Postpartum mood disorders (PMDs) continue to occur with great frequency. Yet, despite the high prevalency rate of PMDs, the majority of medical and mental health professionals and other support providers receive minimal training on what PMDs are, how to assess, and how to treat. However, the new health care bill signed by President Obama will mandate that professionals understand about, assess, and treat PMDs.
In Postpartum Mood Disorders: A Guide for Medical, Mental Health, and Other Support Providers, Dr. Kimberley Zittel educates health care providers and women who suffer with PMD and their families on the treatments available for those who suffer with this illness. This timely volume discusses ways that the United States is currently attempting to address PMDs, models that are used around the world, and ways that the United States could improve on efforts to assist those experiencing PMDs.
About the Author
Chapter 1: Introduction
Chapter 2: Postpartum Mood Disorder Theories
Postpartum Mood Disorders
Chapter 3: Baby Blues and Postpartum Depression
Chapter 4: Postpartum Anxiety Disorders
Chapter 5: Postpartum Psychosis
Impact of Postpartum Mood Disorders on Others
Chapter 6: Newborns, Infants, Children, and Adolescents of Mothers with Postpartum Mood Disorders
Chapter 7: Fathers
Other Reproductive Mental Health Issues
Chapter 8: Spontaneous and Elective Abortion and Mood Concerns
Chapter 9: Infertility and Mood Changes
Chapter 10: Pre- and Postadoption Depression
Chapter 11: Multidisciplinary Roles and Approaches for Treating Postpartum Mood Disorders
Chapter 12: Medical Interventions
Chapter 13: Psychosocial Interventions
Chapter 14: Access to Postpartum Mental Health Care
Checklist of Postpartum Mood Disorder Risk Factors: Factors Obtained through the Empirical Literature
Checklist of Postpartum Mood Disorder Symptoms: Symptoms Obtained through the Empirical Literature
Referral Resources for Postpartum Mood Disorders
Postpartum mood disorders (PMDs) include the experience of depression, anxiety, or psychosis typically six weeks after the delivery of a baby. These disorders occur with alarming frequency. Conservatively, one in seven women experience postpartum depression (PPD) (Moses-Kolko & Roth, 2004). Women in the United States had an estimated 4.3 million live births (U.S. Department of Health and Human Services, 2009). Using conservative postpartum depression rates, approximately 430,000 to 645,000 women in the United States experienced postpartum depression; compare this with the estimated 192,280 men who were diagnosed with prostate cancer in 2009 (American Cancer Society, 2009) Although it is certainly important to have education campanions, patient and doctor education, and research dedicated to prostate cancer, it is vital to offer the same for postpartum mood disorders. A woman is more likely to be admitted into a psychiatric hospital during the first postpartum year than during any other time in the life cycle (Kendall et al., 1987). Currently, suicide resulting from PMDs is the leading cause of death for perinatal women in the United States (Lindahl, Pearson, & Colpe, 2005). Failing to assess, diagnose, or treat women with PMDs can have detrimental results on women, children, spousal or partner relationships, and the entire family (Tammentie, Tarkka, Astedt-Kurki, & Paavilainen, 2002). Left untreated, these women often have difficulty developing a strong bond with their baby (Sagami, Kayama, & Senoo, 2004), which can lead to cognitive, behavioral, language, and developmental delays (Deave, Heron, Evans, & Emond, 2008; Poobalan et al., 2007; Sohr-Preston & Scaramella, 2006). Despite the negative effects of PMDs on the family, many women are still not receiving the assistance they need, and few social workers, counselors, psychologists, or doctors ever receive specific training on how to assess, diagnose, or treat these disorders (Oates, 2000).
I first became aware of postpartum mental health through a friend of mine. She was very open with me and others about her experience, due to a strong desire to create change and to help others who may be suffering in silence. She described in vivid detail, that following the birth of her daughter she began to have irrational thoughts like accidentally throwing her newborn over the railing of the stairs or into a fire burning in the fireplace. Paralyzed by these fears, she avoided the stairs and the fireplace. As she spoke, I found it peculiar that she had not had these fears prior to having her baby. This caused me to look into her condition a little further. The more I looked, the more I realized that I, too, had suffered with mental health changes both during and after pregnancy. During my fourth month of pregnancy, I became extremely anxious, depressed, and irritable. Coincidentally, it had been just weeks since my father-in-law passed away from cancer, and I was one month away from completing my PhD coursework. During delivery, my son’s heart rate dropped rapidly, the umbilical cord was wrapped around his neck and an emergency cesarean section was imminent. Within minutes, there was a doctor sitting on my gurney, holding my son’s head in place to avoid further complications. Doctors and nurses were running everywhere, pulling cords from the walls, throwing them onto the gurney, and I was traveling full-speed down a brightly lit hall. As the gurney turned a corner, I looked up and saw three doctors scrubbing for surgery in a sterile, cold, metallic sink. No sooner had we turned the corner, I was placed on an icy metal table, bright lights on my body, a screen placed between my head and my body, my arms stretched out and I remembered asking, "Where is my husband?" I knew just enough about medicine to know what was happening, but not enough to be secure in the situation. I could feel pressured movements. I could hear the instruments suctioning my blood. When my husband finally arrived, he looked me in the eyes, and I continually asked, "Are they done yet?" He was supportive and reassuring, but I could tell that he was nervous as well. He recalled later that in a matter of seconds the entire birthing room was vacated; he was left standing there with my cousin, a physician’s assistant, both of them staring at each other, unsure of what to do, what was happening, or if things would be all right. About 30 minutes after the surgery, , a nurse came in with our son, who was wrapped in warm blankets. She undid my gown, put him in my arms, squeezed my nipple hard, and led my son toward it to encourage him to suckle. I was so "out of it." Then, while he was still in my arms trying to feed, she placed a form on the table in front of me and told me to sign it. The form stated that she had taught me how to breastfeed. Seriously!
When we returned home, I had the baby blues. I remember crying to my mother, "Things will just never be the same again." She comforted me and reassured me. Things were not the same. I was overjoyed with my son, overjoyed by watching my husband hold him, watching everyone enjoy him. However, I was not producing enough milk for him. I started to think, "I am unable to care for him – to keep him alive – to nurture him the right way." This evolved into thinking that I was killing him because I could not feed him right. I stopped nursing and felt better knowing that he was eating, but still felt immense guilt that I was unable to nurse him, to be a good mother. In addition, for about six weeks, I had flashbacks to the events in the hospital, thinking that he could have died, that I could have died. These feelings of guilt, fear, anxiety, and depression only grew. I would lie on the couch and watch others helping him and think, "Thank God someone knows how to care for him, how to love him the right way, to give him what he needs." I became terrified when he slept that he would die from sudden infant death syndrome (SIDS). Therefore, I would place my hand on him while he slept or laid him on me – so in case he stopped breathing I would feel it. I did not sleep very well and felt constantly exhausted.
Why am I explaining this to you? Well, at the time I had my first son, I was a masters-level, practicing, clinical social worker for six years. Mental health and medicine were my specialties. Moreover, if I was not aware that what I was experiencing were postpartum depression, anxiety, and posttraumatic stress symptoms until speaking with my friend three years later, how do untrained mothers, fathers, family members, and friends know? I had no idea that mental health changes during or after pregnancy occurred so frequently. Most of us have heard of the sad story of Andrea Yates, the mother of five from Texas who, in the late 1990s, drowned her children in response to voices in her head telling her "killing them would save them from the devil." In Andrea’s mind, she was protecting her children from evil, thereby loving them. I thought that what the Yates family went through was postpartum depression, not what I had experienced.
In fact, in all my years of professional education, up through my PhD, I had never heard postpartum depression mentioned. Research states that many medical professionals will not assess for PMDs because they are unsure of what to do if detected. Therefore, when I started my first position as a college professor, I made it one of my missions to educate students, my peers, and the general community about PMDs.
The effects of PMDs on the family, particularly when not treated, are enormous. Many communities lack PMD treatments, leaving medical professionals with limited alternatives such as medication or hospitalization. Making matters more complicated, many women who silently suffer with PMDs and continue to remain silent out of fear that her children will be removed, that there is "something wrong with her," or have experienced unsupportive remarks from professionals or unwanted treatment options (Hanson-Lynn, 2005; Logsdon, Wisner, Billings, & Shanahan, 2006; Small, Brown, Lumley, & Astbury, 1994; Wood & Meigan, 1997).
Luckily, more people are speaking out about PMDs. Brooke Shields, for example, courageously published Down Came the Rain: My Journey Through Postpartum Depression in 2005, where she openheartedly described her postpartum depression experience. She not only provides a well-described picture of postpartum depression, but also supports the need for women to receive education and care.
This text explores theories, epidemiology, risk factors, at-risk populations, and treatment options, to best prepare families, social workers, other counseling professionals, and medical professionals at all system levels to assist women who are experiencing PMDs. Chapter 2 presents biologically, psychologically, and sociologically based theories that propose underlying predictive factors for developing PMDs.
Chapters 3 through 5 cover details of each mental health diagnosis in the PMD spectrum, including: baby blues, depression, general anxiety, panic, posttraumatic stress, obsessive compulsion, and psychosis. Each of these chapters includes a biopsychosocial theoretical support, symptom descriptions, and diagnostic considerations.
Through research projects and by presenting at community seminars, I have learned a lot from others. During question-and-answer moments, several community professionals have also inquired about the postpartum mental health of men, couples who adopt, women who miscarry, women who have abortions, couples with infertility issues, and the effects of postpartum mood changes on children. Therefore, I chose to address these questions in chapters 6 through 10.
I also chose to write this book in a helpful format for medical and mental health professionals, family members, family supports, other paraprofessional support providers, and as an educational self-help guide – an "every-person guide" leading families toward assistance. Chapters 11 through 14 present assistance options from a multidisciplinary, multicultural, and international perspective, with particular emphasis on access to care needs.
It is important to note that some of the terminology used across disciplines and countries varies. A glossary is included at the end of the book to clarify terms. Sometimes, I use the terms interchangeably. Sometimes, I refer to women, but as fathers experience postpartum mood changes, the term "women" can be interchangeable with fathers at times. In addition, I will often refer to couples as mother and father; however, same-sex couples can be considered in these instances as well.
By the end of this text, you will have comprehensive knowledge about the full range of PMDs, how to assess and diagnose these disorders, intervention and treatment options, and the tools and strategies needed to advocate for people with PMDs across disciplines and system levels. You will understand the effect of PMDs on partners, children, other family members, and support systems. You will also understand the need to develop more programs in communities to improve access to care for those experiencing PMDs and for those supporting a loved one with these disorders.
Kimberley Zittel, PhD, MSW, is an assistant professor in the social work department at Buffalo State College (BSC). She holds a bachelor’s degree in psychology from Houghton College, an MSW from SUNY at Buffalo, and a PhD in social welfare from SUNY at Buffalo. She has extensive clinical experience working in medical settings and research experience with postpartum mood disorders and access to care issues. Dr. Zittel is the principle investigator of the Postpartum Mood Disorders Initiative at BSC, committee member for the Buffalo State College Women’s Studies program, and board member of Postpartum Resource Center of New York. She has published nearly 20 peer-reviewed articles, and she has lectured locally, nationally, and internationally. Dr. Zittel has received several national and regional awards for her clinical and research accomplishments, including the 2007 NASW WNY Social Worker of the Year Award and honorary membership in Phi Alpha Social Work Honor Society.
Postpartum Mood Disorders: A Guide for Medical, Mental Health, and Other Support Providers is an extensively researched manuscript that will serve as a comprehensive guide and resource for providers of women’s health care. Dr. Zittel has organized the material in an accessible way for both practicing clinicians and students; and she has explored the effects of postpartum mood disorders on the family and other caregivers. This is an impressive and useful addition to the lexicon!
Dr. Kim Griswold, MD, MPH, RN, FAAFP
SUNY at Buffalo, NY