Overcoming Baby Blues: A Complete Guide to Perinatal Depression - Softcover

Parker, Gordon

Softcover

ISBN 10: 1743316771 ISBN 13: 9781743316771

Publisher: Allen & Unwin, 2014

Synopsis

Pregnant women are expected to glow, and new mothers are expected to bask in the delight of their baby. But for some women, this is a time of unsettling mood shifts and uncertainty. One in ten women experience clinical depression either during pregnancy or in the postnatal period, while the majority of new mothers face the 'blues', anxiety and other emotional changes.

Overcoming Baby Blues shares intimate stories of mothers' experiences with depression and other mood problems during pregnancy and their baby's first year. Their stories shine with wisdom, humour and fortitude. Also included are research-based guidelines on assessing moods, causes of perinatal depression, and effective management strategies. Safety of medications in pregnancy and breastfeeding is covered, as are suggestions for adapting diet and lifestyle to reduce symptoms, and advice for partners.

About this title

About the Author

Gordon Parker is Scientia Professor of Psychiatry at the University of NSW, Professorial Fellow at the Black Dog Institute, and a renowned researcher and expert on mood disorders. Kerrie Eyers is a psychologist based at the Black Dog Institute, Sydney. Gordon Parker and Kerrie Eyers are editors of the bestselling Journeys with the Black Dog and several other books on depression. Philip Boyce is Professor of Psychiatry at the University of Sydney, Professorial Fellow at the Black Dog Institute, and an international expert on postnatal depression.

Excerpt. © Reprinted by permission. All rights reserved.

Overcoming Baby Blues

A Comprehensive Guide to Perinatal Depression

By Gordon Parker, Kerrie Eyers, Philip Boyce

Allen & Unwin

Copyright © 2014 Gordon Parker Kerrie Eyers Philip Boyce
All rights reserved.

ISBN: 978-1-74331-677-1

Contents

List of tables and figures, 
Preface, 
Introduction: From blue to black and beyond, 
1. What are perinatal mood disorders?, 
2. Risk factors for perinatal mood problems, 
3. Screening for perinatal depression, 
4. Diagnosis and treatment options, 
5. Protecting yourself with realistic expectations, 
6. Learning to live in motherland, 
7. Do you need help?, 
8. Where to get help, 
9. Tackling stigma and mothers' guilt, 
10. Managing a mood disorder and maintaining recovery, 
11. Fathers and the extended family, 
12. Mothers' strategies, 
Appendix: Medications in the perinatal period, 
Glossary, 
Notes, 

CHAPTER 1

What are perinatal mood disorders?

Advocates of industrial androgyny say pregnancy is not an illness. Well, neither is busting a femur or ripping open a scrotum on a fishhook, but that doesn't mean it's not a good idea to keep still for a while afterwards.

Emma Tom

During pregnancy many women experience at least some depressive symptoms and around 10 per cent are at risk of developing a clinical 'syndrome'. A similar number of women are affected during the postnatal period, too. Following the birth, and particularly in the next days or months, women are vulnerable to fluctuating moods, including:

• the baby blues

• depressive reactions brought on by adjustment difficulties

• non-melancholic depressive syndromes, that is, as later depressions brought on by the stressful situation rather than caused by a chemical imbalance in the body

and several more biological conditions (that is, those caused by chemical imbalances rather than stress, although they can still be be worsened by stress), including:

• melancholia or melancholic depression

• puerperal psychosis (or psychotic depression)

• bipolar disorder.

Postnatal depression (PND) is usually non-melancholic (that is, caused by stress rather than a chemical imbalance) but in about 10 per cent of cases is melancholic (for more, see 'Postnatal depression' below). Postnatal disorders can, while present and if severe, interfere with the bonding and attachment of mother and her baby and impose strains upon the parents' relationship, as well as cause distress to the new mother herself. A depressive episode is also marked by decreased confidence, which can create secondary problems, and may also drive feelings of irritability and anger. All such mood disorders — apart from the baby blues and puerperal psychosis — can occur at other times of life and display the same clinical features, but doctors will tailor their treatment choices differently when a woman is pregnant or breastfeeding.

The following 'map' of the perinatal mood disorders may help you determine whether you're in the territory of perinatal mood disorders or not. The geography of motherland seems deceptively familiar until you get there.

THE TERM 'PERINATAL'

In this book we use the term perinatal to refer to the time from the start of pregnancy to the end of the baby's first year.

The strict definition used for statistical purposes by the Australian Institute of Health and Welfare classifies the perinatal period as starting at 20 completed weeks of gestation and ending at 28 completed days after birth.

DEPRESSION: AN OVERVIEW

One day I was at home alone with the kids. I was exhausted and on the verge of tears. My 3-year-old climbed onto my lap and took my face in his chubby little hands and said, 'Don't worry, Mummy.' It was my awakening. At last I could admit to myself that I had a problem.

Zara

'Depression' is a word that is used loosely. It is used to describe everything from mood states to economic recessions, so a diagnosis of depression is diffuse and liable to variable interpretation and misinterpretation. Depression is, in essence, a term more comparable with 'pain'. It is a marker of superficially similar but actually quite diverse entities. When the term 'depression' is used to describe a mood state it needs to be more closely defined. For instance, it is important to differentiate between 'normal' depression (or everyday temporary unhappiness) and clinical depression — in the same way a dermatologist would be expected to distinguish a benign mole from a melanoma — as it influences the type and success of treatment.

Signs and symptoms of depression

Someone with depression feels down and hopeless, helpless and pessimistic, but one key symptom is a drop in self-esteem and, correlated with that, an increase in self-criticism. This decline in self-regard distinguishes depression from other conditions such as grief, sadness or anxiety.

Grief is the distress felt following usually irretrievable loss and separation, when an attachment bond is broken. While grief can be severe and disabling, it is not accompanied by a drop in self-esteem. Sadness is an emotional reaction to losses or disappointments, a feeling of being down and unhappy, that dissipates within days and self-worth is rarely diminished. Anxiety is essentially a state of insecurity or fear and hyper-arousal. People with depression (including PND) are frequently anxious (and anxiety can set the stage for depression), and some people who are grieving will later develop depression, but clarifying the primary emotional state is the best way towards effective treatment.

The Edinburgh postnatal depression scale (EPDS; see Chapter 3) is a widely used screening instrument for postnatal depression. As the instrument includes anxiety as well as depression items, a percentage who score positive will do so due to having a primary anxiety rather than a primary depressive condition during the postnatal period.

ANXIETY AND PANIC ATTACKS

A new mother has to traverse some very unfamiliar territory, which can be more than somewhat overwhelming. Many women already have lifelong anxious tendencies, but when anxiety becomes more prevalent than feelings of wellbeing, something else is going on. As many of our essayists attest, a baby provides a focus for intense worry and anxiety-based preoccupations.

Most people never experience a panic attack, although they would recognise the symptoms, which are the feelings people experience when they're frightened or under threat — the so-called 'flight or fight' response. A panic attack seems to come from nowhere, though. Feelings of panic and terror build up and intensify to such a degree that the sufferer may feel like they're having a heart attack or a stroke or like they're literally going to die. Symptoms include tightness in the chest, chest pains, a racing heart, dizziness and breathing too fast, tingling all over, numbness, weakness, sweating and muscle cramps. A panic attack is so unpleasant that it can create a feedback loop, where feelings of panic increase the feelings of panic. Nevertheless, people can have panic attacks and not recognise them as being a symptom of a mood disorder. They think they're going mad or have some terrible physical disorder but don't consider the attack as indicating that something is psychologically wrong, since panic attacks are so awfully physical. Poorly understood or untreated panic can result in secondary symptoms, particularly depression and phobic avoidance. Avoidance responses often take the form of a disabling mantra, such as, 'What if [insert disastrous event] occurs?', which can lead to fear of even leaving the house.

In addition to panic attacks, women who have an anxious, worrying temperament can experience increased anxiety during the postnatal period, and obsessive-compulsive disorder (OCD) can worsen — or emerge for the first time.

Such anxiety states generally benefit from different treatment from those used to manage the depressive conditions. This is another good reason to seek out a competent clinical assessment to identify your primary condition.

'Normal' depression

Depression can, in fact, be normal. Experiencing a depressed mood (that is, feeling down, experiencing lowered self-esteem, feeling like giving up) is a universal human experience, but such states are generally brief, lasting from hours to days, lift of their own accord or respond to pleasant events, and do not disrupt normal living. While there is no distinct boundary between a depressed mood and clinical depression, the latter is more severe and persistent, unlikely to lift by itself and associated with distinctive features. Clinical depressive conditions are highly likely to benefit from tailored professional assistance.

STRESSORS

A stressor is an event or interpersonal interaction that causes distress. Stressors can be acute (that is, short-term, such as the immediate aftermath of an accident) or chronic (that is, ongoing, such as poverty or a poor marriage). They cause strain that can distort personality development and lead to anxiety and depression. Psychologists define stressors in the sufferer's recent and/or current life as proximal stressors and those in the sufferer's past as distal stressors.

For more on stressors, see Chapter 2.

Clinical depression

Non-melancholic depressive disorders

The non-melancholic depressive disorders are made up of a raft of depressive disorders arising from the impact of personally relevant stressors on individual personality styles, and lack specific defining features. While people suffering from non-melancholic depression may be severely (even suicidally) depressed, there is usually some reactivity in their mood (that is, they can be cheered up in certain circumstances) and they can experience some level of pleasure in life (even if reduced). Psychomotor disturbance (see box below), a key feature of melancholia, is absent. Sleep disturbance is more likely to involve difficulty in getting to sleep or patchy sleep (and even excessive sleeping) rather than early morning wakening.

PSYCHOMOTOR DISTURBANCE

'Psychomotor' is a word used in medicine to describe the link between mental processes and physical movements. In depression, neural connections can become disturbed, leading either to 'retardation' or 'agitation'. Retardation is characterised by slowed thinking, walking and speech, a lack of energy for even the most basic tasks (called anergia) and poor concentration and memory. Agitation is characterised by excessive worrying and morbid ruminations, and physical symptoms such as pacing the floor, a churning stomach and racing thoughts that may be perplexed and full of foreboding (such as 'What will become of me?').

In comparison to melancholia, a depression underpinned by biological changes such as imbalances in brain chemicals, the clinical patterns of non-melancholic depression are determined by its causes and are relatively non-specific. For example, a woman with an anxious, worrying temperament may, when depressed, internalise her anxiety by worrying more and isolating herself from others, or externalise her anxiety via irritability and anger.

The majority of perinatal depressive disorders are non-melancholic. Pregnancy and the postnatal interval provide many potential stressors that can lead to non-melancholic depressions such as adjustment disorder, and situational and reactive depressions. These tend to resolve over time as the sufferer adapts to the stressors, unless there are maintaining factors in their life. That is not to say, however, that we would ever advise simply waiting for a depressive disorder to lift naturally. Left untreated, such a depression can cause impairment that at this crucial time is likely to have significant influence both on the mother's mental and physical health and on the psychological wellbeing of her whole family.

Non-melancholic depressions respond well to psychological strategies, although medication is of benefit when symptoms are severe, or to address some symptoms (such as restoring sleep or muting anxiety). For more on the principal types of non-melancholic depression — and differing management suggestions — see the Black Dog website and our book by Gordon Parker and Vijaya Manicavasagar, Modelling and Managing the Depressive Disorders: A Clinical Guide.

Melancholic depression

Medical intervention is needed to treat melancholic depression or melancholia (once known as endogenous depression). This type of depression is more distinctly biological (that is, caused by changes in brain chemistry rather than external stressors), is unlikely to lift on its own and may take a long time to improve without medical treatment. Postnatal melancholia has a distinct pattern of symptoms (see below) and generally appears within four weeks of the birth. Riley's story illustrates a common pattern:

I ended up having an emergency caesarean. When I got to hold my baby I was completely underwhelmed. I remember the nurses kept having to put the baby back on my chest as I was kind of holding her like a football under one arm and she was slipping off the bed. When my own mother called all I could say was that the baby had hairy shoulders. Intellectually, I could see that she was stunningly beautiful and physically perfect, but emotionally, it just wasn't registering.

People told me a lot of my feelings were probably due to the caesar, so I gave myself time to recover but it never got brighter. My whole life was stained with grey ... like limp wet washing with no sun or breeze. I was slowed down, listless, no appetite, awake from the crack of dawn though so exhausted. I struggled with everything. Not just with the baby but absolutely everything: news bulletins, road signs, phone conversations. It was like coming out of hospital and everyone was speaking Japanese. My whole world had literally changed. I had changed. And while I coped with that I was supposed to look after a baby as well? Motherhood was monotonous and joyless and terrifying. But when I tried to explain what was happening it just came across as so silly, though by this stage even my voice sounded peculiar to me.

The principal clinical feature of melancholic depression is psychomotor disturbance. The chance of a melancholic PND is increased in women who have had episodes of melancholic depression in the past or who have a family history of melancholia.

Features of melancholic depression include:

• over-represented symptoms and signs (that is, more prominent than you would expect for depression in general) (see below)

• a family history of melancholic depression (that is, a genetic predisposition)

• changes in sleep patterns, circadian rhythms (that is, bodily responses to the time of day) and brain neurotransmitters (messenger molecules)

• a better response to physical treatments (that is, antidepressant medication) than to psychotherapy or counselling.

Management of melancholic depression (see Chapter 10) generally involves medication initially, and then a set of non-medication strategies (such as psychotherapy or counselling) to address illness-related problems or to maintain recovery.

Symptoms of melancholic depression include:

• psychomotor disturbance — see box above.

• an 'anhedonic' and non-reactive mood — a lack of pleasure (called anhedonia) in present or anticipated activities, and no lift in mood in response to positive events. Such symptoms may be either absolute (unchanging) or partial ('I guess seeing my child lifts my mood somewhat'), and either continuous or relieved only briefly ('Seeing my child gives me some pleasure but it doesn't last').

• diurnal variation of mood and energy — changes in energy and mood in response to the time of day or night, in particular being worse in the morning.

• non-specific features — including early morning waking, and loss of weight and appetite.

Although melancholic depression was once thought to emerge without any obvious precipitant or in response to only a minor trigger, we now recognise that stress may bring on melancholic depression — particularly the first episode. The depressive response is, however, generally more severe, persistent and out of proportion to the stressor.

Melancholic depression is slightly more likely in women with an obsessional or stoic personality style, who then commonly conceal their symptoms. Actor Brooke Shields provides a poignant account in her book Down Came the Rain.

Psychotic depression

Psychotic depression has a melancholia base. Its key features are psychomotor disturbance and an anhedonic and non-reactive mood (described above). However, diurnal variation in mood and energy (that is, across the day) are not necessarily present with both compromised across the day. Psychomotor disturbance is usually more severe than in melancholia, and observable to others. Someone with psychomotor retardation may just lie in bed or slump in a chair and have minimal interaction with others — while many develop constipation as their bodily processes slow down. In addition, sufferers have psychotic experiences, losing touch with reality through delusions (false beliefs) and/or hallucinations (seeing or hearing things that aren't there, or experiencing abnormally heightened senses of taste and smell).

In a postnatal psychotic state the mother may feel that she and her baby have no future and would be better off dead. While psychotic depression is uncommon, if it occurs postnatally it is often described as a puerperal psychosis and is treated as a psychiatric emergency.

PERINATAL DEPRESSION AND ANXIETY: AN OVERVIEW

The baby blues

Up to 80 per cent of new mothers develop the baby blues as their hormones fluctuate and oestrogen and progesterone levels drop sharply after birth. The baby blues generally come on three to six days after birth (though earlier if the birth has been difficult), and while some episodes end naturally in a matter of hours, most do so by around two weeks after birth. They are slightly more likely to be experienced by second-time mothers than those having their first baby.

Though the baby blues are distressing and associated with many depressive symptoms, they do not constitute a psychiatric disorder. They are also widely experienced and transient.

The most common symptoms include:

• being overly emotional and changeable in spirits (having what doctors call a labile mood)

• crying (often unable to stop) or feeling tearful

• being oversensitive

• tiredness and fatigue

• inability to concentrate — getting forgetful and muddled

• irritability, anxiety and feeling tense

• sadness, low spirits and a depressed mood

• inability to show feelings

• insomnia, despite feeling exhausted.

During such episodes many women also report intervals of happiness, calmness, liveliness and confidence, so that the baby blues are better viewed as changeable, unsteady and easily altered emotions rather than a constant down mood. In essence, they are a state of emotional dysregulation that dissipates within a few days.

(Continues...)

Excerpted from Overcoming Baby Blues by Gordon Parker, Kerrie Eyers, Philip Boyce. Copyright © 2014 Gordon Parker Kerrie Eyers Philip Boyce. Excerpted by permission of Allen & Unwin.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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Edition details

• Publisher: Allen & Unwin
• Publication date: 2014
• Language: English
• ISBN 10: 1743316771
• ISBN 13: 9781743316771
• Binding: Paperback
• Number of pages: 256