DE-MYSTIFYING POSTPARTUM DEPRESSION by Deborah Clemente, MA Sp. PSY.

Each year hundreds of thousands of women experience pregnancy and postpartum imbalance (commonly referred to as perinatal mood disorders). In conventional medicine, these disorders range from mild hormone-related mood disturbances known as the "baby blues" to a spectrum of perinatal mood and anxiety issues. As a holistic health counselor, I prefer to use the term "imbalance" instead of "disorder" for the simple fact that these issues are temporary and treatable. For example, biochemical imbalance (hormonal, neurochemical, nutritional) inhibits our body from manging stress and experiencing positive moods. When a new mom get's proper treatment in these areas, she becomes more balanced so she can meet the challenges of new motherhood with grace and ease.

As a mom who has healed many of these imbalances myself, I know that the terminology used can be a bit frightening and stigmatizing but it's important to know the terms so you are familiar with them when you speak with a licensed medical doctor. Think of them simply as words to help doctors communicate instead of labels. If you don't buy into the labels, they won't. 

The terms most commonly used to describe this spectrum are: antepartum depression and anxiety, postpartum depression, postpartum anxiety, postpartum OCD, postpartum psychosis and postpartum post-traumatic stress disorder. Symptoms begin as early as pregnancy and can first appear any time in the 12 months after birth. 

One thing I know from first hand experience is that postpartum imbalance is temporary and treatable when a new Mama seeks the help of trained physicians (Functional Medicine is particularly important), holistic health care providers and soul centered therapists who specialize in postpartum imbalance. However, many women do not get the treatment they need because they are looking for help in the wrong places. There is a misconception that every OB/GYN or physician will know how to promote healing in this area. Many new mothers are baffled that their own doctors don't know how to help them partly because there is very little detail about it in medical and nursing books so it's neglected in medical schools. And because there is so little training, OB/GYNs don't know how to properly diagnose it. Even worse, some are so misinformed that they don't think it's serious until a woman threatens suicide. Don't let this happen to you. If you feel your doctor is dismissing you, seek out a specialist immediately.

Until a mom can get to a postpartum specialist, I suggest she write the following intention down on a piece of paper: "I am safe, I am not alone. I will regain my balance and feel like myself again. I am receiving loving care and effective treatment as I partner with a postpartum specialist to heal any imbalances so I may become reclaim my magnificent self." 

DEFINING PERINATAL IMBALANCE
According to A Natural Guide to Pregnancy and Postpartum Health by Dean Raffelock, D.C., Robert Runtree, M.D., and Virginia Hopkins and Melissa Block, the scientific consensus is that postpartum depression (PPD) is multifactorial, which means there are many variables - hormonal, psychological and neurochemical. These factors share one important and commonly overlooked characteristic: The balance of each of these systems relies upon proper nutrition. If the nutritional building blocks that the body needs to make hormones, neurotransmitters, and other mood-altering body chemicals are not present in adequate amounts, mood and physical health can both be compromised."   And since the mind and body follows spirit, we must start healing at the spiritual level.
  
Although you'll read countless articles and books that say we don't know what causes these imbalances, I'm here to say that we do! Research shows perinatal imbalance is likely to result from a combination of three factors: biological, psychological and social. This is referred to as the biopsychosocial model. Another way to simplify this is to say that Perinatal Imbalance is likely to result from a combination of factors relating to Mind, Body & Spirit or what I like to call the biopsychosocialspiritual model:

Mind (psychological, emotional)
Body (biological, biochemical, nutritional, hormonal, neurochemical)
Spirit (energy, connections to society, source and self) 

The key in treating perinatal imbalance is to find caregivers who can do 3 things:
1) Screen for risk factors. 
2) Provide a comprehensive assessment.
3) Co-create a multifaceted biopsychosocialspiritual treatment plan that identifys the spiritual, psychological, biochemical, nutritional, hormonal and/or lifestyle support a new mother needs. 

The key for us as Mothers is to commit to the spiritual journey back to the self - to become empowered and enlightened! To MPOWER-UP and ENLIGHTEN-UP! We MPOWER-UP when we become informed. When we become informed we can make wise empowering choices. (For more info check out our MPOWER-UP and FAST FACTS pages) 

SPECTRUM OF POSTPARTUM EMOTIONAL REACTIONS
Nutritional, hormonal and neurochemical imbalance can affect women differently. Below are a list of symptoms compiled from (I'm Listening: A Guide to Supporting Postpartum Families, www.postpartumprogress.com, www.postpartumhope.com) and my personal experience working with Moms):

Antepartum Depression or Anxiety (13%-15% Moms / Onset Pregnancy) "I'm so afraid"
Sadness and unusual weepiness, lethargy, anxiety, insomnia, fear of pregnancy, low appetite, rumination, regret, intense fears.

Baby Blues (60-80% Moms / Onset within first 2-3 weeks) "This is hard - I'm overwhelmed" 
Crying, irritability, anger, insomnia, exhaustion, tension, anxiety, restlessness. 

Normal Adustment to change and Marathon of Motherhood: Crying/tearfulness, irritability, anger, sleep disturbance, fatigue, dysphoria (sadness), appetite changes, loss of interest in formerly favorite things/activities, anxiety, emotional lability (moodiness), feelings of dout, postpartum exhaustion (denial of depression/anxiety, feeling over-whelmed, unable to sleep/rest, head or stomach aches)

PostPartum Depression (10-20% Moms / Onset within 1st year) "I can't do this - I will never be able to do this." Mama's feel hopeless and trapped and want to run. (This is a worsening of baby blues or normal adjustment symptoms) depressed feelings that don't go away no matter what one does, feeling sad most of the day, more days than not, no energy-tired all the time, frightening feelings and thoughts, over-concern or no feelings for the baby, exaggerated anger or frustration, even over little things; these feelings targeted at baby or spouse, feelings of inadequacy (feeling like a failure most of the time), inability to cope, guilt, helplessness, hopelessness -see no hope of things will get better in the future, lack of interest in sex in spite of physically "being ready" to resume sexual relations, inability to enjoy things one used to enjoy, exaggerated highs or lows, inability to sleep even when the baby is sleeping, no appetite, no enjoyment of food or constant cravings and compulsive overeating, feeling that one would be better off dead than feeling this way, suicidal thoughts.

Postpartum Anxiety or Panic (10% Moms / Onset Any time first year) Rapid heartbeat, temp fluctuations, feeling of dread and apprehension, insomnia, dizziness. Comon fears: goin crazy, illness, losing sight or ability to breathe. Fear of being alone. Fluctuates in intensity and frequency.

Postpartum OCD (3%-5% Moms / Onset Pregnancy through first year) Repetitive and intrusive images, thoughts or fears that are disturbing or abhorrent to the mom. Anxiety about specific places (open spaces seem to trigger this) or activity, ritualized avoidance or compulsive controlling behaviors. Repetitive fears about health and safety.

Postpartum Psychosis (.1%-.2% Moms / Onset Birth-12 months) Hypomanic or manic symptoms, delirium, periods of delusional thought, possible auditory or visual hallucinations. Suspiciousness, withdrawal. May be denial of birth or glorification of baby.

Post Traumatic Stress (1.5% - 6% Moms / OnsetPregnancy through first year) PTS can result from anything that is 'experienced' as life-threatening. Symptoms are: Anxiety, panic, or intrusive thoughts related to specific event (e.g., birth or past trauma.) Recurrent images or nightmares, fears, ruminating, withdrawal and anger. Dissociation and depersonalization.

MAJOR RISK FACTORS 
Baby Blues: History of premenstrual depression
Postpartum Depression: 50-80 percent risk if mom had a previous postpartum depression, clinical depression or significant anxiety during pregnancy, personal or family history of depression or anxiety, abrupt weaning, social isolation, poor social support, history of premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD), mood changes while taking birth contrl pill or fertility medication, thyroid dysfunction.

PREGNANCY SCREENING
In an ideal world, when you become pregnant, your doctor or midwife would ask you for a health history to identify whether you are at high risk for Postpartum Depression. And, if needed, test you for nutrient depletion, brain neurotransmitter and hormonal imbalance to identify what kind of nutritional, hormonal or lifestyle and emotional support you will need. They will will have resources available: mental health professionals with postpartum training, contacts at family support agencies and organizations, information about free self-help support groups for pregnant and postpartum families and childbirth educators/Doulas/Mother Coaches to help create postpartum plans for practical and emotional support. In the real world however, that doesn't always happen. This is why we must become our own advocate starting in pregnancy. That way, even if we don't have the perfect practitioner, we can prompt them to provide us with optimum health care now so we don't pay later!

For example: We know now that we can screen for stress hormones at 25 weeks of pregnancy to head off adrenal imbalance, a major factor in postpartum depression because many hormonal imbalances are the direct result of Adrenal insufficiencey. Recently a study (conducted at the University of California, Irvine) suggested that postpartum depression is the result of hormonal imbalances. Is this new information? No, there are countless doctors, books, research that point to hormonal shifts as a factor in postpartum depression. However, this study is the first of its kind to associate CRH (Corticotropin-releasing hormone) with postpartum depression and recommends that a routine blood test be performed around the 25th week of pregnancy in order to assess the risk of developing this condition. And this gives us leverage to request the test when we need it!

The study said that Stress induced hormone release is considered normal when the brain discharges minute amounts of Corticotropin-releasing hormone, or CRH, to help the body cope with stress. During pregnancy, however, the brain could potentially release copious quantities of CRH to help the mother during labor and thereafter drastically reducing the production of this hormone by contrast. This sudden rise and fall of hormonal levels can cause the endocrine system to behave abnormally and create havoc for the mother during the postnatal phase. CRH is also known to trigger a surge of activity in the pituitary and adrenal glands, resulting in an unusually high output of the stress hormone, cortisol. Abnormal levels of stress hormones produced by an endocrine system out of balance can lead to conditions such as anxiety/depression. (see also Hormones 101) Important to note, according to studies, the brains of suicide victims, upon examination, revealed elevated levels of stress hormones.

DIAGNOSING PPD
Mama's are a tricky bunch when we have postpartum depression and many of us won't volunteer to let our doctors, friends and family know what we're going through. In fact, Childbirth Connection's 2008 report found that 3 in 4 mamas with depressive symptoms had not consulted a professional about health problems. This happens for many reasons. Understandably, we're scared and confused and it's hard to articulate everything that's happening. We may not understand our treatment options and fear separation from our babies during treatment. We may be in toxic relationships that don't provide a safe place for us to share what is really going on for us or we are being told it's all in our head and to snap out of it. On a financial front, we may not have the resources to handle healthcare issues. And the list goes on and on. For this reason doctors have the added responsibility of asking the right questions and one of the best ways to do this is with the thoroughly validated screening tools available, such as the Edinburgh Postnatal Depression Scale. 

Well informed Doctors know that a mother requires a full 12 months to recover from the rigors of pregnancy and birth and that maternal mood imbalances can occur anywhere in the first year or more.  In fact, many new mothers, biological and otherwise, are chronically malnourished.  Nutritional deprivation can become part of a vicious cycle of broken sleep patterns, lack of appetite and poor nutrional intake and assimilation.  

Misinformed but well meaning Doctors may have been taught that postpartum mood imbalnce only happens within the first 3 months.  If your Doctor says this to you and refuses to test your hormones and treat you holistically (Mind, Body, Spirit), it's time to find someone who can.  Doctors of Functional medicine, Midwives and OBGYN's and Physician Assistants who also specialize in Postpartum Mood Disorders will be a great place to start.

POSTPARTUM RECOVERY 
According to Penny Simkin, a leader in the childbirth education movement, Postpartum recovery has taken place when the following items below have been accomplished.  I have added a few in pink that I believe are important (For More Info Check Out Our Self Nurturing Plan Page):

Maternal physical factors relating to pregnancy and childbirth are normal or nearly so, such as: all incisions or lacerations have been healed; involution is complete; feeding - breast or bottle - is well established; adequate sleep is occurring regularly; and all physiological systems are functioning well. Mothers should be receiving optimal nutrition, exercising regularly, practicing self-care and nurturing and taking part in activities that provide spiritual upliftment and joy.

Maternal psychosocial factors are normal, or nearly so, such as: support system is adequate and functioning well; relationships with father/partner and extended family are positive; mother's emotional state is normal and stable; mother-infant attachment indicators are positive; and mother is ready and able to resume some pre-pregnancy interests and activities.

Infant development and temperament factors are healthy and normal.  The infant is: thriving physically; responsive to parents' attention; suckling well; consolable, sooth-able; able to give cues to indicate some needs; and is successfully integrated into the family." 

Sources:
A Natural Guide to Pregnancy and Postpartum Health by Dean Raffelock, D.C., Robert Runtree, M.D., and Virginia Hopkins and Melissa Block
Postpartum Recovery and Adjustment: A Definition (handout), Penny Simkin, 2000
I'm Listening: A Guide to Supporting Postpartum Families, Jane I. Honikman, M.S. 
www.postpartumprogress.com
www.postpartumhope.com