In the past several years, much progress has been made in understanding, diagnosing and treating psychological issues that develop the first year after childbirth, commonly referred to as 'postpartum depression.' Even the condition's name has been revisited.

"There is no specific diagnosis called 'postpartum depression'," says Leslie McKeough, a Leesburg therapist specializing in perinatal and postpartum issues. "That term is a general umbrella that medical professionals use to describe a group of mental illnesses experienced after the birth of a child - and it's the label we use for insurance purposes."

Mental health experts now say there are a whole host of 'adjustment disorders' that women (and even some men) experience in the first year after the birth of a child. Properly referred to as "Postpartum Mood and Anxiety Disorders," these illnesses include episodes of depression, anxiety disorders, mood disturbances, obsessive-compulsive behavior, post traumatic stress disorder, bipolar disorder and other related conditions. Often a patient experiences more than one of these illnesses simultaneously.

causes
"Child birth is this 'perfect storm' of changes - physical, hormonal, diet, sleep, new stressors in the home, new identities for family members, etc.,” says Esther Boykin, a licensed family therapist located in Haymarket, VA. “These changes create imbalances that we believe can trigger these postpartum illnesses." It is still unclear why 20% of women develop one or more of these disorders after childbirth, though researchers are getting closer to understanding the factors that may put some women at risk. For example, if a woman's mental health history includes a previous diagnosis of a psychiatric illness, she has a 50% chance of developing a postnatal mood and anxiety disorder. If one or both of her parents have a history of depression, she is also more susceptible to these conditions. Another risk factor for determining whether a woman might suffer from a postpartum mood and anxiety disorder is a woman's reproductive history.

"If she had irregular periods, severe premenstrual syndrome, miscarriages and/or trouble getting pregnant, a woman has a marked increase in the likelihood of developing a postpartum psychological disorder because her hormones may be less balanced to begin with," says Adrienne Griffen, a survivor of postpartum anxiety and the founder of Post Partum Services Virginia (postpartumva. org). The organization is dedicated to reaching out and further educating women and medical practitioners about how to treat postpartum disorders.

Other causes include the stress and anxiety associated with fatigue, changes in the marital relationship, concerns about finances and feeling isolated from family, friends and the pre-baby social structure. Women may experience these conditions after the birth of her first baby or, surprisingly, after her second or third child is born. If she experiences a postpartum psychiatric condition once, she is more likely to experience it again with subsequent births.

Women in the D.C. area may have a greaterthan- average risk of developing post pregnancy psychological issues because the population is more transient than in other parts of the country.
Many new parents suffer from a lack of support when they bring baby home because they don't have family nearby, which can make them feel isolated, anxious and depressed.

There may be another reason why so many women in the Washington D.C. area suffer from postpartum mood and anxiety disorders. Some therapists believe these conditions appear to be more prevalent in women with 'Type A' personalities.

"Of the 700+ women we help each year," says Griffen, "The majority of them are in their 30s. They have had very successful careers; they are the classic overachiever types. Many of them went through fertility treatments to get pregnant and when the baby finally arrives - after all of those years of waiting and planning and hoping - these women are completely thrown for a loop. To make matters worse, these highly educated and informed women are not flagged as high risk, so they don't see this coming. They may not have paid too much attention to information about psychological disorders in the books they read and the pamphlets they received because they may have assumed this was not going to happen to them."

symptoms
Even women who do educate themselves about the possibility of postpartum psychological issues do not always recognize the symptoms when they occur. The clinical descriptions of symptoms presented in the common literature do not fully convey the depth of despair that many women experience. Here are some of the symptoms commonly listed in pamphlets and on web sites about postpartum disorders, followed by actual descriptions from moms in the metropolitan Washington D.C. area about how they felt during their bouts with postpartum mood and anxiety disorders.

Symptom - Feeling depressed, despondent and/or emotionally numb, excess feelings of sadness or weepiness.

"You know when you are watching a really sad movie and it's that point when the tears are about to start spilling out - I felt like that all of the time. Any little thing and I would start sobbing uncontrollably."

"When you are down, you are overcome by big thoughts. If you got a splinter in your toe it felt like the world was ending." “My mom was in another city and she was worried about me so she kept sending me books and links to web sites about postpartum depression but I was so down that I didn’t even bother to read them…I kept thinking ‘what is the point’? Finally she started reading the books herself and calling me summarize what she had read.”

"My older daughter kept asking me, “Mommy why are you so sad?” which made me feel even sadder."

Symptom - Anxious or panicky, feel guilty for feeling so bad

"Bringing home the baby was, for me, like someone handing me a violin and telling me I had to play in the symphony tonight. I had no experience, no training - I was completely unprepared…I panicked."

"I felt like I was hanging on to a cliff by my fingernails... like I was about to go over t h e edge any minute."

"I felt like I was under water struggling to breathe - like a weight was crushing my lungs and I was thrashing around in the waves gasping for air."

"I kept having images of my baby being hurt. If I was walking down the stairs, I pictured dropping her. If I put her in the car seat, I had vivid images of a car accident. One time I put her swing on the floor and there was a ceiling fan on and I kept envisioning the fan flying off of the wall and chopping her up. I was scared all of the time that these crazy things might happen.”

Symptom - Unexplained anger and irritability

"My two year old came over to ask me a question and I was so angry that she interrupted me that I picked her up and kind of dropped her on the floor. I didn't hurt her but she lay there on the floor for a few seconds, stunned. My sister-in-law saw the whole thing and told my husband’s family that I was beating my baby."

“I was constantly yelling at my husband. Everything was his fault. Even when he wasn’t around, I blamed him for everything. One morning he left a cereal bowl in the sink and it incensed me so much that I couldn’t get over it for the entire day. He walked in after work and I screamed at him, ‘I couldn’t make you dinner because I didn’t get anything done today because you left your cereal bowl in the sink this morning!’ It sounds so irrational now but in my head at the time, it made sense.”

Symptom - Decreased interest or pleasure in all activities, changes in sleep patterns

 "All I wanted to do all day long was sleep."

 "I kept thinking that everything I was feeling... all of it would just go away if I could get a full night's sleep."

"I had a phone list of friends who had agreed to help me if I needed it. I remember calling one of them and saying, 'Come get my kids right now - I need to sleep or I'm going to lose it.' "

Symptom - Poor concentration and difficulty making decisions, fear of being alone or leaving the house, isolating one’s self from friends and family

"My husband left for work one morning and I remember calling him hysterical a few minutes after he left. All I could say, in-between my sobs, was 'I cannot do this. You've got to come home.' "

“I would wake up in the morning and look at the clock on my night stand and try to figure out what to do first…if I showered, the baby might wake up…if I didn’t shower, I might not get a shower today…I went back and forth like this for an entire hour…I was literally paralyzed with indecision. Finally the phone would ring or the baby would wake and I would be forced to get out of bed.”

“Friends would invite me to things but unless they came and physically picked me up, I didn’t go anywhere…I just couldn’t get myself together – I didn’t want to.”

Symptom - Feelings of inadequacy, worthlessness, guilt and regret for having the baby

"I constantly asked myself, 'Why did I do this? Why did I want this baby so badly?’ Then I felt so guilty for feeling that way."

"I was miserable and I really thought this is what motherhood must feel like. I tried to force myself to accept it as my new reality but I hated every second of it. It felt like a life sentence."

Symptom - Disconnected thoughts of harming the baby or herself

"I felt ambivalent about the baby. I didn't want to hurt him but I don't think I would have minded much if he got really sick and died."

"I locked my children in their rooms and went out onto my balcony. I kept thinking that I didn't want to live...that my children would be better off without all of my sorrow and sadness in their lives."

“I thought about throwing the baby out the window or smacking her to make her stop crying. Then I felt guilty for having those thoughts.”

In her New York Times Bestseller, "Down Came The Rain," actress Brooke Shields describes her battle with postpartum depression and what she calls one of the darkest points of her life:

"I had no desire to hurt my baby and didn't see myself as the one throwing her, thank God. But the wall morphed into a video game and in it her little body smacked the surface and slid down to the floor."

Shields isn't the only celebrity to go public with her postpartum struggles. Gwyneth Paltrow, Courtney Cox Arquette, Marie Osmond and Lisa Rinna have all spoken out about their psychological difficulties after the birth of a child. Some medical experts speculate that Angelina Jolie may have also suffered a postpartum illness after the birth of her twins (she reportedly spent weeks in bed, waking only to eat and nurse) and that Britney Spears' over-the-top behavior, including the shaving of her head, may be attributed to a postpartum episode of bipolar disorder.

extreme cases
For the majority of women who have thoughts of harm coming to their babies during postpartum distress, there is still a very small, rational voice in their heads that keeps them in touch with their rational selves. As down as they feel, they are still able to consciously determine right from wrong. However for a small percentage of women (.2%), their postpartum illnesses are so bad that they progress to a state of 'postpartum psychosis', defined as, "loss of contact with reality."

About 5% of these cases result in maternal suicide and about 4% result in infanticide. These are the stories we hear about on the news that make us cringe. Remember Andrea Yates, the mother of five who drowned her children in the bathtub because she felt they deserved a better mother? She suffered from postpartum psychosis. Susan Smith was the mom who strapped her children into their car seats and then drove the car into a lake. Even here in our own backyard we have been witnesses to tragic episodes of postpartum psychosis. Respected college professor, midwife and mother of four, Michelle Davidson, held her obstetrician and his family at gunpoint in their Leesburg, VA home several years ago because she said she heard voices telling her to do so after her baby was born with cerebral palsy. These cases make headlines but they are extremely rare and, as was the case with all of three of these women, there is usually a history of mental illness prior to these women giving birth.

getting help
If you suspect that someone you know might be having difficulty postpartum, therapists say to look her in the eye and ask her "How are YOU doing?"

"Nine out of ten times if a woman is suffering from a postnatal disorder, she will burst into tears when you ask that question," Adrienne Griffen says. The most important message to send to someone suffering is - "You are not alone, you are not to blame, this is a real medical condition and you will get better with help." In fact, the 'cure rate' for postpartum mood and anxiety disorders is very high. Most women recover fully.

85% of all postpartum women experience what is commonly known as 'Baby Blues' for up to two weeks after delivery with symptoms that are similar to those of these more serious conditions. The key differences are depth and duration of those feelings. Women experiencing normal hormonal changes have a predominantly happy emotional state and the symptoms almost fully disappear by two weeks postpartum. With the onset of postpartum mood and anxiety disorders, the predominant emotion women experience is either sadness or anxiousness and the symptoms persist for weeks, months and, if left untreated, possibly even for years.

In her book, Brooke Shields says this about how down she felt:

"In the past, if I got depressed or if I felt sad or down, I knew I could counteract it with exercise, a good night's sleep, or a nice dinner with a friend. I knew these feelings wouldn't last forever. But this was sadness of a shockingly different magnitude. It felt as if it would never go away."

Therapists and survivors agree that the "conspiracy of silence" about how difficult it really is to take care of a new baby may prevent some moms from seeking help. Many women report 'putting on a front' around their friends, colleagues and even their spouses.

"I got dressed, put on makeup, went out and showed off the baby," says one mom. "But the whole time I was dying inside. I did a good job hiding it because I could fake being happy for a few hours each day." Another mom reported avoiding a colleague for years after having a postpartum breakdown in her presence. She confessed, "I avoided looking at her or talking to her for years because she knew my secret and I was so embarrassed that she had seen me in that state.”

The main tool to diagnose a postnatal mood and anxiety disorder is a self-administered test called The Edinburgh Postnatal Depression Scale. This test, which is available on dozens of web sites (Google search word: EPDS), consists of 10 questions that can be answered in fewer than five minutes. Scoring above a '10' means a woman should contact her doctor to discuss the possibility that she may need professional help. Many women (especially the Type-A variety) have a hard time asking for assistance. A simple, "I'm having a really hard time adjusting to life with the new baby and I think I could use some help," should open a dialogue with a medical practitioner.

Before confirming any diagnoses, a woman’s OB or general practitioner should order a full thyroid and anemia screening. Both of these medical conditions can be brought on by childbirth and both involve symptoms similar to those of postpartum psychological disorders.

treatment
Once a diagnosis is confirmed, a postpartum mental health treatment plan should include one or more of the following components: Improved Self Care - Women need adequate rest to allow their bodies and hormones to recover from the demands of creating life inside them for 9 months, going through childbirth and caring for a newborn. Moderate exercise and fresh air are also highly recommended. These suggestions may seem obvious but to a mom suffering from depression or anxiety, they can be extraordinarily difficult to execute. One postpartum depression survivor recommends breaking the day down into 2-hour intervals. "My worst time of day was after the baby's nap and before my husband got home so I started scheduling a walk around the block in the late afternoon just to keep busy and to get out of my house, which really helped me," she said.

If getting enough sleep proves too difficult to do without another set of hands, women should consider asking relatives to come stay with her for one-week shifts or hiring a night nurse to help with overnight feedings, especially if her husband has a job that does not allow for him to help out at night. Local resource: Mother & Baby Matters (motherandbabymatters. com) for night nurses and postpartum doulas.

Social Support - All mothers with newborns need help from their spouses, families and friends in order to get through the first few weeks after labor. Mothers who are battling psychological conditions may require even more help for longer periods of time. Women should consider joining new mommy groups or putting together a support team of friends who they can call in times of need.

"My girlfriends in my neighborhood literally saved my life, " says one Ashburn, VA mom. "Often times I would knock on my neighbor's door with mascara running down my face, my hair uncombed and I knew she wouldn't judge me."

Several moms said their husbands were key ingredients to their feeling better. One husband hired a babysitter so his wife could get time out of the house and another husband set up a weekly ‘mom’s night off’ so his wife could go visit friends, get a manicure or take a long nap. Local resource: Visit meetup. com to find a new mothers group in your town.

Talk Therapy - Peer-led support groups and one-on-one support (via phone, email or in person) are also helpful for some mothers. Esther Boykin says, "People are relational– being able to come into a group can be a powerful thing. Women say they leave the group feeling validated. After a few sessions, they start to feel good again."

There are dozens of therapists (psychiatrists, clinical social workers, psychologists and other counselors) in the metropolitan Washington D.C. area who specialize in treating postpartum disorders. Local resource: To find a counselor in Northern Virginia who has agreed to see new patients within 24 hours of being contacted, visit postpartumva.org.

Medication - It is important for women to know that not all postpartum sufferers require medication in order to recover. While many anti-depressants, such as Remeron and Pamelor have no adverse affects on nursing babies, others such as Fluoxetine, commonly known as Prozac, and Wellbutrin can cause complications in a small percentage of nursing babies, according to The UIC Postpartum Mental Health Project. While there is much social pressure (and many documented benefits) to nursing a newborn, experts agree that the mental health of the mother should take precedence over her desire to breastfeed. A healthy mother results in a healthy baby.

A study conducted by the Royal College of Psychiatrists in London finds that, "Compared to children of mothers who are healthy, children of mothers suffering from mild-to-moderate depression and anxiety in the period around birth are more likely to have increased behavioral, emotional, and/ or cognitive difficulties. These, in turn, may have an adverse impact on the children's peer relationships and school attendance."

If a new mom is having difficulty putting her own needs ahead of her baby's (in terms of taking medication, finding time to see a therapist, etc.), she could be causing long-term harm to her child. The airline directive to "put your own oxygen mask on before helping others" applies to this situation. Your helpless infant needs his or her caregiver to be well.

sad dads
This summer, a groundbreaking research report came out from the Eastern Virginia Medical School that suggests that up to 10% of new fathers may experience postpartum depression after the birth of a child, which is double the national average for depression in men in general. Researchers concluded that fathers experience many of the same symptoms as women but these symptoms tend to peak 3-6 months after the birth of the baby. It is unclear if there is a link between a woman's postpartum mood and anxiety disorder and her husband's, but the study did find that if the mother experiences postpartum depression, her husband is more apt to experience postpartum depression as well. Having two depressed parents could severely impact a newborn's physical, emotional and social development, so couples are advised to speak to health care providers throughout a woman's pregnancy to discuss signs and treatment options should symptoms present themselves in one or both parents.

further research
Earlier this year, researchers at The Center for Addiction and Mental Health issued a report that they had successfully used brain imaging to detect an elevation of a particular brain protein in women suffering from depression after childbirth. This protein, called MAO-A, removes certain chemicals, including serotonin, which help to regulate mood. Scientists now believe they may be able to develop dietary supplements that provide the chemicals removed by the elevated proteins. In other words, in the future women may be able to take prenatal vitamins to help prevent episodes of depression after giving birth. As part of the healthcare reform bill, the "MOTHERS Act" was passed into law, which, according to the bill’s sponsors, “Establish a comprehensive federal commitment to combating postpartum mood and anxiety disorders through new research, education and support programs.” One such program is the National Institute of Health's large-scale study, currently underway, to test various methods of intervention, which may prevent postpartum psychological disorders. Results of this study will be published in December of 2010.

As more research is done to understand, diagnose and treat postpartum mood and anxiety disorders, more new parents will experience the full joy that a new baby can bring to their lives rather than a traumatic period they can't, or don't want to, remember. "This was a dark and foggy time for me,” laments one survivor. Another says, "I have no memories of my son’s first year of life. Isn’t that sad?”

At least two out of every ten new moms reading this magazine have suffered - or will suffer - from postpartum mood and anxiety disorders. We as a community must do more to open a dialogue with our friends, family members, colleagues and neighbors to end "the conspiracy of silence" surrounding the challenges of caring for a very young child - and the pain caused by these debilitating psychological conditions.

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Chris Croll is a freelance writer and mother of two. To see what she is working on, and to suggest topics for future articles, visit chriscroll.com