Moms Who Kill

The National Institute of Mental Health is examining these hormone-mediated mood shifts and Victor Pop, Ph.D., of the University of Tilburg in the Netherlands, has presented his own findings at the annual meeting of London's Royal College of Psychiatrists, suggesting that women who produce certain thyroid antibodies during pregnancy were nearly three times more likely to experience depression after childbirth.

"I think there will be a role for hormones in treating postpartum illnesses in the future," says Valerie Raskin, M.D., clinical associate professor at the University of Chicago. "[Hormones] will probably be used as a treatment first, then later as a preventive measure. The reproductive process may be the kindling, and the drop in hormones after childbirth may be the ember that starts the fire."

Various nonhormonal factors may also contribute to postpartum disorders of mood. Some studies suggest a relationship between a traumatic obstetric experience and PPD. Women who had caesarean deliveries, for instance, were significantly more susceptible to mood disorders as noted in one study appearing in the Australian and New Zealand Journal of Psychiatry.

Thyroid disease may also be a physiological trigger, suggests research by Stephen Pariser, M.D., a psychiatrist and mood-disorders specialist at Ohio State University Medical Center. Women's thyroid levels drop significantly after giving birth, and low thyroid levels have long been associated with depression-like symptoms. Having a personal or family history of mood disorders also increases the odds of developing PPD, pointing to a possible genetic factor.

Women who develop PPD or postpartum psychosis following delivery have a significantly greater risk of developing these conditions after subsequent childbirth. These women should be counseled about future pregnancies. If they do conceive additional children, careful psychiatric monitoring is mandatory.

Certainly, social elements also play an integral role in postpartum well-being. One important factor is a lack of social support, which includes poor relationships with others and insufficient childcare during the pre- and postnatal period. Strong support systems can help nurture and maintain self-esteem at stressful times, Kleiman asserts. "In turn, high levels of self-esteem are linked with adaptive coping behaviors—feeling entitled to ask for help, for example."

As a society, we tend to romanticize motherhood, creating a disparity between a woman's expectations and the reality that she will experience. "Society reinforces the myth of the perfect baby in the arms of the perfect mother, with all her maternal instincts intact," says Kleiman. "When there is a significant discrepancy between what a woman anticipates and what she actually experiences, guilt, confusion and great unhappiness can result."

In addition to societal pressures, personal adversities such as loss of a loved one, marital conflict or lack of financial security, can put some women at greater risk, according to PSI. Lifestyle and role changes also create internal conflict and stress: A new mother may lose the independence, spontaneity, personal time, sleep and physical shape that she once had, along with her role as an attention-drawing pregnant woman or as a career woman. Finally, she may simply miss adult company in general. "Women with PPD will find adapting to these losses especially difficult," Kleiman notes, "because of their increased vulnerability."

Mending Mothers

Most experts agree that combining talk therapy with medication seems the most successful approach to treating PPD. "Medication is warranted," Raskin explains, "because the situation is urgent and the quickest treatment makes sense." Depending upon the patient, psychotherapy may be combined with both group support and medication, which is prescribed according to the patient's individual symptoms while monitoring the various drugs' side effects.

The most commonly prescribed are the newer antidepressants including Prozac, Zoloft, Paxil, Celexa, Wellbutrin, Serzone and Effexor, as well as antianxiety drugs such as Ativan, Lorazepam and Klonopin. When the underlying cause of PPD is bipolar affective disorder, mood stabilizers—Lithium or Depakote, for instance—are also appropriate.

For women experiencing postpartum psychosis, more aggressive treatment is required. These mothers may be a threat to both themselves and their babies. Psychiatric hospitalization, as well as antipsychotic and other psychiatric medications, is standard treatment along with individual, group or cognitive behavioral psychotherapy.