How is postpartum depression (PPD) different from depression that is not related to childbirth? Excellent question. And one that you’ll need a good answer to when your clients ask you.
And they will.
According to the Diagnostic Statistical Manual (DSM IV), postpartum depression is distinguished from other major mood disorders by the “postpartum” specifier: Postpartum Onset. This specifier defines PPD as a depressive episode that begins within four weeks of giving birth. Doesn’t give us much wiggle room, doesn’t it? But we know that 60% of patients have an onset of symptoms within the first 6 weeks postpartum (Z. Stowe) and others report that postpartum depression is usually diagnosed within the first three months postpartum. And what about all the women we see who come to us five, six, eleven months postpartum?
We’ve all heard the joke: Is it possible to have postpartum depression after 21 years? She won’t leave the house!! What’s not so funny is that postpartum depression can and does linger. Our clinical experience shows us that it can emerge any time during the first postpartum year and due to the excessive demands – physically, emotionally, biochemically, environmentally – many specialists extend the diagnostic period to the first two postpartum years.
Simply put, postpartum depression is the presence of a clinical depression during the postpartum period. In that way, postpartum depression is exactly like any other depression that is unrelated to childbirth. But there’s more to it than that.
Take a look at the symptoms of depression, as put forth in the DSM IV, (present in a two week period, five or more of these symptoms):
(1) depressed mood most of the day
(2) markedly diminished interest or pleasure in all, or almost all, activities
(3) significant weight loss or weight gain or decrease or increase in appetite
(5) psychomotor agitation or retardation
(6) fatigue or loss of energy
(7) feelings of worthlessness or excessive or inappropriate guilt
(8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
(9) recurrent thoughts of death.
Consider the woman who is feeling five or six or all of these symptoms listed above as many of our clients do. It’s hard for her to get out of bed, difficult to get herself ready for the day and virtually impossible to think about anyone or anything else other than how she feels. As her symptoms begin to define her, the feelings of sadness, fatigue, exhaustion, inadequacy, uncertainty and suicide permeate her day. Under the best of circumstances, even with sufficient support and excellent healthcare, this is a distressing picture.
Now, imagine this same woman with an infant. Just the two of them. Overwhelmed by a quintessential force that feels both euphoric and inconsolable, she looks into the eyes of a child she doesn’t know. She questions everything. How will I do this? Why did I have this baby? What is wrong with me? Can someone take the baby away? Can I go away?
Imagine the strain, the pressure, the utter disbelief in her capacity to respond appropriately. Little things become big things and big things become insurmountable. The inability to take care of herself makes it feel impossible to care for anyone else. When a woman does manage to care for her infant by going through the motions and dissociating somewhat from her core pain, she may be able to carry this off for a while. When her sheer survival depends on the success of her deception, she is left with shame and an empty heart.
This juxtaposition of one of life’s greatest gifts and one of life’s most unkind illnesses is what makes postpartum depression different from “regular” depression. It’s hard to put into words, but this is what we mean when we say, it’s the same, but it’s very very different.
An analogy inspired by my creative co-author of This Isn’t What I Expected, Valerie Raskin Davis, MD, explains it this way:
Imagine two women going in for operations, one to have a kidney removed, one to have a breast removed. In both cases, the women will experience many similar things; they will both will undergo anxiety, surgery, pain, recovery, and the loss of a body part. But in addition, the woman who loses her breast will experience feelings and changes related to sexuality, self-esteem and self-identity.
So in many important ways, the two are exactly the same.
But in this way, the two are very, very different.
Adapted from Therapy and the Postpartum Woman (Routledge, 2009)
by Karen Kleiman, MSW, LCSW