Jane I. Honikman, M.S.
927 North Kellogg Avenue
Santa Barbara, CA 93111

Postpartum Support International, Founding Director
(805) 967-7636; fax 805 967-0608

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Mental illness related to childbearing is one of the most prevalent complications for childbearing women today. Each year in the United States over 400,000 women suffer from pregnancy and postpartum mood and anxiety disorders.

The impact this has on a woman and her family can be profound. If left undiagnosed and untreated, it can lead to such tragedies as chronic affective disorders, poor infant-mother bonding, marital discord, divorce, suicide, infanticide, child neglect, and substance abuse. Yet the vast majority of women's physicians, childbirth educators, lactation consultants, and pediatricians are not fully educated about these issues and therefore, cannot respond to mother's needs. Leaders in the mental health field have an important role to play in order change this disturbing situation.

Breaking Down the Jargon

Words and phrases such as "euphoria," "sadness," "overwhelmed," "crazy," "losing it," or "concerned" are part of the common language women use to express their emotional states after childbirth. Psychiatric and psychological terms for the same states include: "maternity blues," "adjustment," "stress," "depression," "anxiety," "panic," "obsessive/compulsive disorder," "distress," and "psychosis." The distinguishing features of the continuum and spectrum view of postpartum mood and anxiety disorders can range from very mild ("baby blues") to very severe (psychosis), although the distinction between them can become blurred. Such a plethora of terminology indicates the complexity of this syndrome, and, in part, explains the confusion surrounding the issue.

The Postpartum Scientific Movement

The history of naming postpartum depression (PPD) according to its symptoms or syndrome dates to the American Psychiatric Association’s removal of the term "postpartum" from the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952. It is a sign of practitioners’ growing awareness of this problem, however, that the term "postpartum depression" was included in the 1994 DSM IV under "Mood Disorders with a Postpartum Onset Specifier."

Maternal mental health has been researched and studied by the scientific community since 1838, when the publication of two volumes by Esquirol began a 19^th-century rebirth of interest in the topic in France. The first half of the 20th century witnessed a drop in studies of maternal mental health, but during the latter half, there was an increase in research among the diverse, yet interrelated, disciplines of psychology, biology, anthropology, and sociology. Many of these have focused on the etiology and treatment of PPD. We are indebted to Dr. James Hamilton (1907-1997) who dedicated his professional career in the United States to bringing professional attention to the importance of this topic. In 1962 he authored Postpartum Psychiatric Problems and thirty years later co-edited Postpartum Psychiatric Illness: A Picture Puzzle. He was a co-founder of a scientific organization formed in 1980 and named for another early 19^th-century French doctor, Louis Marcé, who published on the subject in 1858. The Marcé Society has held biennial international conferences on PPD and related disorders since 1984. The issues of public and professional awareness that have emerged because of these and other conferences are prevention, early detection, and intervention of childbearing mood disorders.

The Postpartum Support Movement

The importance of parent self-help support groups received little attention until the 1970s and 1980s, with the beginning of the postpartum consumer movement. This included prevention and treatment issues within the cultural component of social support systems. Scholars from several disciplines now recognize the role of social support. Anthropology professor Lawrence Kruckman of Indiana University of Pennsylvania suggests that social support promotes mental and physical well-being, especially in the face of stressful experiences. The Pacific Post Partum Support Society (PPPSS) in Vancouver, British Columbia, Canada was the first organization formed to specifically address mothers’ mental health. Postpartum Education for Parents (PEP), which began in 1977 offers perinatal support through its "Warm Line" and new parent groups in Santa Barbara, California. Depression After Delivery (DAD) is a national information and resource organization that has been disseminating postpartum materials to callers of their "800" number since 1985. The global network is Postpartum Support International (PSI) founded in 1987. Members of PSI are the consumers, self-help groups and professionals who lead the postpartum social support and mental health movement. There now exists a wealth of scientific knowledge and successful models of support for national action.

The Problem

Keeping a mother mentally healthy during this time is of vital importance to the future of the entire family and the community at large. In keeping with the ecological model that is at the center of postpartum support movement, if the mother is not well, then everyone is at risk. Tremendous attention is focused on a woman from her child’s conception through the postpartum period, which altogether comprises the process of childbearing. There is a valuable window of opportunity waiting for action. The woman needs to know that she can turn to her midwife, obstetrician, or family doctor and their nursing staffs for consultation about education, her options for treatment and referral to help.

An Opportunity

A woman’s personal history of previous psychiatric illness and her family’s mental health history are clues for future mental wellness. Accurate assessment is critical. The reasons to screen during pregnancy and through the first postpartum year on a routine basis are linked to the consequences if women’s mood disorders are not detected and treated. This has extraordinary implications: the identification of women at high risk for major mood disorders is related to her intervention, treatment, and the prevention of further trauma. She must not be abandoned or left to wander through a maze of unrelated and uninformed professionals. Childbearing is a time of vulnerability and therefore becomes an opportunity to build trust between the consumers and providers of health care.

Solutions

1. All women of childbearing age must know about her own and her family’s mental health history and share this information with her caregivers.
2. An accurate assessment of a woman’s mental health must be completed at every visit to her caregivers during pregnancy and during her first postpartum year.
3. All health professionals must provide in their offices written educational information, resources and treatment options for mood disorders related to childbearing.
4. A continuity of healthcare for women and their families must be available in every community.
5. Timely and appropriate referral to other professionals must include follow-up by the referring party to insure quality of healthcare.

1. It is a myth that pregnancy is a universally glowing, happy time and that new parenthood is "the most wonderful time in your life".
   
2. The reality is that symptoms of depression and anxiety occur in ten to twenty percent of expectant and new mothers. This means that these emotional symptoms are the most common complication of pregnancy, affecting up to 400,000 women per year in the U.S.
   
3. Warning signs during pregnancy or postpartum include difficulties with sleeping, eating, or caring for herself or baby; thoughts about hurting herself or baby; or intense feelings of energy, anxiety, or sadness.
   
4. Depression and anxiety during pregnancy can decrease blood flow through the umbilical cord, resulting in low birthweight, small head circumference and possible effects on the baby’s brain development.
   
5. Depression and anxiety in the mother after birth can affect the parent-child relationship, resulting in developmental, learning, and behavioral problems in the child.
   
6. Depression and anxiety in the mother can also affect her relationships with others, particularly the baby’s father.
   
7. Women are not to blame! Maternal mental illness is not a weakness, and women cannot will themselves well. Women with a personal or family history of emotional difficulties are at greatest risk.
   
8. Postpartum obsessions, thoughts about harm that can come to the baby, affect 3 to 5% of new mothers. These thoughts represent no danger to the baby and can be distinguished from postpartum psychosis, in which there is a risk for the baby.
   
9. Education is the first line of defense, for realistic expectations about new parenthood can decrease the occurrence of depression and anxiety.
   
10. Help is available! These illnesses are treatable. For more information call Postpartum Support International (PSI) at (805) 967-7636.

1. Know the facts about postpartum depression, be up-to-date on current research and treatment options.
   
2. Know your local community’s resources and stay connected with other agencies and organizations.
   
3. Be comfortable with the topic of mental illness, listen actively to what a woman is expressing and do not judge her.
   
4. Offer accurate, written educational materials on the topic in a lending library that is affiliated with support groups.
   
5. Build a network in your community and make appropriate referrals to others. Follow-up to know that the woman and her family’s needs have been met.

1. You are not alone. (VALIDATION)
   
2. You are not to blame (REASSURANCE)"
   
3. Your experience is real, it is treatable and you will be well. (HOPE)

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