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Beyond Depression: Understanding Perinatal Mental Health

Published on December 4, 2014

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In part one of this series I noted that my approach to postpartum depression research was a little bit different than most others. Namely, I didn’t ascribe to either the nomenclature of the syndromes, whether defined by popular culture or by the DSM, the timing of the onset of the symptoms nor the explanation of the causes. I think the symptoms are largely hormone related, and as such, ought to be distinct entities diagnostically. That requires understanding, testing and then defining the spectrum of symptoms and their relationships with individual and hormone patterns. I’d like to discuss symptoms first, even though this particular research was conducted after finding hormone – symptom relationships and informed by the patient stories collected in conjunction with that research.

Postpartum Depression or Not?

Not, but with a caveat.

As I accumulated data for my hormone symptom study, those data along with participant stories led me to design a broad-based symptom study for postpartum women (this particular study did not include pregnant women, as some my other studies did). I wanted to test whether the typical designations of postpartum depression clustered statistically within discrete but consistent diagnostic categories. Did postpartum depression exist and if so, did the symptoms mirror those in the DSM or in the popular science? Or was depression just one among many types of symptoms that emerged and how would those symptoms fall together statistically? In other words, I wanted to test what the women were telling me about their experiences and against what my other data were showing. The study:

Dimensions of Postpartum Psychiatric Distress: Preliminary Evidence for Broadening Clinical Scope

Study Basics. The study was online with questions covering nine dimensions of postpartum mental health that I had found relevant in previous work: depression, anxiety, mania, psychosis, obsessive-compulsive behavior, self-image, social support, mental status and perceptions of motherhood. The questions were retrospective and the participants were asked to rate the frequency of symptoms experienced over the first 30 days following childbirth on the following scale: 1-never, 2-occassionally, 3-frequently, 4-most of the time. We had 215 women complete the survey. From those data we did an exploratory factor analysis (EFA) to see how the symptom data grouped itself statistically. Did the symptoms group by established psychiatric dimension e.g. depressive symptoms in a depression category, anxiety symptoms with the anxiety category, psychosis with psychosis, etc.? Or would the symptoms group in some other manner?

Results. As I expected, the standard categories were not statistically grouped. That is, there was no such thing as postpartum depression or postpartum anxiety or postpartum psychosis. Rather, there were unique clusters of symptoms that grouped together and contained aspects each traditional symptom category. The EFA data revealed 10 new and distinct factors or symptom groups. Most telling were the first three factors or groupings: mental status, psychoticism/morbid thoughts and a general anxiety. Notice, I didn’t find a depression grouping. Indeed, depressive symptoms were interspersed throughout the 10 categories, but most densely and the most severe within the psychoticism group. Let me explain. Here are the 10 symptom groups or factors, listed in order of importance or prominence (variance accounted for):

Mental status – This was the most prominent cluster of symptoms, with upwards of 40% of the women reporting difficulty with two primary areas of mental status: memory and attention, and motivation – or lack of motivation. Some of the symptoms ascribed to within this group included: difficulty completing simple tasks and staying focused, mind going blank, difficulty organizing thoughts, losing track of time, no motivation, difficulty expressing thoughts, fatigue and loneliness among others. From other research conducted, we know that measurable cognitive difficulties, especially those associated with attention and memory, are common problems amongst pregnant and postpartum women. That this was the highest ranked factor, meaning that it accounted for the most variance, was consistent with my previous work.

Psychoticism and morbid thoughts – This was the most striking category and accounted for what many would consider the most troubling symptoms. This factor grouping included everything from intrusive and morbid thoughts, to hallucinations and suicidality. It truly represented what would have been the most serious of psychiatric conditions but was not akin either to a strictly depressed state or psychosis in the most traditional sense or even to an obsessive compulsive disorder, emphasis on obsessive. Rather it had components of each, uniquely focused on the maternal state. Some of the symptoms ascribed too included: images of the baby being stabbed or thrown out of a window, fear of harming the infant, thoughts of violence, hearing voices to harm myself or others, inability to keep bad thoughts out head, afraid to be alone with baby, afraid of harming self, frightening dreams, the feeling that others want to harm me (the mother) or the baby, feelings of terror, no hope for the future, feel like someone is controlling one’s thoughts, worrying that the infant will suffocate.

General Anxiety – this grouping of symptoms is what I believe may represent milder forms of distress that to some degree all women feel as they enter into motherhood. Some of the symptoms include: ‘I believe others see me as a bad mother’,’ I think I am a bad mother’, confusion, no confidence, overwhelmed, mind racing, losing control, constantly being judged, no one understands me, among others.

The remaining seven factors or groupings were somewhat more specific to traditional psychiatric categories but also included psychosocial aspects relative to self-image, relationship and social support. They also accounted for far less statistical variance, indicating some degree of specificity to certain groups of women rather than being applicable to most postpartum women and/or were far less relevant to the overall distress. These groups included:

Panic – fear of large crowds, fear of leaving the house, feeling keyed up, restless, on edge, skin crawling

Guilt and emotionality – a range of guilt related feelings, but also, mood lability – switching from happy to sad, quickly and frequently

Compulsive behaviors – cleaning and checking

Hyper-vigilance – a sense that the new mom was the only one who could care for the child

Contentment – positive relationship, social support, and general well being

Negative self-image – range of negative self-image attributes, along with a sense that her body was shutting down –that something was wrong with her.

Mania – hyper excitable, excessive energy despite a lack of sleep, impulsive behavior

What Does This Mean?

The results from this study suggest that neither the current diagnostic categories nor the popular nomenclature appropriately categorize the types and severity of postpartum related mental health issues. Depressive symptoms were neither the most common symptoms nor contained within a defined category. Rather depressive symptoms were interspersed throughout each category with the most severe depression symptoms, loss of hope and suicidality loading to the psychosis/morbid thoughts category. Along with the more severe depression symptoms, this category contained hallmark psychosis symptoms like hearing voices, seeing things, but also what could only be described as violent, frightening intrusive thoughts.

What was particularly interesting is that mania, which has long been linked to postpartum psychosis, was neither present in the psychosis/morbid thoughts category nor accounted for much variance at all within this study. This could mean that mania is not a common component of the most serious forms postpartum distress for most women, but rather a distinct subset of the disorder. Instead, it may be the violent intrusive thoughts and the hallucinations that are associated with the most serious symptoms of depression – the suicidality. From these data, the postpartum spectrum is not from mild sadness (baby blues) to more intense sadness or postpartum depression to psychosis but rather based on the degree and severity of intrusive thoughts and hallucinations – the degree of psychotic symptoms may very well determine and drive the ‘depression.’ Additional research will tell if this is the case.

Addendum

Phase II of this study, a follow up confirmatory factor analysis was begun, some data collected (n=100), but not completed. When the economy tanked in 2008-9, I, and many other adjunct faculty were let go. I hope to resume this research soon through Hormones Matter.

Before She was Born: Seeds of Postpartum Depression

by Margaret Aranda, MD

Published on June 17, 2014

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She was insy tinsy, curled up in a comfy ball. When she was happy, she did summersaults in the amniotic fluid, with plenty of room to spare. She had no idea, but first she went to the left, and then she swooned to the right, floating with pure bliss. There was no yesterday, and no tomorrow. There was only “now.”

Sometimes, she could hear a bigger voice, sometimes calm and sometimes yelling and screaming. With the screaming came a faster heart rate, pounding her ears and making her own heart beat pound!-pound!-pound! … beating faster and faster itself.

Then there were the nights. She didn’t know they were ‘nights’ per se, but she knew that when things got dark, the sound of the lady crying would start again and again. Over and over she would hear the crying, feel a hand over the wall covering her, making her shake and shake and shake all over again. Every night. The sobs scared her, making her crawl up in a ball as tight as she could get. She just wanted to disappear, to be invisible, to be nonexistent because she was made to feel so unwanted. Her mother never sang to her, never put Mozart music on her belly, never gave her a backrub from her buttocks to her head. So she never knew what she missed. She was just cold. She knew coldness.

On the other side of the wall, her mother was crying again, mascara blobs leaving black eyes as if she was in a bar-room fight. Her hair was dirty; she hadn’t bathed in a week. Her belly was big and she was running out of clothes to wear, down to the last pair of sweatpants. She couldn’t go to sleep and instead, she was tossing and turning from side to side, dragging the baby in the abdomen with her with a plop! to each side. And she woke up all night, on and off. Early morning awakening was all too common, with the mother up long before the sun rose. Her eyes burned from sleeplessness, tearing without crying. Crying without tearing. She felt that she was in a brain fog; she was boiled down to pure misery. How is she supposed to live like this?

She walked out to the apartment balcony, five stories up, and she toyed with the idea. She toyed with the idea of climbing up the balcony and jumping off, just to end it all. She wasn’t capable of caring for herself, let alone a baby. She would take the baby with her as she jumped, to spare her any more harm in this harsh world. She toyed with the idea, and then she slumped her shoulders, failure that she was, because she failed at everything and today would just be another day of failure. She turned around and walked away, towards the bed. Then she shut the sliding glass door on the way back in, locking it as if for safekeeping. She forced herself to eat, for the baby’s sake.

Weeks went by. Eventually, alone and in the darkness, she passed the mucous plug. Then the amniotic fluid broke, leaving a huge pile of wetness on the sheets and floor as she dragged herself to call 911 on the speakerphone.

Fluid still running down her leg, she just lay there crying real tears this time, wondering what she was supposed to do with a new baby girl. She was afraid she would throw her out the balcony. She was afraid she would sleep on top of her and crush her. She knew she wasn’t in her normal state, but she didn’t know what to do, whom to ask for help, what would happen, or what was wrong with her.

She didn’t know whom to call.

Her uterus contracted hard now that they were in an operating room, pushing the baby’s head down toward the cervical os and therefore, the outside world. In the meantime, the little baby’s head pressed flat on its way out of the vagina as she reluctantly made her way out to the outside world. She heard many voices, and the Cling! Clang! of metal instruments being thrown here and there. It hurt her ears! It shocked her!

It was cold, harsh, and they scrubbed all the wonderful, warm amniotic fluid solution off her with a cold, wet towel. She frowned at them with distaste. Then they laid her on a cold, hard scale, they pricked her foot for blood, and she screamed. It was just the beginning. She screamed and screamed and screamed.

After a few days, it was time for Mom to take the baby home. Everyone else was happier for Mom than she was for herself. The baby cried for her breast milk, and Mom whipped out a boob every two hours. Tired, sleepless, undernourished, Mom was wheeled out of the hospital with no balloons and no flowers. Her friend drove her home after ensuring the baby car seat was intact.

Mom’s sleeplessness continued. Her thoughts of throwing the baby out of the window resurfaced, her guilt and panic ensued when the baby cried, and this went on for months. No one knew. She didn’t have any friends. She wanted to jump off the ledge with the baby.

Disheveled, she went grocery shopping. She had no glow on her face at being a new Mom, and you were the first to notice. So you struck up a conversation with her, pushing yourself into her life, almost against her will. But not really. Because secretly, she wanted you there, and inwardly, she yearned to have you there. You offered to babysit one night, exchanged phone numbers, and you called her the next day to ask her if she needed anything from the drug store. Any shampoo? Baby lotion?

And the more you talked to her, the more you discovered a probable diagnosis. So you gave her an ‘800’ number to call, and she did it. And she was one of the few women who got the diagnosis made, received treatment, intervention, and after about one year, she was cured. What was her diagnosis?

Diagnosis: Postpartum depression. Also known as maternal mental illness, it is more varied and common than previously thought, perhaps occurring in one of five pregnant women (Gaynes, 2005). During pregnancy, the etiology is due to hormonal complexity involving stress, hormones, and genes, wherein some endocrine hormones can go up greater than a hundredfold (Sichel, 2003). After childbirth, hormone levels fall to the ground, resulting in another hormonal insult swinging in the opposite direction. Sounds like a roller coaster to me, or the giant tick-tock of a ginormous grandfather clock, with a huge pendulum swinging two different ways. Either way, one could easily see it makes one prone to get sick.

So, maternal mental illness does not just occur in the postpartum period of up to one year (Belluck, 2014). It can occur during pregnancy. It is often accompanied with social isolation and/or it overlaps with common symptoms of pregnancy itself, confounding the diagnosis even more. There are a paucity of studies that include the screening, multi-ethnic, diverse socioeconomic status, pre- and post-partum depression assessment (e.g., “mild” vs. “severe” depression), the institution of an intervention, and the follow-up of the effectiveness of the intervention. Nevertheless, there are a variety of Resources and Help Sites available to turn to for use (Belluck, 2014).

The following states have actually passed laws for screening, education, and treatment of maternal mental illness, in an attempt to prevent baby drownings and maternal suicides: Texas, New Jersey, Illinois, and Virginia. New York is considering such legislation. Patient awareness and standardized physician questionnaires are needed to assess risk, not only of depression.

In this author’s view, every pregnant woman needs and deserves the assessment of the risks of: being battered, suffering emotional abuse, forming diagnostic criteria for diagnosing mental illness including maternal mental illness and/or psychosis, infanticide due to maternal mental illness, nutritional status, obesity, diabetes, and hypertension. Improved medical education should also ensue. For the women that are seeking prenatal care, the gynecologist is poised to be the “Gatekeeper”. Psychiatry should be front-runners in grading maternal mental illness through the DSM-V, and should take “front and center” in leading this riveting cause for women and their babies.

About the Author: Dr. Margaret Aranda is a USC medical school graduate, as well as an anesthesiology resident and critical care Fellow graduate of Stanford. After a tragic car accident in 2006, she unfolded her passion of writing to advance the cause of health and wellness for girls and women. You can read more of her work on her personal blog, Dr. Margaret Aranda, her Pinterest page, a page on Postpartum Depression, her author’s page at Tate Publishing or follow Dr. Aranda on twitter @DrM_ArandaMD.

References

Belluck, P. ‘Thinking of Ways to Harm Her’. New findings on timing and range of maternal mental illness. Postpartum Depression. Mother’s Mind: First of Two Articles. The New York Times. http://www.nytimes.com/2014/06/16/health/thinking-of-ways-to-harm-her.html?_r=0. June 15, 2014 (Accessed June16, 2014).
Belluck, P. ‘Thinking of Ways to Harm Her’. New findings on timing and range of maternal mental illness. Postpartum Depression. Mother’s Mind: First of Two Articles. Resources: Where to turn for help with maternal mental illness. The New York Times. June 15, 2014 (Accessed June 16, 2014).
Gaynes BN, Gavin N, Meltzer-Brody S, Lohr KN, Swinson T, Gartlehner G, Brody S, Miller WC. Perinatal Depression: Prevalence, Screening Accuracy, and Screening Outcomes. Evidence Report/Technology Assessment No. 119. (Prepared by the RTI-University of North Carolina; Evidence-based Practice Center, under Contract No. 290-02-0016.) AHRQ Publication No. 05-E006-2. Rockville, MD: Agency for Healthcare Research and Quality. February 2005.2 (Accessed June 16, 2014).
Sichel, DA. Neurohormonal aspects of postpartum depression and psychosis, in Infanticide: Psychosocial and Legal Perspectives on Mothers who Kill. Edited by Spinelli MG. Washington, D.C., American Psychiatric Publishing, 2003, pp 61-80.

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