Birth and the Blues

For too many American women, the birth of a baby is less the arrival of a bundle of joy than a passage to depression.

Childbirth is an emotionally intense event; mood changes in the days following delivery are particularly common. Up to 85% of new mothers may experience mild postpartum "baby blues" beginning three days after birth. However, they usually resolve on their own within 14 days.

Postpartum depression is a more severe condition that typically begins two to three weeks after delivery and lasts for at least two weeks, sometimes over a year. Approximately 10% to 15% of women in the U.S. suffer from the sometimes debilitating disorder.

Most of them, however, do so in silence. They may be persistently sad or experience mood shifts, crying, feelings of anxiety or of being overwhelmed, inability to sleep, irritability or agitation, and poor appetite. A woman may lose interest in caring for her child.

Despite the prevalence of postpartum depression, it carries risks to the mother, to the child's development and even safety—and to every family member. Nevertheless, it remains a largely hidden disorder.

More than half of women with the disorder do not seek professional help. And for those who visit family doctors the condition is missed up to 50% of the time.

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Those most at risk have had a prior depressive episode before pregnancy or a family history of depression. In addition, women who have an unwanted pregnancy, have experienced complicated labor or delivery, who lack social support, or who have experienced some form of major stress such as the death of a loved one are also at increased risk. A woman who suffers depression after the birth of a child is three times more likely to develop depression following a subsequent birth.

Depression at any time reflects the interplay of many factors, and experts believe that postpartum depression similarly results from the complex conjunction of biological and psychosocial factors. Childbirth is a time of hormonal upheaval—and of major psychological adjustment.

Labor and childbirth are accompanied by dramatic changes in estrogen, progesterone, and even the stress hormone cortisol, among others. All of these hormones are known to influence functioning of the nervous system. Yet studies have not demonstrated that normal postpartum shifts in hormones are responsible for pathologic mood changes in women.

At least not by themselves. Experts point to the fact that the postpartum period is a very fragile time of psychological and social reorganization for all women. What's more, it's particularly challenging in U.S. culture, where new mothers are relatively isolated despite a heightened need for social support. Studies show that feelings of isolation and lack of support—from partners, family members, physicians, or friends—are particularly acute among those women who develop postpartum depression.

For most women, the birth of a child represents a huge change in lifestyle as well as identity. And for anyone in the brand new role of caring for a little stranger so totally dependent of their ministrations, the early days of motherhood challenge anyone's sense of competence.

Maternal depression at any time poses risks to children because it threatens lack of parental responsiveness to children's needs. But postpartum depression is associated with special risks because it can disrupt the establishment of a secure mother-infant bond, which is the cocoon in which infant development takes place. Studies show that maternal depression occurring early in infancy can have enduring effects on a child's nervous system and behavior.

The tragedy of postpartum depression is not simply that it so often goes unrecognized, but that it does so despite the fact that childbirth is the time when women are most likely to seek out medical care.

According to the American College of Obstetricians and Gynecologists, most often new mothers are embarrassed about feeling unhappy at a time when society expects them to feel elated.

The hidden nature of postpartum depression has given Victor J. Pop, M.D., Ph.D., something of a mission. A professor of clinical health psychology at the University of Tilburg in the Netherlands, Dr. Pop has developed a blood test that can help screen women early in pregnancy and identify those who are at risk of developing depression after childbirth.

The Dutch doctor has found that women who test positive for a specific type of thyroid antibody by 12 weeks of gestation are three times more likely than other women to become depressed postpartum. The antibodies, for thyroid peroxidase (TPOAb), indicate an autoimmune thyroid disorder. It's not clear exactly how thyroid disease is linked to depression; but researchers have for some time recognized that activation of the immune system produces states of anxiety and depression.

The test does not identify all women who later exhibit postpartum depression. That's because many factors other than thyroid abnormalities influence development of the disorder. Even in his study of 300 women, those with a past episode of depression or major life trauma were also likely to develop postpartum depression. Still, 14% had the antibody in their blood.

"Especially during the postpartum period, tiredness, sleeping problems, weight loss, and other signs are regarded as related to the night feeding of the baby," says Dr. Pop. "Knowing that a woman has TPOAb may reduce the risk that depression is overlooked."

Treatment for postpartum depression depends on the severity of symptoms. As a first step, doctors usually seek to rule out the presence of thyroid disease or anemia.

Psychotherapy is usually indicated, alone or in conjunction with antidepressant medication, typically one of the SSRIs. But none of them has been approved for use by nursing mothers.

The best treatment for postpartum depression is prevention. Research has identified several strategies that can minimize the emotional upheaval of childbirth.

  • It's critically important for women to enlist the help of their spouse and others; every new mother needs social support and the availability of someone she can talk to about her worries and concerns.
  • Since the responsibilities of motherhood are learned, prospective mothers need information about their new job.
  • Interaction with other people who are experienced parents helps.

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