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When Baby Blues Darken

Malkie Schulman

The term “postpartum depression” is actually a misnomer. Signs of the condition often start during pregnancy, and depression is not always the telltale symptom. New research is changing the way doctors diagnose and treat this challenging — but highly treatable — condition

Wednesday, April 18, 2018

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“I felt like such a failure. I was supposed to be a nurturing mom and I couldn’t hold my baby without having a panic attack. The guilt consumed me. Some days I couldn’t get out of bed. I would shut the curtains and literally hide under my blanket and wait for the waves of panic to overtake me”

I t was only in hindsight that Leah realized that her postpartum depression (PPD) started before she gave birth.

“I had these obsessive thoughts during my third pregnancy — like I didn’t believe the ultrasound that showed everything was fine with the baby. I knew I wouldn’t be able to relax until I was able to count those ten toes and ten fingers,” shares Leah, who was diagnosed with PPD after both her second and third pregnancies.

“During the whole third pregnancy, I kept saying to myself, ‘You’ll be fine, Leah, you won’t get postpartum depression like you did last time.’ I woke up with these obsessive thoughts, spent the whole day ruminating on them, and went to sleep like that.” Even more alarming was the rage that would wash over her while she was driving, making her want to crash into things.

Most people assume that “postpartum” depression begins after delivery, as the name suggests. But recent research indicates that, in many situations, depression and other mental disorders often begin while the baby is still in the womb. A 2015 study involving more than 8,200 women from seven countries found that in those with the most severe symptoms — suicidal thoughts, panic, frequent crying — symptoms most often began during pregnancy, not after giving birth.

These findings are backed by other research. “Of those women who present with postpartum depression, about 50 percent of the time the depression most likely started during pregnancy,” reports Meredith Weiss, MD, assistant professor of psychiatry at New York Presbyterian Hospital, and board-certified staff psychiatrist and assistant training director at The Motherhood Center of Manhattan, a facility that provides supportive services and treatment options for new and expectant mothers.

The term “postpartum depression” is a misnomer on another account, adds Dr. Weiss, because the condition is not necessarily characterized by classic depression, as previously thought. “We’re finding that women with this disorder have a lot of anxiety during pregnancy and the postpartum period. They also may have panic disorder, obsessive compulsive disorder (OCD), or psychotic episodes, among other psychiatric disorders.”

There are no definitive studies indicating that this is the primary cause of PPD, although it is the primary cause of the baby blues — which, Dr. Weiss stresses, is a totally normal phenomenon

Tamara associated PPD with depression, so she never entertained the idea that she might be suffering from it during her second pregnancy. “I wasn’t sad, I was active. I was busy volunteering and participating in community events,” she says. Though Tamara wasn’t depressed, she did experience periods of inexplicable rage and emptiness.

Because of the confusion caused by the name PPD, most clinicians today actually refer to postpartum depression as PMADs — perinatal mood and anxiety disorders. This is just one example of how the medical community at large is changing its approach to both diagnosing and treating this condition, which, according to the American Psychological Association, affects up to one in seven women.

 

Hiding Behind a Plastic Smile

Yad Rachel is a community-based organization in Lakewood, New Jersey, that services women suffering from, or who are at risk for, PMADs. The team there includes Bashie Reiss, LCSW, and Miriam Lowinger, LSW, who specialize in helping women suffering from anxiety and depression. They say that many clients don’t drag themselves into Yad Rachel looking disheveled, like they haven’t been out of bed in weeks (although there are those who do). “Many women look better than you or me. They’re put together; their houses are neat. They’re fulfilling all their outward responsibilities. But inside, they’re falling apart,” says Miriam. 

“I didn’t stop functioning when I had my baby — I was over-functioning,” Leah shares. The fake smile plastered on her face fooled everyone but those she confided in. “Nobody knew that I returned to work four weeks after my daughter was born because I felt I needed to get away from her,” says Leah, who remembers giving her newborn daughter a bath and feeling hatred, with the terrible thought of “the water can go over her and drown her” going through her mind. “Even today, no one except for close friends knows that I’m taking three types of antidepressant and anxiety medications to function.”

Tamara says she was so deep into her disorder that even after her daughter was born, she didn’t realize anything was wrong. Thankfully, her husband did. “He noticed that I wasn’t bonding with my child at all,” she says. “He sat me down and said he was going to make an appointment with a psychiatrist for me. That’s when I burst into tears. I felt like such a failure. I was supposed to be a nurturing mom and I couldn’t hold my baby without having a panic attack. The guilt consumed me. Some days I couldn’t get out of bed. I would shut the curtains and literally hide under my blanket and wait for the waves of panic to overtake me.”

The psychiatrist, who first saw Tamara two months post birth, quickly diagnosed the problem: “He told us that my symptoms were classic PPD and immediately started me on medication.”

Everybody agrees that the sooner the disorder is detected, the more effective treatment will be. “This applies on many levels,” contends Bashie. “The earlier the woman gets help, the fewer unhealthy neural pathways are created, the less time it will take to lessen the symptoms. Also, the less collateral damage will be created. A woman who is suffering from PPD does not suffer alone — her husband and children suffer along with her.”

Another major concern is that PMADs affect bonding and attachment, which are vital for a newborn’s emotional, psychological, and physical development. A mother who is laid low by a PMAD will have a harder time bonding with her child.

“If the problem is treated after six weeks instead of nine months, the damage done to everyone will be much less,” Bashie emphasizes. And if you can catch the problem during pregnancy, all the better. Studies have shown that severe depression and anxiety can actually change the environment in the uterus. Cortisol, a hormone that’s produced during times of stress, is released into the uterus and may be unhealthy for the growing fetus. It has also been documented that women with very high levels of cortisol are more likely to give birth early and have babies with low birth weight and smaller head circumference.

 

Who’s at Risk for PMADs?

Postpartum depression was once thought to be primarily due to plummeting hormones of progesterone and estrogen after delivery. But, in fact, there are no definitive studies indicating that this is the primary cause of PPD, although it is the primary cause of the baby blues — which, Dr. Weiss stresses, is a totally normal phenomenon.

Giving birth is a shock on the body for many reasons; one of them is the loss of progesterone and estrogen hormones at birth. Yet if all other factors are on board, says Miriam, the brain will be able to reregulate and get back to its job. The mother will just have the normal baby blues. But if other factors are not in place, then this can lead to a postpartum reaction.

Today, doctors understand there might be a host of factors that contribute to PMADs. The multifactorial approach consists of the biological/genetic component, the psychological component, and the social/environmental component.

The biological factor will take into account the woman’s personal history and her family history. For instance, a woman who historically has mood symptom changes around her reproductive cycle, such as severe PMS, might be more at risk for developing PMADs. Sometimes when women nurse, they experience feelings of sadness when their milk comes in, a condition known as dysphoric milk ejection reflux. There are also women who experience panic attacks specifically when they stop nursing, so each case has to be assessed individually.

The psychological family history is also examined. Does Mom or Dad have a mood disorder? If a woman has a personal or family history of depression, anxiety, OCD, or panic disorders, she’ll be predisposed to PMADs. If she had PPD with a previous birth, she’ll also be at greater risk. It’s also important to focus on the woman’s psychological makeup, says Bashie. For instance, is the woman a perfectionist? Is she an optimist or a pessimist? Does she have a healthy perspective on life?

Bashie might also look at what kind of modeling the expectant mother had for dealing with stress. Sarah, who suffered from panic attacks during her pregnancy and was diagnosed with PPD after giving birth, didn’t grow up learning how to successfully cope with difficulty. “My mom had a hard time handling any discomfort,” Sarah shares. “She didn’t model the idea that, as a mother, even if you’re not feeling well, you can cope and take care of your children.”

For instance, if Sarah’s mother was tired, she’d leave her children by themselves and take a nap. As a result, Sarah’s reaction was to freak out whenever she felt herself getting sick when she still had the responsibility of caring for the kids. She had to learn that it’s okay to be physically uncomfortable, and that, even in a weak state, you can still function and take care of your children.

Finally, the environmental piece is also crucial. Does the expectant mother have close family living nearby? Are they supportive? Is her husband helpful? Are there a lot of other children at home? Did she move recently? What’s the financial situation at home? “Financial stress is huge,” emphasizes Miriam. “It can follow you every single moment of the day.”

Other risk factors include significant stressors like divorce, trauma, or difficult family dynamics or relationships. Miriam adds that in our frum world, newlyweds often move to a new community, start a new job, and have a baby all in a relatively short time. These may all be positive changes, but nevertheless, they do cause stress, and can be a factor in determining whether a woman might develop PMADs.

 

Red Flags Doctors Look For

When a woman comes to The Motherhood Center at any point in the perinatal stage, she is asked if she has experienced any of the following symptoms: a sad or depressed mood, or a decrease in or loss of interest in previously enjoyed activities; a change in sleep habits ( too much or too little); feelings of guilt; decreased energy; a change in appetite ( increased or decreased); feeling agitated or lethargic; and devloping thoughts of hurting herself or the baby.

“However,” Dr. Weiss stresses, “this constellation of symptoms is only diagnostic for depression, not for other disorders of PMADs, which include, but are not limited to, panic attacks, anxiety disorder, and OCD.”

At Yad Rachel, “we first want to find out what the patient’s baseline is — what is her normal level of functioning, behavior, and mental health?” says Miriam. A key way to determine if there’s an issue that requires intervention is the acronym FID — Frequency, Intensity, and Duration. This means any mood change that’s accompanied by more intense feelings around it, lasting for longer periods of time, and occurring with increasing frequency.

For example, it’s normal to worry about your newborn and call the doctor even a few times a week. But when the new mom is calling the doctor 10 or 20 times a day, or calling her mother 10 or 20 times a day, then there might be an issue. Or sometimes a woman might be feeling sad and not want to socialize. But if this is how she’s feeling a majority of the time, that may signify a problem. Developing acute fears is another possible clue for PMADs.

Obsessive thoughts can indicate PMADs, too. When a woman starts to obsess over something specific, it creates a lot of anxiety and can become very frightening. “I had a nurse for the first six months and the same thoughts kept repeating in my mind nonstop: Do I need a nurse? No, I don’t need a nurse. Yes, I do. No, I don’t. It caused so much anxiety,” says Tamara. “Then I would start on, Is the baby eating enough? Why am I not coping? I’m such an awful mother. Everybody else manages except for me.”

Six weeks after giving birth, Sarah went to her sister-in-law’s wedding and ended up hiding in the kallah room crying. “I had left the baby with the nurse, but the entire night, I was obsessing about the nurse running off to Jamaica with my baby. I called her every 20 minutes and if she didn’t answer, I had a panic attack.”

Bashie shares a subtler example of obsessive thinking. “A pregnant woman whose teenage child was acting out in school became obsessed with what she could do to help him. Nobody recognized this as PMADs because they thought it was situational. It made total sense that this mother was going to obsess about her at-risk child. It’s tricky, but we recognized her symptoms as pathological because of the frequency, intensity, and duration.”

Extreme and suicidal thoughts are also common in women suffering from PMADs, causing anguish in the moment and long afterward. “Two weeks after my son was born, a voice in my head started screaming  and telling me to bash him against the wall. I know now it was not me, it was my hormonal imbalance, but it was terrifying and I hate thinking about it today,” says Sarah, who also had thoughts about ending her life: “I went into the shower and turned it on to the hottest temperature because I wanted to burn myself.”

In Dr. Weiss’s practice, she sees a lot of women with OCD. “Sometimes the behavior will exhibit before the baby is born and sometimes afterward. Some possible behaviors might include excessive bottle or pump equipment cleaning, or there may be elaborate rituals around diapering the baby and/or feeding the baby. It may take the form of incessant Internet searching or Googling before the baby is born or, postnatally, becoming excessively worried because she went over a bump when the baby was in the stroller. It’s similar to regular OCD but now the object of the obsessions and compulsions is the baby instead of, for example, dirt and germs.”

Dr. Weiss clarifies that these worries are different from the experience of first-time pregnancy or motherhood in that they take up huge amounts of time during the day, and possibly the night, and can interfere with eating, sleeping, and personal-hygiene patterns. “Also,” notes Dr. Weiss, “generally, a first-time mother can be reassured. It’s normal to have some anxiety, but it becomes pathological if the woman does very little else but worry.”

 

Getting the Right Help

Treatment for PMADs depends on what the underlying cause(s) of the condition is and how soon it’s detected, but since usually it is a combination of psychological, environmental, and biological, care providers will work on addressing all three.

Psychotherapy is most effective for teaching healthy thinking patterns, says Bashie. Disciplines like cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT) are particularly effective and teach important life skills. They help women to think more positively, learn how to self-regulate, work on not being overly sensitive, gain the ability to laugh things off, and eliminate the “shoulds.”

Leah feels strongly that not only the meds but the behavioral changes she learned to make were crucial in her healing. “I was able to take care of my children all day but after they went to sleep, I’d watch hours of videos. My therapist worked with me slowly. ‘Can you take a break for ten minutes just to put the dishes away?’ That became my goal in the beginning.”

Regarding psychotropic medication, Dr. Weiss posits that those who have mild to moderate symptoms may not need medication, while those with moderate to severe symptoms may have symptomatic indication for psychotropic medication. “We try to optimize everything else before we go to medication,” Dr. Weiss emphasizes. This means, among other strategies, encouraging women to maintain healthy diets, get adequate sleep, and go to weekly therapy sessions.

Dr. Weiss points out that not taking medication when indicated may be more damaging to the baby in utero. There’s a significant amount of medical literature on the topic suggesting that there’s no direct negative outcome to the baby when a woman takes psychotropic medication as prescribed, whereas there are known possible negative obstetrical outcomes associated with severe maternal depression.

Although Sarah’s PMAD was severe and she needed to take antidepressants, she also says that exercise and diet played a role in her recovery. “I know that sugar aggravates me. I also eliminated heavily processed foods from my diet, which helped as well.” Other measures Sarah took to help with her PMAD were to get adequate sleep and to reach out to others in her situation. “Joining a support group for women with PMADs was a game changer for me,” Sarah says. “Just having other women in the same space as you and validating your experience is helpful.”

As for the environmental stresses, care providers generally try to get more family on board to pitch in and help, and to encourage women to work on self-care — whether it be through hiring a nurse like both Tamara and Sarah did, having the husband participate in family care, postponing returning to work for a few months, or reducing hours at work.

Miriam points out that while a woman may be proactive and do all the “right” things to prevent a postpartum reaction,  sometimes the biological risk factor may be stronger than her attempts. “It’s important not to fall into a thought pattern of self-blame and the belief that if she only tried harder, she wouldn’t be suffering from postpartum depression or anxiety,” Miriam says. “One of Yad Rachel’s clients was a woman who ate and slept properly and got a nurse while her mother took care of her other children after birth. But she still got a PMAD and had to be on medication.”

There are many preventive measures a woman can take to either lessen the effects of PMADs or eliminate them altogether. For instance, maintaining normal sleep habits, obtaining physical and financial help before the situation is out of hand, getting the husband to help, and working with the husband’s expectations of his wife. Even addressing and eliminating one risk factor can go a long way in mitigating the severity of the disorder.

The longer a woman waits to get the help she needs, the harder it will be to get back to herself, experts agree.

For Leah, rabbinical guidance was indispensable. “When we discovered I had a PMAD, we immediately discussed it with our rav. He stressed the importance of taking care of myself physically and emotionally so I could be there for the family I already have. In the beginning, I didn’t want to tell my parents and siblings about my PMAD. But it just made it harder on me because I missed out on their help and support. Now I feel more accepting of who I am. I understand that having PMAD doesn’t mean I’m an inadequate mother.”

Even when she’s not pregnant, Leah continues with her CBT and breathing exercises. This doesn’t surprise Bashie: “Some women,” she says, “report that their PMAD was actually a blessing in disguise because it forced them to learn crucial life skills that are important in every aspect of a person’s life.” 


(Originally featured in Family First, Issue 588)

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