postpartum depression

Perinatal Mood, Cognition and Hormones

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While searching through old research files for an article I am writing on mitochondria and hormones, I stumbled upon the presentation notes for my thesis defense. I thought some of our readers might find them interesting. Although, I was not able to find the original PowerPoint presentation, I did find a later presentation that included my thesis and dissertation research, along with the some background information on neuroendocrinology. You can read my thesis here and/or the articles published from that research here and here. I added a few subheadings for readability, but otherwise, the presentation remains unchanged.

Perinatal Mood, Cognition, and Hormones

The purpose of this study was to identify the cognitive and emotional changes associated with pregnancy hormones both during pregnancy and postpartum and to identify early markers for perinatal mood dysfunction.

This research was based upon several physiological presumptions regarding pregnancy and postpartum. Conventional wisdom holds that during pregnancy reproductive hormones increase exponentially to support the pregnancy. It also posits that after delivery those levels decrease rapidly to below normally circulating levels and remain low until breastfeeding ceases and menstruation begins.

Animal research shows that many reproductive hormones are neuroactive and potently modulate numerous neurotransmitters systems. Given the large and sustained increased in such hormones followed by the precipitous decline, one would expect clear behavioral changes associated both with the elevated and diminished states of circulating hormones. We would also expect that the change from high hormone to low hormone state would mimic an addiction/withdrawal syndrome.

Numerous animal studies indicated that this was the case, but the connection between hormones and behavior in human studies was inconsistent and inconclusive for many reasons outlined in my research. The most important failing of previous research has been the lack of theory or evidence-based design. That is, not only has previous research failed to recognize, and hence, postulate neurosteroid/neurotransmitter mediated behaviors, but often failed to recognize the clearly articulated affective dysregulation presented regularly in clinical case research.

The question of which hormones modulate which neurotransmitters and to what behavioral consequences has not been asked, nor has the possibility that perinatal mood might be altered across several domains ever been addressed. Instead, most if not all, research focuses exclusively on progesterone and estradiol without so much as even speculating which neural circuits might be involved. Moreover, despite ample clinical evidence to the contrary, most research thus far measured and continues to measure only anhedonic depressive symptoms.

This study was different. Because extensive clinical case research revealed that perinatal mood was more often than not comprised of multiple syndromes of which depression was merely a part, I expanded the psychiatric domains measured to include assessment of 9 common psychiatric modalities and utilized a standardized and validated measure.

Additionally, previous studies measured only progesterone and/or estradiol. This study measured five hormones, progesterone, DHEAS, estrone, estradiol, estriol and testosterone.  The timing of assessment in other studies has been inconsistent and again not obviously evidence based. With approximately, 70% of all cases of postpartum psychosis occurring in first two weeks post-delivery, I thought it was important to measure within that time frame to capture those changes. Since case reports reveal premorbid symptoms during late pregnancy, I also measured at 37 weeks of pregnancy.

This study utilized salivary assays to measure hormone levels and controlled time of day and food intake. All previous studies measured hormones at non-standardized times and did not control food intake. Hormones have diurnal rhythms, and food intake, particularly with salivary assays will comprise results.

But perhaps the most important difference between this and previous studies is that this study was designed, all instruments were selected and the timing of testing was determined, based upon the presumed neuromodulatory activity of these hormones and the predicted concomitant behaviors associated therein, using an addiction/withdrawal framework. Thus it was imperative to test in the immediate postpartum so as to capture changes before neurological and behavioral adaptation occur.

It’s All About GABA

Given these considerations, much of the study design was based upon progesterone’s capacity to modulate the GABA system.

Progesterone is a potent allosteric GABAa agonist and anxiolytic. However, chronically elevated progesterone becomes anxiogenic via its actions on receptor conformation. It was postulated that during the course of pregnancy, the women would be the beneficiaries of the progesterone’s anxiolytic actions, but that towards the end of the pregnancy, as receptor conformation changed, the GABAa receptor would become immune not only to progesterone’s actions but GABA’s actions as well with the net behavioral effect of increased anxiety.

Postpartum, when progesterone was withdrawn the lack of CNS GABA transmission would induce hyper-excitability across several CNS systems that would be expressed in elevated anxiety symptoms and mood lability.

Major Findings: It’s Not Progesterone or Estradiol and It’s Not Depression

What I didn’t know going into this study was that DHEAS also modulated GABAa but did so antagonistically. What I also didn’t know, and what is in fact the first major finding of this study, was that circulating DHEAS levels increased throughout pregnancy and postpartum. All previous research indicated that DHEAS increased over the first two trimesters, decreased during the third and returned to normal immediately proceeding delivery. This was not the case. Although I have only two test times, DHEAS levels were clearly very high at 37 weeks, and increased postpartum by an average of 34%. Indeed only 6 participants showed waning postpartum DHEAS levels.

Returning to the GABA hypothesis, as is now becoming clear, during most of the pregnancy progesterone positively modulates GABA transmission. Toward the end of pregnancy when progesterone levels presumably level off but are nonetheless at supra-physiological levels, the chronicity of exposure elicits conformational changes in the receptor making it unresponsive to progesterone and according to animal research unresponsive to benzodiazepines as well. Concurrently, DHEAS levels are increasing and are now blocking whatever limited GABA transmission exists. Parturition occurs, progesterone levels diminish by some 93% while DHEAS levels continue to increase. So now whatever remaining GABA binding sites are still available become blocked and CNS hyper-excitability ensues leading to the behavioral lability seen in almost all women during the first two weeks postpartum.

The behavioral sequelae of these rather dramatic physiological changes include increased anxiety, phobia, OCD, paranoia psychoticism, and importantly many physiological symptoms tapped by the somatization scale of the SCL-90R, particularly cardiovascular dysregulation, increased heart rate, respiration, sweating, etc.

Postpartum, even in asymptomatic women, that is the 80% of women who experience what is imprecisely called “baby-blues” is often marked by hyper-excitability and mood lability as much or more so that anhedonia and depression. This is with good reason given the neurochemical and physiological changes occurring as these hormones adapt to the non-pregnant state.

Thus, the second major finding in this study was that although depression was certainly present, it was by no means the sole determinant and I would argue not even the primary or causative factor in the observed mood dysregulation postpartum. This is really important because insofar as previous and indeed current research continues to focus on postpartum depression rather than perinatal mood more broadly, hundreds of thousands of women get misdiagnosed, under-diagnosed and inappropriately treated. The findings from this study indicate that not only do negative mood symptoms begin in late pregnancy but that the disorder itself is characterized as much by anxiety or positive type symptoms as it is by depressive and anhedonic type symptoms.

The third major finding of this study was the connection between late pregnancy and post-delivery hormones to negative mood. As was outlined in my research, the design of this study was very strongly based upon the neuromodulatory capacity of progesterone on the GABAa system. Results from this research indicate that progesterone was not correlated with negative mood and thus I was wrong about progesterone. Nevertheless, I was correct about GABA being a major player in perinatal mood dysregulation.

Recent research suggests that DHEAS is a potent GABAa antagonist similar to the drug picrotoxin. That is, it is capable of binding to a site deep within the receptor, thereby limiting GABA influx.

Given DHEAS’ influence on GABA, its increase late pregnancy and post-delivery, one would expect clear and consistent correlations between DHEAS levels and mood. That is exactly what I found. Pre-delivery DHEAS was correlated with paranoia and psychoticism.

Post delivery DHEAS was strongly and significantly correlated with just about every mood symptom measured by the SCL-90R including anxiety, phobia, paranoia, somatization, and the GSI. Recall that DHEAS levels increased an average of 34% and increased for all but of 6 of the women postpartum. In some women, those who had the most severe postpartum difficulties, DHEAS levels increased 2-4X pre-delivery levels.

Moreover, the fourth major finding from this research showed that pre-delivery testosterone was correlated not only with pre-delivery negative mood (phobia, psychoticism, somatization and GSI), but was correlated strongly and significantly with almost every negative mood symptom measured by the SCL-90R post-delivery as well, including anxiety, hostility, psychoticism, somatization, OCD, interpersonal sensitivity, depression and GS. And the correlation was negative. That means that diminished testosterone (amidst the presumably elevated levels of pregnancy) were correlated with increased negative symptoms. This is important for a number of reasons, not the least of which is its predictive possibilities, but it suggests that the adrenal androgens of which DHEAS and testosterone are key component are implicated in perinatal mood.

This is groundbreaking. It has never been addressed before in the literature. If we look at the biosynthesis of steroid hormones during pregnancy, we see that DHEAS is produced both by the fetal and maternal adrenals and is intra-converted in the placenta as well. Biologically, DHEAS is considered inactive, meaning that it must be converted to DHEA before other downstream hormones can be metabolized. DHEAS is storage component for DHEA. If more DHEA is converted to DHEAS, for whatever reason, then less downstream hormones-testosterone are synthesized. These are the results I found. Since I didn’t measure DHEA, I can only speculate, but these two factors in hormone synthesis appear to be altered and these alterations are related to the mood perinatal mood dysfunction. Future studies are needed to confirm these findings and determine their etiology but preliminarily these results open up an entirely different direction for future research that has yet to be addressed, the implications of which will be far-reaching.

Perinatal Cognitive Changes

The cognitive results from this study were no less impressive but not as easily interpreted because cognitive ability was not consistently linked to either mood or hormone data but was obviously impaired.

As a group, these women were educated with many having graduate degrees. The average estimated IQ was approximately 1 SD above the mean and might have been higher if complete testing had been performed. Most of these women worked outside the home in a professional capacity for the duration of their pregnancies, and yet when tested, showed significant memory and executive function deficits when compared to age and education matched normative data. The degree of impairment was striking, and quite frankly, unexpected.

In verbal memory measured by the CVLT-II, many percentile rankings were below the 20th percentile. When testing these women, it became apparent how important semantic memory was, with those women recognizing the categories of words having little difficulty completing the task and probably skewing the data somewhat. However, for a large percentage of the women, there was absolutely no recognition of the categories inherent in the task and their ability to recall even a fraction of the words was hindered tremendously. The women also repeated words, in some cases 2 and 3 times during the course of a trial and recalled words that were not part the trial list.

On spatial memory tasks the deficits were no less obvious. As is exemplified by the CFT tasks, shown in the appendix of my thesis, the impairment was at least in part related to an inability to see the drawing as an entirety. If we look at these drawings closely, we see that in the copy phase, the core of the drawing, the rectangle is missing. That is, each section of the figure is drawn separately. This presents difficulties in encoding that will ultimately limit performance of the recall portion of the task. Again notice the piece meal quality of the figures in the recall task, with large portions of the figure completely missing. The examples illustrated here are representative of performance across participants.

The mood to cognition relationship was interesting if not paradoxical. Conventional wisdom would suggests that negative mood, particularly depression and anxiety would impair cognitive performance. This was not the case. Indeed depression actually improved performance.

The hormones to cognition relationships were no less confusing except that changes in DHEAS were correlated with poorer performance on the CVLT-II. Given the magnitude and direction of change in DHEAS levels this was consistent with the earlier results. Progesterone, was not correlated with mood symptoms but was correlated to both aspects of the design fluency task and the estrogens were correlated with a variety of task both pre and postpartum.

What was particularly interesting about this aspect of the research was that cognitive ability declined in many areas postpartum, but participants perceived themselves as having improved. The disconnect between perception and performance was clear almost across the board.

Finally, it may be that as in the case of other mental illnesses, cognitive functioning is not correlated with severity of symptoms but is associated with measures of therapeutic outcome such that higher premorbid functioning predicts one’s ability to function during and after an episode.

This possibility begs the question that if another group of women was tested having lower premorbid cognitive function and lower socio-economic status, would they have fared as well as the women in this study. That is, would their ability to withstand the physiological and consequent emotional/behavioral change associated with pregnancy and postpartum be comparable to the abilities of this group?

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More people than ever are reading Hormones Matter, a testament to the need for independent voices in health and medicine. We are not funded and accept limited advertising. Unlike many health sites, we don’t force you to purchase a subscription. We believe health information should be open to all. If you read Hormones Matter and like it, please help support it. Contribute now.

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The studies addressed here were published in 2007 as part of my PhD dissertation. This post was published on HM on November 29, 2018.

Severe Postpartum Anxiety, Suicidality, and Polypharmacy

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Early Health History

I was vaccinated as a kid. I got ear infections, stomach bugs, and I had mononucleosis. I ate a pretty good diet for half of my childhood. My mom always made sure to have meat and vegetables at dinner. I had the flu in high school once, and once in college. In high school, I was very active in the marching band and I was a twirler. I was always a healthy weight and ate reasonably. I believe that I had the flu shot and meningitis shot in college.

In high school, I could take or leave any kind of food or sweets. However, in my second year of college, I crossed over the imaginary line of addiction with food. I began to binge eat, especially sweets. I noticed I was overeating but I couldn’t control it. Eventually, I found help in 12-step programs for my food addiction. I gained weight here and there over a few different times during college. However, since then, I’ve always been able to maintain a healthy weight by not bringing home my binge foods.

A Healthy Pregnancy but a Difficult Postpartum: No Sleep, Anxiety, Suicidality, and a Whole Bunch of Medications

In November 2020, I had my baby.

I took high dose vitamin C throughout my pregnancy and had a very healthy pregnancy and birth. It was supposed to be at the birth center, but that fell through when I tested positive for COVID. I forgot to pack my vitamin C when I went to the hospital, which I think may have affected me. At the hospital, I only got 4 hours of sleep over two days. On the third day, we came home. I got another two hours of sleep, but I became suicidal due to lack of sleep. So I had to go to the mental hospital on my baby’s third day of life.

I was put on Zoloft and Ativan and trazadone in the hospital. I came home from the hospital and things were okay. I had to get a medication adjustment by switching to Seroquel.

Due to my significant other not allowing me to make medical decisions for my baby, I went into fight or flight mode and I became suicidal again on December 7. I had to go back to the mental hospital for about two weeks. None of the anxiety medicine (Buspar, hydroxyzine, and maybe another one) I was taking away resolved the fight or flight. The anxiety was so bad that I could feel my insides shaking from head to toe. I couldn’t sleep at all for days. The only way I was able to sleep was when they finally prescribed me the extended release version of Seroquel. During both hospital stays, I did have a UTI and was treated with antibiotics. I don’t know which antibiotics I was given at the hospital. In February of this year, I had another UTI and was given Macrobid 100mg.  

Crushing Fight or Flight Anxiety

When I came home from the hospital, my fight or flight anxiety was still so bad that I couldn’t even change the baby’s diaper. When I got some Xanax, I was finally able to get stuff done and function. My anxiety finally calmed down to where I could function without Xanax, however, I still had anxiety pretty bad.

On January 8, 2021, I started eating an all whole foods diet, nothing processed, no sugar, flour wheat, dairy, or high fat.

When I eat, I getting very foggy, despite eating a whole food diet. After posting in the orthomolecular group on Facebook, some people pointed out histamine intolerance (HI). So I’ve come to learn that I have HI and probably salicylate and oxalate intolerances too. I’m assuming this because the fogginess after I eat is bad. Also, after meeting with a nutritionist, she pointed out that my prolonged anxiety probably affected how I digest food, hence now causing me to have all these food intolerances. I have found research, a Harvard study, that prolonged fight or flight can cause HI/ digestion issues and actually cause digestion to stop. I have been unsuccessful with a low HI diet due to lack of freezer space/ stress of freezing/defrosting.

I’m also jaundiced. I can’t gain weight and my eye twitches every so often. I’m 5’7” and about 109/110 pounds. It is very scary how thin I am. You can see my sternum and my spine, despite eating three whole food meals a day that are weighed and measured, plus whole food snacks throughout the day.

I went to a natural chiropractor and he told me I was still in fight or flight, which didn’t surprise me because my anxiety was still bad, even though I could function. The anxiety is in my shoulders and is a constant throughout my day. It’s not like the head to toe fight or flight anxiety I had, but it is still bad. It caused me to have these intolerances that I’ve never had in my life. So I’ve officially been in fight or flight mode for over 6 months.

A few months ago, I tried taking Niacinamide for the anxiety. I took about 1500-2000mg a day for about 2-3 weeks but I didn’t notice any difference, so I stopped taking it since it was increasing my metabolism.

I have started a very low dose of thiamine HCL (1 mg- if that) but I noticed it is causing me to be foggy just like when I eat. This is very concerning to me because if I plan to titrate up, that means I’m going to be experiencing fogginess to a very great extent and pretty much all day. I do have magnesium and a B complex vitamin, and plan to supplement with potassium as well. I also magnesium lysinate. I’ve been drinking coconut water for potassium, however, I’ve slacked off because it was causing worse mind fogginess. I have magnesium malate in powder form, but I need to get an encapsulation system. I started the b-complex vitamin today. I have potassium chloride in powder form to supplement with if I don’t use the coconut water. I believe I’m taking about 12 mg of thiamine a day. I also take Nutrigold’s fish oil, and a prenatal vitamin.

My doctor allowed me to wean off Zoloft a few months ago. I’m currently taking Seroquel and Seroquel ER.

Will the thiamine control the anxiety once I’m able to take it in high doses and rid my food intolerance? My anxiety is situational and unfortunately, the situations aren’t going to change, so I’m curious if you think it will help me. Due to my body being in fight or flight mode and not rest and digest mode, I’m not sure the high dose thiamine will help, since my body isn’t absorbing any nutrients and I can’t keep weight on.

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More people than ever are reading Hormones Matter, a testament to the need for independent voices in health and medicine. We are not funded and accept limited advertising. Unlike many health sites, we don’t force you to purchase a subscription. We believe health information should be open to all. If you read Hormones Matter, like it, please help support it. Contribute now.

Yes, I would like to support Hormones Matter.

Beyond Depression: Understanding Perinatal Mental Health

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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.

Do I Have Postpartum Depression? Case Scenario and Resources

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Postpartum depression may occur in up to 1 of every 8 pregnant women. Here, we produce a fictional representation of how it may present to you in real life, whether you are a family member, friend, or spouse. It is important to note that postpartum depression can also occur during pregnancy, and can occur as a seemingly ‘normal’ event of childbirth depression, yet postpartum depression carries more burdens and feelings of being totally overwhelmed, less in control of one’s life, anger, and rage. Gradiations of postpartum depression thus can be so subtle that you think nothing of it, yet with extreme postpartum depression, the mother is encompassed by hallucinations or voices incessantly talking to her, instructing her to harm herself and/or her child. The number one cause of death in new mothers is suicide, with thoughts of suicide and self-inflicted harm as very serious problems (Moses-Koldo, 2009; Lindahl, 2005)

Recognizing Postpartum Depression: A Case Scenario

Her name was Anna, little Anna. She soundly slept in the car all the way home, as if she was going to be a “good baby.” Her little hands scrunched up into balls every so often, and although she slept, her eyes moved just so, proving that she was in rapid eye movement sleep.

In the front seat, the mother with the straggly hair, Josephina, put on the smiling face of a clown. None of the doctors had noticed a thing that was wrong with her, even though she did complain to one good-looking young doctor in training. All he did was scoff at her. He made her feel ashamed and silly. But inwardly, she was petrified, just petrified, of being left alone with this little being that depended on her for everything.  Her thoughts of throwing the baby off the ledge and jumping in after her, like diving into a pool, continued to grow in their intensity, frequency, and enormity.  Josephine was scared to turn the lock and enter back into her apartment that represented loneliness, so she let her friend Marissa do it. Marissa stayed long enough to lay the baby in a clothes drawer on the floor, surrounded by blankets so soft that they still smelled like fabric softener.

As Josephine said her goodbyes and closed the front door with barely a squeak, she silently turned her back onto the white painted door. Slowly, ever so slowly, she slid down the door crying silent yet violent tears, body heaving, until at last she was sitting on the floor. All the thoughts continued to pound in her head: “Throw the baby out the balcony! Jump in and just dive in after her!” Her unkempt hands held her head, fighting the increasing enormity of the battle. “Do it!” “Do it!” Josephine grasped aloud at these intrusive thoughts that didn’t belong in her brain. She knew they didn’t belong there, and she felt cursed upon realizing what an ungrateful new mother she must be. Maybe she didn’t deserve to have this little Anna at all. Laden with guilt, she rocked herself on the floor and thankfully, the baby slept through it all.

She thought, as she wiped her tears for the millionth time, “Do all mothers feel this way? Do they all go through this? Aren’t I supposed to be happy?” Of course she was tired. No, she was exhausted. Of course she had continuing insomnia and her mood swings were unpredictable and covered the expanse of linear possibilities: one minute laughing and the next minute, crying. She looked at her hands and they were trembling as another layer of guilt fell over her like a black sheet at Halloween, showing only her eyes. She ran to the bathroom and threw up for the third day in a row. The thoughts turned into guilt and shame, chastising her very soul. She should be happy, but she wasn’t. She should be having happy thoughts, but she wasn’t. Another black sheet of guilt and remorse fell upon her, and her shoulders drooped with the heavy weight that she bore. She wanted to scream! She wanted to run! And yes! She wanted to jump over that balcony!

The exhaustion, insomnia, and the overwhelming state of mind were perfectly normal for any new or seasoned mother, indeed. Each pregnancy was different, but all pregnancies carry with them the dawning of another layer of new responsibilities, the screaming of a helpless being, the bursting of the mother’s eardrums, a hundredfold changes in circulating hormones, and concurrent inflammatory reactions that all but wreak havoc on a woman’s body. If she also suffers from poor nutritional status, this further compounds the biochemical reactions in her body, adding another twist of lime. When the baby cries, the breasts drip milk; it’s just automatic. Her body is a robotic machine, connected inexplicably to her baby, just as if the umbilical cord had never been cut. Mother and child are still tied together. Like a parasite of alien proportions, the baby sucks at her breasts and also sucks at her life.

Transition to Motherhood: When Postpartum Depression Rears its Ugly Head

For most women, this depression hits its worst on the day of the “Third Day” blues. Then it seemingly disappears just as quickly as it came. The blues gently fade away with day number four; they can last a week or two. Mom is smiling and laughing again. She has no thought of harm to herself or her baby.

Risk factors and symptoms for postpartum depression are broad and ill-defined. Some research focuses on the sadness, the lack of energy and the depression, while other research suggests postpartum depression is not really a depression in the classic sense, but an anxious feeling of unease, marked by increased intrusive thoughts, like those Josephina experienced. In truth, how and when women present with postpartum depression is highly variable. The symptoms can begin in pregnancy, 3-6 weeks after childbirth, or really anytime. For more information about pregnancy and postpartum psychiatric distress, the following articles may be helpful: Framing the Pregnancy Postpartum Hormone Mood Debate, Beyond Depression: Understanding Perinatal Mental Health,  Maternal Psychiatric Disturbances and Hormones, What Causes Postpartum Depression? You might also consider reading the personal stories listed on our blog about postpartum depression. If someone you know is suffering from postpartum depression after childbirth and you reach out, you may save a life.

Reaching Out to a Postpartum Woman

So you are the one that had met Josephina in the market before she had her baby, and you exchanged phone numbers with her. You are new in town, live comfortably with your husband and two toddlers, and are looking for a friend. You want another baby, but your husband does not. You decide to call Josephina to see how she is doing.

“Hi Josephina. This is Elena. Remember we met in the grocery store? My kids and I were wondering if we can stop by and visit. We have a gift for you and the baby. Call us back when you can, ok?” You leave a message on her cell phone, as Josephina did not pick up. She was too busy staring at the floor, feeling too sad and guilty to move.

You call her again the next day, after Josephina had awakened in a sweaty bed, had only two hours of sleep, and felt like a walking zombie. This time, Josephina picked up the phone and said you could come visit.

You and your children arrived to her apartment door knowing that it was the right one; you could hear the screaming baby all the way down the hallway. You, being so perceptive, also noted that you could not hear any words of consolation, no kisses, no whispers or singing of lullabies. Josephina answered the door, walking away without saying hello. She mumbled something about going to get the baby, and came back from the bedroom with little Anna. You let your children play with the baby laying in her portable car seat, while you pulled Josephina aside.

“What’s wrong, honey? You don’t look so good to me.” Clearly, Josephina was sorely depressed and had not yet bonded with her baby. She was thin as a rail, malnourished, unkempt to the extreme, and you sought immediate help for a diagnosis of Postpartum Depression. You told Josephina to go take a nice bath or shower, put on some clean clothes, and by the time she was finished, you would have a few phone numbers for her to call, a few resources for her to use so that she could get help and not be all alone with this beautiful baby girl.

Josephina stood still. She was catatonic. Immobilized. So you turned on the shower, took away the razor blades on the tub, and got her undressed. You went back and forth, checking on the baby, looking for baby formula, and watching Josephina shower. “Put the shampoo on first, Josephina.” You got internet access on your iPhone and did a search for Postpartum Depression. Finding a page full of resources, you checked on the baby and the children, then on Josephina again, saying, “Okay, Josephina, time to do shampoo number two!”

And you started making phone calls. You learned that Postpartum Depression is the #1 complication of childbirth. 1 in 8 women suffer from Postpartum Depression (that we know of), many going undiagnosed.

Approaches to Postpartum Depression

Treating postpartum depression presents unique challenges and concerns compared to treating depression or other mental health issues in non-pregnant women. In addition to the concerns about breastfeeding, new moms are sleep-deprived, sometimes feel isolated, have just undergone enormous hormonal changes and are often nutritionally deficient. Tackling these issues may require multiple treatment modalities. Here is an overview of the standard approaches to postpartum depression treatment.

  1. Counseling/Psychosocial Assessment and Support. This first-line road to better mental health helps with talking about your thoughts, coping mechanisms, and problem-solving; removal of solitude can make a huge difference. In addition to individual therapy, a number of postpartum and parenting support groups exist in every community, and many referral systems are in place through helpline resources, such as Resources International “Get Help”  http://www.postpartum.net/Get-Help.aspx .
  2. Anti-depressants, anxiolytics and/or other medications.  A common method to treat postpartum depression, but it is not without controversy and risk. If you are breastfeeding, be sure and talk to your doctor about which drug(s) to go on. Medications may pass from the mother through breast milk to the baby. It is crucial to note that with adolescents and young adults and postpartum women some antidepressants may lead to “…increased risk of suicidal thinking and behavior…” exacerbating the situation. (NIH; Package Insert). You may want to seek at least two opinions before starting antidepressant therapy.
  3. Hormone therapy. Still an area of controversy, some clinicians advocate attenuating the decrease in postpartum estradiol with transdermal estradiol (Moses-Kolo, 2009). The thinking is that if this hormone declines more gradually over time, the symptoms of postpartum depression may lessen or diminish completely. The research is mixed. Other research suggests declines in progesterone are linked to symptoms and thus, treating with progesterone may alleviate the symptoms. (It should be noted, however, that synthetic progesterone as is found in birth control pills, exacerbates postpartum depressive symptoms and should be avoided.) And yet, other research suggests that it is not the decline in estrogens or progesterone that spur postpartum symptoms, but rather abnormal fluxes in androgen hormones. It should be noted that undiagnosed thyroid conditions are common in women, especially during pregnancy and following childbirth, and so, thyroid disease might also be responsible for the onset of symptoms. With postpartum psychiatric issues, thyroid disease should always be tested for and treated if found, ideally prior to beginning other therapeutic interventions.
  4. Ongoing NIH Clinical Trial: If you are interested in participating in a clinical study on mood changes after childbirth whether or not you have had postpartum depression before, you can visit the NIH website here. This Screening Program to Evaluate Women with Postpartum-related Mood and Behavioral Disorders (Study 03-M-0138) is currently recruiting volunteers. Selected patients may be asked to participate in a follow-up study using estradiol for postpartum depression.
  5. Nutritional therapy. Emerging evidence connects nutritional deficits to postpartum psychiatric symptoms. With the added physical burden of pregnancy and childbirth, previously hidden nutritional deficits become unmasked and can initiate a cascade of psychiatric and inflammatory reactions.

From Postpartum Depression to Psychosis

“Put on your conditioner now, Josephina,” you instruct, as you sit and make some phone calls. Even your own hands are shaking now, because you don’t want her to lose her baby to the State, but you also don’t want her to take her baby and jump off the balcony. By this time, she has told you everything. It is almost too much. You are overwhelmed and you know that she needs professional help. You know that the next 15 minutes will be crucial, even staggering, in how you approach her illness. Your concern for how this will impact the rest of her life almost leaves you frozen, but you know that you know that you know that two lives hinge on your decisions. And to further confound matters, you know that none of your options will be optimal. No matter which path you choose, you could be perceived as ‘the bad guy’. The diagnosis may be made, but the treatment options are limited and wrought with controversy. There is no easy answer. Every choice comes with a consequence and you can only do your best.

Frightened at the unknown future results of your own actions, you begin to doubt yourself as pessimistic thoughts cry out: “What if I make the wrong decision?” You oscillate between worries, “If I do nothing and she hurts herself, it would be my fault.” On the other hand, “But if I call 911 and they take the baby from her, I would have to live knowing that I did that to her and the baby.” Back and forth you go. The reasonable, pragmatic side of you knows for a fact that Josephina can not take care of herself and can not be left alone with her baby. For one moment, the squeals of the baby break through the coo’s of your own children’s laughter, almost as a reminder, say yes! It is a reminder of how things are ‘supposed’ to be. Again, you internalize this conclusion, knowing that you need help yourself. You cannot bear this burden alone. You have no experience with this, you dread making a life-long or fatal mistake. You are smothered into a corner to do something NOW!

So you decide to call for help.

When Postpartum Depression Becomes an Emergency: Finding Help

Debating psychotic disorders and parenting, and the relevance of a mother’s children for general adult psychiatric services was, in 2000, Louise Howard’s project as a Research Fellow. She stated that women with psychiatric issues who become pregnant should be specifically identified for further study, assessment, and improved outcomes, considering their children. The impact of the parent’s illness on the children, as well as a need for supportive services, needed further study.

In 2000 in the UK, a woman could voluntarily admit herself to a the first psychiatric unit, the first women-only residential mental health crisis unit in Drayton Park, North London, where children could be admitted with their mothers (Killaspy, 2000).  Residential alternatives to inpatient ward care in England have since been shown to provide more patient autonomy, greater satisfaction, less coercion, more ‘voice’, less aggression, and less anger (Osborn, 2010). Since the 1980’s, these residential units have been rampant throughout the Australia, UK, Europe, and New Zealand.

In the USA, there are many ‘postpartum depression treatment centers’ that can serve as the initial call for help, and provide care in the outpatient clinic setting. This resource seems most appropriate for women with depression who are not hysterical, hallucinating, are overcome by intrusive thoughts, or are having visions or hearing voices. For a government department (i.e., Substance Abuse and Mental Health Services, or SAMHSA) that is continually updated and offers local, mental health referrals, use telephone 1-800-662-4357, 1-800-662-HELP, and/or website www.findtreatment.samhsa.gov .

During the week of August 11, 2011, the U.S.’s first treatment center based on the Drayton Park, London model of inpatient mother:child care opened. This was first inpatient facility for severe postpartum depression for both mothers and babies. It is still located at the University of North Carolina’s Chapel Hill hospital’s psychiatric ward. Brown’s University has a Postpartum Day Hospital opened for mothers and their baby’s weekdays from 9 am to 5 pm (Stampler, 2011).

A bipolar woman who gets pregnant has an increased chance of having postpartum depression leading to postpartum psychosis (Marks, 1992), but she may not seek care for her needs, for fear that her baby will be taken away from her (Howard 2000). When things have escalated to the point of Mom wanting to harm herself or the baby because of voices in her teeth telling her to do so, psychosis may exist and this demands immediate emergency care. Society still places a stigma on mental illness and it is unfortunate that an involuntary admission to a psychiatric unit is usually accompanied with separation from the child(ren).

In the United States, the most common route is for the woman to be rather forcefully taken by the police to determine her fate in jail or a psychiatric ward. Nonetheless, you must call 911 for any immediate danger to self or baby. When you do, a number of things may happen depending upon the state that you reside in.

As a useful tool to help you assess whether or not you have severe postpartum depression, Harvard Medial School’s “Edinburgh Postnatal Depression Scale” is an online test you can take in 5 minutes.

From Bad to Worse: When Postpartum Depression Risks Harming the Mom and Baby

Poor Josephina cannot dress herself. So you help, frequently checking on the baby and your own children who are happily playing in the living room. You ask Josephina several questions, “Do you have anyone to help you with the baby? Any relatives here?” Josephina just nods her head, “No.”  As you continue to help her get dressed, you ask her if she’s taking any medications. “No.” You ask her if she is still having these thoughts of jumping off the balcony and she slowly nods her head, “Yes” as her eyes widen and her eyes turn maliciously toward yours. “Get her away from me. Take her now. Please take her now and take care of her. I can’t take care of her. I beg you to please take her.”

You are in shock as you make her write it down on a piece of paper, dated and signed with her signature. You only left her for 15 seconds to check on the children, but already she had bolted with the car seat and the baby, and was trying to unlock the sliding glass door. You turn to Jimmy, the older boy and look him in the eyes. “Call 911 now.” He’s not sure why, but he can tell Mommy is in no mood for questions. As he picks up the phone, Josephina and Elena fight at the sliding glass door lock, each trying their own destination: Josephina to open it, and Elena to close it. The baby is suspended in mid-air and Elena says, “Put the baby down! Put the baby down now!” Josephina looks like a maniac now, bloodying up her fingernails on the door latch in a desperate attempt to jump off the balcony. They both hear, “Um. I’m not sure, but my Mom and a lady are fighting over a baby at the balcony.”

The little child of Elena, Cristal, starts crying. Mommy said, “Go and lock yourselves in the bathroom. Here, take the baby with you.” And in one final attempt and with all her bloody might, Elena kicked Josephina enough to sidetrack her for a microsecond. Elena forced the baby car seat out of Josephina’s grasp, and ran with all three children to the bathroom. As she turned the corner, she could see that Josephina was staring at her bloody fingernails, then looked up at her, then began to dart for the bathroom door. Elena got all the children in, and told Jimmy to lock the door. Now, the children were safe.

This 1 in 10,000 chance of a psychotic depression has turned into a police matter now, and Elena poses. She is ready to fight for all the babies. But she speaks in a calm tone, reminds Josephina of the calm shower, and gets her to sit down. Shortly thereafter, the police are at the door and they take Josephina away to book her for Child Endangerment and Danger to Self.

It’s not Josephina’s fault that her psychosis led her to this. If one person had listened to her earlier, she would have received help earlier, and this never would have happened. If she had known, she could have voluntarily turned herself in to a postpartum treatment center. If she had known, she could have taken the Edinburgh Postnatal Depression Scale test on her own, to self-diagnose and self-realize the extent of her own depression. If only…

But there is no pity for her, no blaming the biochemical changes in her brain, much like that described in people with a brain tumor who do aggressive things without realizing it. She is ostracized as a criminal instead of as a psychiatric patient, and is sentenced to 15 years in a Woman’s Prison. Being as there are no relatives that come forward, Elena gains first temporary and then permanent Custody of little Anna, then moves away to another city. Not something she had planned at that first chance meeting in the store.

If Josephina gets a proper diagnosis, showing that she was bipolar before the pregnancy, and receives proper treatment, her chances of recovery are 100%. But there’s a catch. She may never be able to go off her medications.

To learn more about resources for postpartum depression: Resources for Postpartum Depression.

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. Howard, L. Psychotic disorders and parenting – the relevance of parents’ children for general adult psychiatric services. Psych Bull 2000; 24:324-326. http://pb.rcpsych.org/content/24/9/324.full (Accessed June 26, 2014).
  2. Killaspy, H., et al. Drayton Park, an alternative to hospital admission for women in acute mental crisis. Psychiatric Bulletin, 24, 101- 104. Abstract/FREE Full Text
  3. Lindahl, V., et al. Prevalence of suicidality during pregnancy and postpartum. Arch Womens Ment Health. 2005 Jun;8(2):77-87. Epub 2005 May 11. http://www.ncbi.nlm.nih.gov/pubmed/15883651 (Accessed June 26, 2014).
  4. Marks,  M.N., et. al. Contribution of psychological and social factors to psychotic and non-psychotic relapse after childbirth in women with previous histories of affective disorder. J Affect Disord, 1992: 29, 253-264.
  5. Moses-Kolo, E.L., et.al. Transdermal estradiol for postpartum depression: A promising treatment option.  Clin Obstet Gynecol.  Sep 2009; 52(3): 516-529. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2782667/ (Accesed June 26, 2014).
  6. NIH. Transforming the understanding and treatment of mental illnesses. Depression. FDA Warning on Antidepressants. 2011. http://www.nimh.nih.gov/health/publications/depression/index.shtml. (Accessed June 26, 2014).
  7. Osborn, P.J., et. al. Residential alternatives to acute in-patient care in England: satisfaction, ward atmosphere, and service user experiences. Br J Psych 2010: 197:x41-s45. http://bjp.rcpsych.org/content/197/Supplement_53/s41.full (Accessed June 26, 2014).
  8. Package Insert. Fluoxetine hydrochloride. 1987. http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/018936s091lbl.pdf (Accessed June 26, 2014).
  9. Stampler, S. First U.S. Inpatient Clinic for Moms with PostPartum Depression Opens. Huffington Post: Parents. Oct 19, 2011. http://www.huffingtonpost.com/2011/08/19/americas-first-inpatient-postpartum-depression-unit_n_931179.html (Accessed June 27, 2014).
  10. Treatment Centers. Study examines postpartum depression. Psychiatry/Mental Health. May 24, 2010. http://www.treatmentcenters.net/psychiatry-mental-health/study-examines-postpartum-depression/ (Accessed June 27, 2014).

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.

Before She was Born: Seeds of Postpartum Depression

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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

  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.

Maternal Psychiatric Disturbances and Hormones

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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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Postpartum, Parenting and Endometriosis

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I was not diagnosed with Endometriosis until four years after the birth of my daughter.  The pain of endo plus postpartum depression was hell mentally and physically. And did I mention, I was a single mother as well.

When my daughter was born I felt no attachment to her whatsoever, no love, nothing. I felt like she wasn’t even mine. I was depressed; I was in pain from the delivery and emotionally was not available to my daughter. I was also having trouble breastfeeding and after 2 weeks, I gave up. The first week after delivery was especially difficult. I was dealing with the pain of childbirth as well as trying to treat a yeast infection that I had during delivery. Every time I stood up I had severe vaginal pain and this lasted a year after the birth of my child.

My daughter cried from the day I took her home. She was a very fussy baby, only would sleep if I held her. I tried the ‘cry it out method’ and that didn’t work. She wouldn’t drink her formula and up until she was 9 months she drank only 4 ounces 3 times a day.

By the time she was 9 months she started walking. She would get frustrated and wanted to be held, then let down, wouldn’t go in a stroller, would throw herself back if you were holding her, she would cry and cry and cry. Nothing at all I could do could console her. I tried everything. By the time she was one she started to slam her head on the ground out of frustration and that just stressed me out more. She was never on the charts for weight or height but she was very intelligent and met all other milestones and still does.

I would get so frustrated I would put her on the bed and let her scream because I just wanted to throw her. I couldn’t understand why I had these feelings. They were so strong.  I thank God at that time I was living with a family and the husband would take her from 4-11pm when she would just scream bloody murder. I felt like such a bad mother and I really started to resent her being born. I felt angry at her father. I was so tired and my head just didn’t feel right mentally.

I remember having a dream that she was hanging outside the window and she was screaming for me to help, but I just looked at her and I let her fall. When I realized what I had done I ran downstairs to see if she was okay. She was, but she looked at me as if I had betrayed her. Even though it was a dream, in a way I had betrayed her. I wished that she wasn’t born. I felt she ruined my life and was bringing me down into a further depression I just couldn’t get out of.

I went to the doctors told him I must have postpartum depression (PPD) and he told me no that I didn’t. I talked to my mother and said the same thing and she said “I had three children and I didn’t have it and so you can’t have it.” You have to remember I was on my own at this time and everyone was telling me I was fine.

One day I was watching a TV program on PPD when my daughter was three years old. I knew I had PPD. So, I walked myself right into the Emergency room at the hospital and told them that I think I had it. I would never harm my child, I just had thoughts. The doctor gave me sleeping pills and sent me on my way.

I would become so frustrated at my daughter I would scream in her face and tell her to stop crying. Then I would cry because what type of mother does that? One night I felt like there were demons on my room and I was petrified.

Mentally, I was falling apart. I was nauseated, tired, irritated, angry, I had severe acne everywhere, my back, chest, face and neck and in pain in my pelvic area and bowels. To be honest I was just down right out of my mind when I finally went to the doctors again. I was sent to get an ultrasound done and that is when they found the cyst. I went to my gyno and she wanted to put me on Lupron.  I refused, as I did my research about the side-effects. However, I did go on the birth control continuously to see if that would shrink the cyst.

Within one week something happened. It was like a light went on. I never felt so great in my life. The acne started to clear up, I wasn’t angry and my mind was so clear that I couldn’t believe it. That is when I feel like my life changed.  I realized that my entire life I had had something wrong with me hormonally but that it was pushed aside by doctors.  They just kept telling me I was depressed.

I am so glad that I am not like that anymore, but I feel like I damaged my daughter mentally during that period of my life. She suffers from anxiety now.  I really feel it was because of what I was going through.

After having my end treated with multiple surgeries, I feel better, but not great (read my story here, here or here).  I suffer from debilitating fatigue and I think that is the worst when it comes to wanting to do things with my child. When I wake up I feel like a truck hit me and I get a little crusty with my daughter because of it.  I know she can’t understand what I am going through and even if I try to explain to her. I don’t think I will ever get back the first five years of my daughter’s life. I feel like it has been a blur. It is like I don’t remember even being there during that time.

My daughter is very compassionate and understands that I have Endometriosis but it still doesn’t help when I have symptoms that affect her.  And that makes me really sad.

Is there anyone else out there that had endo and then postpartum depression?