Postpartum Depression: Naming the Pink Elephant (Rat) in the Room

One in four first time mothers had depressive symptoms caused by postpartum depression or postpartum stress syndrome. PPD strikes women without any history of depression, without complications in pregnancy, mothers who are in difficult marriages, mothers who are in satisfying marriages, or single.”

Common sense disclaimer: this blog is not intended to diagnose or treat Postpartum Depression (PPD). For a list of resource referrals for PPD screening and treatment, see end of blog.

Recently, I attended a talk at a well-known research university and teaching hospital in San Francisco on the maternal brain. I was so excited to learn more about how the brain is affected during pregnancy and postpartum for mothers, especially as it affects women in recovery, women who struggle with Postpartum Depression (PPD), and their bonds with their children, I excitedly prepared to meet other clinicians and mommies working with mommies and their postpartum brains. This is a brief summary of what I heard:

Mothers that exhibit consistently increased pup LG (i.e. high LG mothers) by comparison with low LG mothers show increased oxytocin expression in the mPOA and the paraventricular nucleus of the hypothalamus and increased projections of oxytocin-positive cells from both mPOA and paraventricular nucleus of the hypothalamus to the VTA…(Shahrokh D, et al., Endocrinology, 151 (5): 2276-2286, May 2010. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2869254/)

WHAT? If your brain has just glazed over, and you heard the teacher in the Peanuts cartoon saying “WaWaWa WAAA,” you are not alone. Ok, it is a given, going to an empirical, research-based talk, that there would be a focus on brain chemicals and how this affects behavior. It is also an ethically understandable given that much of this research would be done on rats rather than human brains, especially the brains of pregnant or newly postpartum mothers. However, when I asked the doctor giving the talk giving the talk how this “licking and grooming behavior” of rats might be different for mothers suffering from Postpartum Depression (PPD), she said “We don’t do these studies or have any research in this area on people with major mental illness, so I can’t comment on that.” And yet, in her conclusions for this talk, she discussed how rats with increased oxytocin and dopamine had increased licking and grooming behaviors, which might show that stronger attachment occurs in human mothers with increased oxytocin and dopamine. So, in my mind, it is not that big of a leap to then ask what about the mothers with decreased oxytocin and dopamine?

Who suffers from PPD?

Despite the myth/stigmatization that PPD is a major mental illness that only affects a few, severely mentally disturbed women, PPD does not discriminate in whom it affects. In their book This isn’t what I expected, Karen Kelinman, MSW, and Valerie D Raskin, MD write:

It is estimated that 400,000 women in the United States suffer from Postpartum Depression (PPD) each year. One in four first time mothers had depressive symptoms caused by postpartum depression or postpartum stress syndrome. PPD strikes women without any history of depression, without complications in pregnancy, mothers who are in difficult marriages, mothers who are in satisfying marriages, or single. It strikes women who had easy pregnancies and deliveries and women who suffered long, complicated labors and/or cesarean sections.

http://www.storknet.com/guests/kleimanppd.htm

In the March 2013 issue of Parenting magazine, it is stressed how susceptible new parents are to depression. “From pregnant women to fathers to mothers of multiples to stay-at-home moms, [new parents] experience depression at rates twice that of the general population.” http://www.parenting.com/article/xanax?cid=searchresult

According to National Research Council Depression in Parents, Parenting, and Children (2009), “fifteen million childrenare living in households with a depressed parent, so there are enormous numbers of young lives at stake.”

So. Lots of women have PPD. Lots. Think of it this way: if everyone has a mother (which we all do) and one in four of those mothers had PPD, one out of every four adults has a mother who had Postpartum Depression.  And most likely, it is more than one in four.

What is Postpartum Depression (PPD)?

According to June A. Horowitz, PhD, APRN, BC, FAAN, the signs and symptoms of PPD include:

Loss of interest or pleasure in life, Loss of appetite, Less energy and motivation to do things, Difficulty falling asleep or staying asleep, Sleeping more than usual, Increased crying or tearfulness, Feeling worthless, hopeless, or overly guilty, Feeling restless, irritable, or anxious, Unexplained weight loss or gain, Feeling like life isn’t worth living, Having thoughts about hurting yourself or your baby

(This link also includes signs and symptoms of postpartum psychosis and anxiety: http://www.mededppd.org/mothers/hear_it_from.asp)

And yet, as noted by Dr Teri Pearlstein et al American Journal of Obstetrics & Gynecology, (357, April, 2009):

The diagnosis of PPD is challenging because of changes in sleep patterns, changes in appetite, and excessive fatigue being routine for women after delivery.

To this I need to say, Right On! Who as a new mother, doesn’t suffer from difficulty falling or staying asleep, loss (or gain) in appetite with breast feeding and/or hormonal changes, and having less energy and motivation to do things in the first year postpartum? Anyone with a child under the age of one year old will have drastic changes in their weight, sleep, energy, and motivation levels during the first year of parenthood!

I am not minimizing PPD here. Just like other forms of depression, there is a spectrum of severity. The California Pacific Medical Center’s Perinatal Mood Disorder program advises if any of the following symptoms exist, to call their nurse triage line to be further assessed (you can also see a 24 hour hotline as a resource at the end of this blog):

Can’t function normally or take care of self, can’t eat or sleep, can’t bond with baby, has suicidal thoughts, says “I just don’t feel like myself” can’t quit worrying, can’t stop crying, get out of bed, or leave the house. (Tung Crystal, Lily, Side by Side Sutter Health CPMC, Spring, 2013)

What I am doing is attempting to normalize that early parenting is difficult and it is most likely that many more women suffer from PPD than are reported or studied in the research literature, and that it is nothing to be ashamed of. And yet…many women still struggle with it (never report it, get assessed and treated for it, recover from it) alone. WHY?

SHAME

(Why every blog I write keeps coming back to this)

There has been an explosion of popularity recently for Brenee Brown’s TED talk on vulnerability and shame. In her talk, Dr. Brown discloses

When I became a vulnerability researcher, I thought, I’m going to leave that shame stuff behind…I became a researcher to avoid vulnerability and that when being vulnerable emerged from my data as absolutely essential to wholehearted living, I had a breakdown. (Brenee Brown on the topic of shame and vulnerability:

http://www.ted.com/talks/brene_brown_listening_to_shame.html)

Brown shares that Jungian analysts call shame the swampland of the soul and advises, “We have to put on our galoshes and find our way and walk around [because] adaptability to change is all about vulnerability.” And new motherhood is all about vulnerability in adapting to change and the discomfort of that. Why don’t any of the virgin mother images show that? Or the glowing pictures of pregnant and new mothers in parenting magazines?

So what heals shame? Brown notes to grow shame, put it in a petri dish with secrecy, silence, and judgment. Add empathy and it cannot survive. This leads to what I believe the missing factor is in naming the “pink rat in the room.” Leaning directly into support and releasing the stigma of shame associated with PPD.

What Helps:

Here are some other things I have found helpful in the first few years of parenting, regardless of whether you meet diagnostic criteria for PPD or not:

1.The Right Kind of Support:

Obviously psychotherapy and medication interventions as provided by a therapist, and/or Psychiatrist can be invaluable and necessary components to recovery from PPD. (For a list of resources in the San Francisco bay area, see end of blog). Seeing your ObGyn, Medical Doctor and/or a Nutritionist can also be helpful for looking at how to best balance your hormones and food plan for healing. Moms groups for postpartum women, Moms groups for women with PPD, childcare and housework help, friends, and family can all be helpful in alleviating some of the weight of new parenthood and/or depression.

I had a nanny start when my baby was 6 months old. She was an older Grandmother and truly a gift sent to me. She would often do laundry or the dishwasher or mop the kitchen floor when the baby was sleeping, even though I told her not to. She was a very humble woman who pitched in to help in many ways without being asked. The incredible help this was to me was unbelievable. I’ve often wondered if it was because she saw how much I was crumbling under the weight of new Mommy boot camp or if she simply was an angel. Regardless, it was helpful. Find that person or those people for yourself. Ask for that help. Ask for the help that you need. Ask your spouse, ask your friends, ask your family. Also, it’s ok to set boundaries with people who are trying to help by offering unsolicited opinions, advice or unhelpful “help.” If you have a partner who repeatedly tries to “fix” you instead of listening to you, it is ok to clarify that’s not what you need. (Partners can also benefit from counseling and book recommendations on PPD as well).

2. Sleep:

I know, I know, you’re saying but that’s the PROBLEM! I can’t get any sleep! I have a BABY! Enlist the support of your partner, support person, or hire a night doula to you replenish your sleep debt. The link between PPD and lack of sleep/poor sleep quality is huge.

http://www.womensmentalhealth.org/posts/postpartum-depression-and-poor-sleep-quality-occur-together/

Also try creating good sleep hygiene by having a consistent bedtime ritual, not using your computer/iphone in bed, and staying off caffeine.

3.  Get out of the house:

Note that I wrote getting out of the house here and not “Go for a walk and get some exercise.” Obviously going for a walk and getting some exercise and sunshine are helpful. But for a new Mom and a new Mom struggling with depression, getting out of the house is a more realistic and difficult enough goal. It can be extremely difficult if you are facing depression and caring for a young child, to get out of the house. It takes turning toward the opposite action (away from what you feel like and toward what feels insurmountably difficult) to get yourself dressed (showered and fed if you can), the baby changed and fed, all the baby gear packed, and the baby into the stroller/car seat/Gemini/Bjorn/Moby wrap and step out of the house! If you walk half a block down the sidewalk, celebrate it! If you get to the playground or the coffee shop, it is a momentous accomplishment. If you meet up with another Mom, great! If you get to the beach or park and do a mildly vigorous walk, WOO HOO! Fresh air can work wonders to shift the claustrophobia of being inside a small house, both literally and in your brain. As a friend of mine in 12-step program says, “better out than in,” in which she meant better to talk about t than keep ruminating about it inside your own mind. There is much more room on the outside for a fresh perspective. This can be true of getting out of the house as well.

4.  Find Humor in and normalize the Shadow side of parenting

When I was a new Mom, I suddenly I discovered there is a whole world on the Internet of Mommy blogs! This helped break the isolation that went along with the difficulty of making plans when having an infant on an unpredictable schedule. I was often so tired that humor helped much more than advice. This is my most favorite humorous parenting blogs. It always makes me feel better. www.crappypictures.com She writes about poop, food, sex, body image, and life before and after kids with short, well, crappy pictures and sentences.

Or check out this funny “Proof that you are fucking up your offspring no matter what” chart recently on Huffington Post (Do not I repeat DO NOT use this to fuel your not-good-enough-Mom critic):

http://www.huffingtonpost.com/una-lamarche/how-to-be-a-perfect-parent

Motherhood is ripe with myths that need to be challenged. Jill Smokler, author of ScaryMommy has written a new book on how actually motherhood doesn’t come naturally that challenges many of the myths of the glowing, natural (nondepressed) mother. She has a confession board on her blog in which Moms can write what they are most afraid to admit, and she writes with humor and experience about challenging the myths of motherhood. Apparently, she also suffered from undiagnosed PPD: http://www.scarymommy.com/category/PPD/

5. Be discerning about what you expose yourself to:

I read on one PPD blog to stay away from depressing movies, books, and literature, http://www.postpartumprogress.com/six-things-you-should-avoid-if-you-have-postpartum-depression This was wise advice. Obviously, you can’t always avoid being exposed to suffering. Suffering and violence do occur. I am not saying stick your head in the sand and be in denial. But putting yourself in the direct line of suffering is not necessary or beneficial. When we had a new baby, my husband and I watched the film “Life is Beautiful.” This isn’t necessarily a depressing movie considering the fact that it is about the holocaust. Before kids, I would have thought, what a lovely movie. However, in seeing a father trying to protect his young son from the horrors of unnamable suffering of the Holocaust with sleep deprivation and being the mother of a baby boy, I found myself wracked with sobbing.

There will be times in your life, if you like them, to watch movies or read biographies on addiction, genocide, madness, eating disorders, holocaust survival, and emergency room dramas. Early postpartum, if you are a sensitive soul, that’s not the time.

6. Bring in Spirituality and Radical Acceptance:

Before baby, I meditated, painted, collaged, journalled and danced! Most of these were just too hard to fit in postpartum. See http://recoverymama.wordpress.com/2013/02/07/spiritual-practice-in-recovery-and-mommyhood/ However, I did find ways to make small collages during naptime or when I had childcare help. These little actions had enormous positive effect on my mood and replenishing my Creative Soul, which was feeling so depleted.

A concept from Dialectical Behavioral Therapy (DBT) that can help with being with difficulty, depression, and hardship is Radical Acceptance. In an interview with Tara Brach on Mindfulness, she writes:

We suffer because we have forgotten who we are and our identity has become confined to the sense of a separate, usually deficient self. All difficult emotions-fear and anger, shame and depression-arise out of this trance of what I call false self…I’ve found that whenever I am really suffering, on some level I am believing and feeling that “something is wrong with me.” (http://blogs.psychcentral.com/mindfulness/2009/09/radical-acceptance-an-interview-with-tara-brach/)

In distressing feelings, in depression, in the immense rite of passage that is motherhood, THERE IS NOTHING WRONG WITH YOU. You don’t always have to like the experience of motherhood. Tara states:

Radical acceptance has two elements: It is an honest acknowledgment of what is going on inside you, and a courageous willingness to be with life in the present moment, just as it is. I sometimes simplify it to “recognizing” and “allowing…” You can accept an experience without liking it.

Thomas Moore, author of care of the Soul, offers the wise suggestion of simply listening to depression, to what it has to say, to what teaching it has to offer, to what needs the Soul has in the emptiness:

Because of its painful emptiness, it is often tempting to look for a way out of depression…But maybe we have to broaden our vision and see that feelings of emptiness, the loss of familiar understandings and structures in life, and the vanishing of enthusiasm, even though they seem negative, are elements that can be appropriated and used to give fresh life imagination…Care of the soul doesn’t mean wallowing in the symptom, but it does mean trying to learn from depression what qualities the soul needs.

If you have PPD or if you are in exhausted new Mommy boot camp, consider that your vulnerability is actually your greatest gift. Consider that the emptiness is the way out, because the way out is through.

Helpful links/Resources:

National Postpartum Depression Hotline: 1-800-PPD-MOMS

Suicide Prevention & Crisis Hotline
(415) 499-1100
It is important for women who might be experiencing suicidal thoughts/ideas/plans to call this number.

TALK Line
Parental stress, child abuse prevention, emergency respite care, single parent network, parents’ group, crisis counseling, substance abuse services and ongoing therapy. 
(415) 441-KIDS (5437)
TALK
www.talklineforparents.org/

GoldenGate Mother’s Group therapist referrals and resources:

http://www.ggmg.org/recommends/Postpartum.html

Postpartum Stress Center:

http://postpartumstress.com/helpful-links/

Linda Shanti McCabe

Linda Shanti McCabe

Dr. Linda Shanti McCabe holds a doctorate in Clinical Psychology and works with women (including pre and postpartum) recovering from food, weight, and body image issues. She holds SoulCollage® groups for women (including pregnant and postpartum) using expressive arts to find and express the many parts of the Self. She blogs at Recoverymama.com.

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4 Comments

  1. selflovewarrior.com on May 6, 2013 at 8:00 pm

    Great post Linda! New parents will be helped by your 5 “what helps” points.
    Blessings,
    Michelle Minero MFT



  2. recoverymama on May 7, 2013 at 3:50 am

    Thanks so much Michelle.



  3. Jacklin on May 17, 2013 at 8:36 am

    Very Nice Informative blog. The knowledge you are providing is really very helpful to me and it’s very helpful for the beginners too.

    postpartum depression



  4. Robert Solley on October 2, 2013 at 3:59 pm

    Thanks Linda, for this very informative, supportive, and helpful article! I’ll add that in John Gottman’s research, 66% of couples experience a large decline in relationship satisfaction within 3 years of the birth of their first child (making it “normal” – however this can be improved with knowledge and intervention). Some of this decline may be interrelated with PPD for both genders. Women’s PPD tends to be closer to the time of birth, and a significant number of men suffer PPD but for them it tends to cluster later in the childs 1st year. One of the biggest differences between the more and less satisfied couples is how emotionally engaged and involved the father is with the baby and mother. Gottman has a great book about this which you may know of called “And Baby Makes Three.”