perinatal mental illness

Resources for Postpartum Depression

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Postpartum depression can be frightening and devastating for some families, but it doesn’t have to be if you and your loved ones get help. Listed below are resources for postpartum families. If you suspect you or a loved one has postpartum depression, find help.

Resource Phone Numbers Available 24/7

  • Suicide Hotline 1-800-SUICIDE
  • National Suicide Prevention Hotline 1-800-273-TALK
  • Disorders.org (Postpartum Psychosis) 1-800-943-0566

Postpartum Depression Websites and Support

More about Postpartum Depression

To learn more about postpartum depression in all its forms, read the following articles.

If you have a postpartum story that you would like to share so that other women and families can navigate this condition, consider writing for us. We accept personal health stories to spread awareness and encourage openness. Write for Us.

If you know of additional resources for new moms and families, local, national or international, please add them to the comments section.

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Before She was Born: Seeds of Postpartum Depression

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Margaret Aranda, MD

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

  1. 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).
  2. 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).
  3. 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).
  4. 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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Maternal Psychiatric Disturbances and Hormones

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postpartum depression anxiety psychosis

As a mom of young children, I was very much affected by the Andrea Yates case. If you recall she experienced successive bouts of psychosis and pursued multiple attempts at suicide following the delivery of each of her children. After her fifth child, she drowned her children, killing them all. The case was a heartbreaking, and I believe, a totally preventable tragedy had her psychosis been taken seriously by medical professionals, family and others in the community. In spite of her psychosis and suicide attempts she was sent home to care for her children, as if a woman with postpartum psychosis is somehow less ill than a man or than a woman whose psychosis develops unrelated to her pregnancies. Raising young children is difficult, even under the best of circumstances, but sending a severely depressed and psychotic woman home to care for young children is just downright negligent. Although there was blame to go around among the doctors, her family and community, I couldn’t but shake the feeling that this tragedy could have been averted if her illness had been taken more seriously.

Identifying the Biological Underpinnings of Maternal Psychiatric Disturbances

The Andrea Yates tragedy inspired me to research and identify the clinical and biological components of perinatal mental illness. My goal was to identify early warning markers; biological tests, that would give women, their physicians and family members a way to predict the possibility of illness and confirm that illness once it had arrived. I thought that if we could predict and identify the risk for this illness, then the families could prepare and maybe even lessen the severity the disease process. At the very least, tragedies like the Andrea Yates case could be prevented.

I knew hormones would be key to the onset and maintenance of perinatal psychiatric symptoms. What I didn’t know is which hormones, when, and related to which symptoms. It seems that no one else did either. Despite years of research and a clear temporal association between the onset of psychiatric distress and childbirth, only tenuous connections between maternal hormone concentrations and varying degrees of postpartum depression had ever been established. This was primarily because the research was focused so narrowly upon the relationships among what are often referred to as the female hormones, progesterone and estradiol, and depressive symptoms. Very little research had examined associations between a broader range of steroid hormones and the full spectrum of potential psychiatric symptoms. This didn’t make sense to me. Certainly, other hormones affected by pregnancy, might also impact brain chemistry; certainly, the range of clinical symptoms that women might experience would go beyond the blues and depression. Even when psychosis appeared, I wasn’t convinced that the psychosis of pregnancy and postpartum was clinically similar to the psychoses that developed irrespective of the vast biochemical changes that took place across pregnancy, parturition and in the weeks and months that followed. If the biochemistry was different, as it most necessarily had to be, wouldn’t everything else about maternal psychiatric disturbances be different as well?

Looking Beyond the Boundaries

And so began my research. For the first study: Beyond Progesterone and Estrogen: Maternal Psychiatric Disturbances Linked to Adrenal Androgens, I recruited healthy, medication free, first time moms, with no previous history of mental illness. This was no easy feat. I soon realized that many women, even pregnant women, were using antidepressants and anxiolytics and many other medications. It seems the old adage that pregnant women should not take medications lest it cross the placental barrier and affect the developing fetus, had fallen by the wayside.

To assess the psychiatric distress, I abandoned the singular blues, depression and anxiety scales used so often in this research and found a broad-based, standardized assessment of psychiatric distress called the Symptom Check List 90R (SCL90R). SCL-90R is a 90-item psychiatric self-report inventory designed to measure the severity and intensity of psychiatric symptoms in both inpatient and outpatient populations. Participants rate the severity of distress experienced during the prior seven-day period using a 0-4 Likert-type scale (0=no distress-“not at all” to 4=extreme). Symptoms measured included: anxiety, hostility (aggression, irritability, etc.) phobic anxiety, paranoid ideation, psychoticism, somatization (perceptions of pain or other physical disturbances), obsessive-compulsive behavior, interpersonal sensitivity (feelings of personal inadequacy), depression and the global severity index (GSI), which reflects the overall symptom severity.

Along with the clinical symptoms, I measured five hormones, progesterone, DHEAS, testosterone, estrone, estradiol and estradiol, using saliva based testing. Symptoms and hormones were assessed twice, first in late pregnancy at 37 weeks (n =32) and again within 10 days following the delivery of their children (n=28, four were lost to attrition). I also conducted a year long follow up of those same participants and will report those data soon.

It’s Not Just Depression and It’s Not Just Postpartum

As I suspected, symptoms were present in late pregnancy and in some cases, increased in severity postpartum, but in other cases, decreased in severity. For some women, pregnancy was more problematic than postpartum, especially those with obsessive compulsive symptoms.

Fully 50% of the women tested experienced symptoms during pregnancy and 57% postpartum. This means maternal psychiatric distress is far more common than generally ascribed. As a group the anxiety related symptom scales, particularly the anxiety and obsessive compulsive scales, had the highest individual scores at each test time and when combined with hostility, phobia and psychoticism contributed the largest increase in symptom severity from pregnancy to postpartum. So it wasn’t the blues and depressive type symptoms that were most troubling, but the agitated, anxiety and even psychotic type symptoms that were the most severe.

Current research suggests that for only 1-2 per 1000 pregnancies psychosis will develop. What I found with this research and from another study,  is that psychotic symptoms were far more prevalent than recognized and may be the symptoms that drive the depression. In this study, we found sub-threshold, but clinically relevant, psychotic symptoms present in several of the women postpartum. Their symptoms were absent concurrent elevations in paranoia (paranoia and psychosis often go hand in hand). The most frequently ascribed to symptoms within this cluster included fears of serious illness (n=8), loss of mind (n=7) and isolation (n=12). Surprisingly, three women showed mild to moderate distress about thought insertion and thought broadcasting, two were concerned about thought control and one woman indicated distress about auditory hallucinations. Interestingly, it was these very same women who had the most dysregulated hormone profiles.

In speaking with the women who indicated these symptoms, the visual hallucinations, involved their children suffering; usually graphic intrusive thoughts, seeing images of their children being burned, thrown out windows, cut with a butcher knife, strangled with the breast pump tubing and the like. When auditory hallucinations were present they berated the women for their weakness, bad mothering etc., inducing guilt and one can only assume, depression. We confirmed the prevalence of these types of symptoms in two subsequent studies, the first published here: Dimensions of postpartum psychiatric distress: preliminary evidence for broadening clinical scope, the second unpublished as of yet.

Aberrant  Androgen Metabolism may be to Blame for Maternal Psychiatric Symptoms

As I suspected and as much research had shown, no symptom clusters were correlated with progesterone, estrone or estriol either pre- or postpartum.  While expected to be a close correlate of postpartum psychiatric symptoms, estradiol was associated with very few symptom clusters in the present study. Instead, it was the androgens that were linked to the symptoms at both time periods and not in a way that might be expected.

Low late pregnancy testosterone was not only related to late pregnancy psychiatric symptoms, but significantly predicted postpartum symptom severity. In conjunction, and this is where the endocrinology gets interesting, elevated late pregnancy DHEAS and supra-elevated postpartum DHEAS were associated with pre – and postpartum symptoms, respectively. This was exciting, because in theory these two hormones should not be aligned. That is, high DHEAS should correlate with high testosterone and it didn’t. So somewhere between DHEAS>DHEA>androstenedione> testosterone there was a problem and I had pretty good idea where.

For now though, we had a pilot study that ripped open the notions that maternal psychiatric distress occurred only during postpartum, was depressive in nature, was rare and was related to the normal or expected hormone changes of pregnancy. It was none of these things. The psychiatric distress was present at both test points, was more agitated, included a spectrum of symptoms, and most importantly, was related to aberrant changes in hormones that were likely exacerbated by the normal or expected hormone disruptions of pregnancy.  I was very excited. If we could identify the problem, then we could fix it right?

Not so fast. I could never get the research published and though I carried on with research I could do without funding, including a long term follow-up of the same participants (to be self-published soon) and an online study of the symptoms of psychiatric distress, the hormone work was routinely and summarily rejected. I learned very quickly how controversial studying hormones in women’s health was. So there it stands, the work was good, it pointed to a biomarker that could be used to identify and then treat a group of women who suffer horribly, but the study needs to be replicated with a much larger and more diverse population of women. It is likely that this is but one of many potential markers along this hormone pathway that could be used to predict and prevent perinatal psychiatric distress. It is also likely that this pattern of metabolism is linked to a host of other mental health and physical health issues. It was because of this research that I began Hormones Matter and have worked so arduously to increase awareness about the need for more research in women’s health. Hormones ought to be measured consistently across a woman’s life span, they aren’t and we need to change that.

Here are the full study details and the article, now officially self-published: Beyond Progesterone and Estrogen: Maternal Psychiatric Disturbances Linked to Adrenal Androgens.

Another portion of this study included assessing cognitive changes: Mommy Brain: Pregnancy and Postpartum Memory Deficits.

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