“It’s okay to tell me that you’re not okay.”
Postpartum depression (PPD) and postpartum or perinatal mood and anxiety disorders (PMADs) are the most common medical concerns for women after childbirth. Yet few medical and mental health professionals really know how prevalent and serious PPD and PMADs are.
There is a great need for better screening to identify women struggling with postpartum disorders. Likewise, more therapists and mental health providers need to know about treatment approaches that are effective in stabilizing and managing symptoms. Those who work with pregnant women and new mothers, as well as children, are in a good position to help.
A Surprising Number of Women Screen Positive for PPD
In the largest study to date, Northwestern Medicine researchers found that one in seven new mothers (14% of the 10,000 interviewed by telephone) screened positive for depression between four and six weeks after giving birth. Among those who received follow-up for the first year after giving birth, 22% had experienced depression.
The most common follow-up diagnosis among the 14% who screened positive was major depressive disorder. Almost two-thirds of these women were found to have additional conditions including anxiety and bipolar disorders.
Occurrence of Other PMADs Also Needs Greater Awareness
Women who experience obsessive thoughts and anxiety are often very confused by their symptoms, because they come unexpectedly and are widely misunderstood. The obsessive-compulsive thoughts and crippling anxiety of these disorders receive even less attention than PPD.
Some brief information on these disorders:
• Postpartum Obsessive Compulsive Disorder (PPOCD) is diagnosed for 3-5% of postpartum women. Brain imaging studies show that the active area is the part that controls maternal instinct, or protective behavior. PPOCD appears to come from intrusive protective (maternal) thoughts.
• Celebrity Brooke Shields struggled with a postpartum mood disorder and is helping raise awareness in her book, “Down Came the Rain.”
• 50% of women with bipolar disorder are first diagnosed during postpartum care.
• 60% of bipolar women present initially as depressed during postpartum care.
• 85% of bipolar women who stop taking medication during pregnancy will experience a relapse of symptoms before the end of pregnancy, according to this study.
Mothers Reluctant to Report Symptoms
Despite these findings, postpartum mental health conditions still go unrecognized and untreated for many women. This situation is partly because many new mothers feel too ashamed to admit to the difficulties they are having.
Also, professionals may not be fully aware of the latest information about the nature of perinatal mood disorders, their prevalence and how to screen pregnant and postpartum mothers more effectively.
Among the 14% of women in the Northwestern Medicine study who screened positive for PPD, some raised very serious concerns.
“We discovered 20% had suicidal thoughts; these are thoughts of death, thoughts of wanting to die, not wanting to wake up,” said one study investigator, Dorothy Sit.
It is likely that some women’s lives were saved because of follow-up care offered to study participants. However, “some patients with very severe symptoms had made the decision to take their lives,” Sit reported.
Like study author Katherine Wisner, M.D., I agree that undiagnosed PPD is a huge public health concern. As medical and mental health clinicians, we can do more to address these issues. Greater awareness among doctors, nurses, obstetricians, pediatricians and mental health professionals is critical to meeting this underserved need.
Why Women Hide Their Symptoms
Just about every woman with a new baby will say it’s a wonderful time. But it’s important to realize that not every woman will truly feel this is the happiest event in her life. She may very much want to experience the love and joy that she expected.
But many women are confused and alarmed to discover they do not − and cannot − feel the elation and other emotions others believe are “normal” for new mothers.
Doctors (and therapists, too) need to know that a woman at risk for postpartum depression, anxiety or other mood disorder may look and behave like any other new mom. Mother and baby come to their appointment on time. Mom is dressed and has her makeup on. The obstetrician or pediatrician sees that she looks good. It may seem as if there is no need to check for depression.
But there is a real need for doctors to ask more questions and to take time to look below the surface.
The Need to Ask the Right Questions
Well-intentioned pediatricians and obstetricians may simply ask, “How are you doing?” Between chatting, admiring the baby and reviewing patient records on the computer, the mom’s emotional state may only get a passing glance.
Truly screening for PPD means knowing that many mothers who are struggling also desperately want to look and play the part of a “normal mom.” They are afraid to broadcast that they do not feel all right.
Asking the right questions means going beyond “how are you?”
Greater knowledge of symptoms and assessment tools can make a big difference in our ability to recognize postpartum mental health issues as clinicians. Some common screening tools include:
• The Edinburgh Postnatal Depression Scale (EPDS), published in 1987. This screening tool is the most common for PPD in the general population. It is freely available in print and online and provides a number score that can help signal the degree of risk for depression.
• The Mood Disorder Questionnaire (MDQ) was developed around 2002 to help screen for bipolar spectrum disorder. It contains 15 questions and can be used to help evaluate the pattern of symptoms and the need for further assessment.
• The Postpartum Distress Measure (PDM) came about in a 2011 study to help find a tool to assess postpartum distress, including depression and anxiety.
The Postpartum Stress Center (PPSC) provides free downloadable copies of these tools, plus additional assessment tools to help clinicians recognize and talk about issues with women who are struggling with symptoms. Some of these tools include:
• The PPSC Suicide Assessment – These follow-up questions are intended for clinicians who administer the Edinburgh Postnatal Depression Scale and wish to do additional screening.
• Postpartum Psychosis Emergency Room Screening Guidelines – This fact sheet is for healthcare workers and first responders to help them recognize psychotic symptoms and the urgency of the situation so they can get appropriate support promptly.