacologic treatment for depression during pregnancy.
“We’re using transcranial magnetic stimulation (TMS), which may allow women with depression during pregnancy to forgo taking medications,” Kim said.