When new motherhood hurts
-- the hidden shame of post-partum depression
"I felt I was completely on the bottom rung. A complete failure
as a mother, as a wife, as a person."
"Each time I faced the decision to seek help, I felt more anxiety
and delayed it -- until I reached what I felt was a crisis state."
These words, from women with histories of post-partum depression (PPD)
at a recent focus group discussion in Hamilton, Ontario, describe pain
that is compounded and deepened by shame: a common experience for those
affected by post-partum mood disorders.
Studies show that depressed mood following childbirth affects 45 - 80
per cent of women and is acute enough to warrant a diagnosis of PPD in
about 12 per cent of cases. Dr. Shaila Misri, a Vancouver specialist in
PPD, calls it "the single most frequently occurring complication
of pregnancy."
Origins of the disorder are manifold. Dr. Jean Francois Saucier, a professor
of psychiatry at the University of Montreal, says: "There are many
points of departure: PPD is the end point. Biology may lend a woman a
particular fragility, and then life events may play a part too."
Although "the baby blues" are a commonly recognized phase of
new motherhood, the true range and depth of emotional difficulties following
childbirth is often missed by health care providers. Missed diagnoses
are due in part to the complex array of causes and symptoms presented
by PPD, and in part due to the continued stigma of depression -- complicated
further by unrealistic social expectations of motherhood.
In the words of one woman with PPD: "You have it all -- or at least,
a beautiful child in your arms -- and all you want to do is cry, or hide
or worse. You feel pretty crazy and are not too likely to just let people
know, especially not a doctor." Dr. Bill Watson, a family physician
at Toronto's St. Michael's Hospital, sees the same dynamic at play in
his practice: "A woman has just had a lovely child and is feeling
absolutely miserable. She feels embarrassment and shame about disclosing
this. Some women will go to the nth degree to hide what is going on."
Other factors that may prevent a woman from seeking help include lack
of initiative and energy (stemming from the depression) and fears that
a mental health diagnosis will result in authorities taking away the baby
from the mother. Also, manic state sometimes occurs in the post-partum
period -- and although just as harmful to the mother and baby as is depression,
it may cause the mother to feel as though she does not need help. Grazyna
Mancewicz, a social worker with the Maternal Support Program at St. Joseph's
Health Centre in Toronto, says that cultural and linguistic differences
also often get in the way of diagnosis: "In the instances where we
do translate for the mother (into Spanish, Polish, Chinese and Tamil),
we have to say "baby blues" in English -- because there is no
easy way of identifying the problem in other languages."
A study conducted by Misri and reported in her 1995 book, Shouldn't
I Be Happy?, shows that the average time between onset of symptoms
and support-seeking by Canadian women is seven months. "They wait
until they are desperate," says Misri. Furthermore, once a mother
eventually does seek help, her health care provider may miss the signs
and fail to identify PPD. Saucier reports the case of one Quebec mother
who recently went to her local emergency department in a crisis and was
diagnosed as having insomnia. She was given sleeping pills, and appeared
three more times at the same hospital, receiving the same diagnosis. After
her fourth emergency visit, the woman overdosed on the pills. Only at
this point did she receive the correct diagnosis -- and a prescription
of antidepressant medication to help treat her mood.
Misdiagnosis stems from a variety of factors, one of which is overloaded
resources. Watson says that psychiatry is in short supply, even in large
cities such as Toronto, where women can wait months just for an assessment.
He also feels that physicians are often busy, with too many clients, and
don't spend the time necessary to assess a problem.
Failure to identify PPD can also stem from the fact that, interestingly,
a mother may actually be over-intrusive toward, rather than neglectful
of, her baby, and thus may seem outwardly to be a very effective, non-depressed
mother. Behind the scenes, however, she may be suffering painful guilt
because she does not feel as happy as she had expected to feel, and is
unable to be what Saucier terms "psychologically present" for
her child.
Many experts believe that another factor hampering diagnosis of PPD is
the fact that, as a society, we tend to emphasize the health of the baby
over the health of the mother in the postpartum period. The correct questions
simply go unasked in many instances.
Furthermore, as Mancewicz says: "A woman can be extremely depressed
one day and the next may have a better day. It's not always a textbook-clear
situation. It represents itself in such different ways: one mother might
be crying; one might be agitated. Both are miserable, both will say, 'I'm
not myself.'" With such a wide variety of symptoms, PPD is easy to
miss; yet failure to diagnose in a timely fashion can lead to painful
or even dangerous crisis situations for mother and child.
Training health care providers to diagnose PPD is an important step.
Christine Long, executive director of Postpartum Adjustment Support Services
of Canada (PASS-CAN), states: "There is a real need to teach doctors
how to respond, to put the pen down and take a few minutes. Traditionally,
the response has often been, 'It's just your hormones -- try to get out
to a movie or shopping,' or 'Here's a script -- come back in a month.'
We need to train physicians' ears to hear what is being said."
More effective screening to identify women most at risk would significantly
reduce the harm of PPD. Health Canada's nationwide "Healthy Babies,
Healthy Children" program -- intended to protect families from a
range of problems including PPD -- varies widely in quality and scope
from region to region, so that many mothers are never screened. Long says
that when it comes to PPD prevention, "the purpose of the program
is to provide seamless service: but there is a lack of dollars and a lack
of political will."
Abigail Pugh
Contacts
Postpartum Adjustment Support Services of Canada (PASS-CAN)
460 Woody Rd., Ste. 3, Oakville, ON L6K 3T6,
tel (905) 844-9009, fax (905) 844-5973,
e-mail info@passcan.ca,
web www.passcan.ca
St. Joseph's Women's Health Centre, Maternal Support Program
30 The Queensway, Toronto, ON M6R 1B5,
tel (416) 530-6850, fax (416) 530-6629,
web www.stjoe.on.ca
Pacific Post Partum Support Society (PPPSS)
1416 Commercial Dr., Ste. 104,
Vancouver, BC V5L 3X9,
tel (604) 255-7999, fax (604) 255-7588,
web www.postpartum.org
Identifying PPD
The following factors may increase a woman's risk of developing PPD:
- hormone sensitivity (i.e., premenstrual syndrome or depression induced
by contraceptive use)
- previous experience of PPD
- history of depression or bipolar disorder
- family history of depression or bipolar disorder
- few social supports
When assessing a new mother for PPD, caregivers should look beyond the
obvious. A sufferer will experience any or all of the following:
- exhaustion
- irritability
- hopelessness
- insomnia
- appetite changes
- difficulties concentrating
- excessive worry
- crying for "no reason"
- no interest or pleasure in the baby
- guilt
- hot sweats or palpitations
- lack of interest in others
- scary thoughts about harming the child
Christine Long says that many PPD sufferers mask their mental state very
effectively. If given the opportunity to merely engage in social pleasantries
and conceal her true distress, a sufferer will usually take this route.
This means that caregivers and doctors should proactively and specifically
ask the following questions:
- Are you able to sleep when the baby is sleeping?
- Are you eating normally, in terms of types and quantity of food?
- Are you able to get out of the house?
- Are you experiencing any scary thoughts about your baby?
Source: PASS-CAN
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(416) 595-6714 
