'When you find a drug which helps you, do not try and persuade your medical advisor to cut the length of the treatment short. You may find when you take drugs that you improve quickly but do remember that depression is an illness ...'
This is just one piece of advice from the leaflet 'Post-Natal Depression' compiled by the Association for Post-Natal Illness. In this small 10-page leaflet, there are nine pointed references to drug therapy as a first line in treatment, and only two rather vague references to 'specialized psychotherapy' as something occasionally indicated.
Implicit in the Association's attitude toward depression in the postnatal period is that it is non-causal. It simply descends on a woman out of the blue - a sort of emotional or hormonal pirate, which needs blasting out of the water with a course of antidepressants. Indeed, the leaflet states at the outset that a mother 'may feel terribly miserable and sad for no particular reason' and that 'these feelings usually have no foundation'.
If a woman has become postnatally depressed, it is likely to be because a number of things have gone wrong for her along the way. Childbirth itself does not increase a woman's chance of becoming depressed. Nor has research into the predictive factors for postnatal depression produced any clear consensus. Indeed, one of the latest theories is that postnatal depression, like PMT, is due to low levels of estrogen.
What has produced results, however are the studies which look into the type of birth a woman experiences and its subsequent effect on a mother's mood. One study in Norway (Journal of Reproductive and Infant Psychology, 6, 4: 229-40) concludes that women who have had traumatic birth experiences are the ones most likely to suffer from postpartum emotional disturbances. In their survey of 161 women who gave birth in hospital, 64 per cent reported a feeling of loss of control during childbirth. Some 69 per cent exhibited signs of depression on the fifth day postpartum; this was related to their feelings that they had received little support from the staff and had 'unmet needs in relation to the midwives'.
The authors further suggest that these feelings are associated with modern obstetric practice and hospital procedures, combined with the absence of psychological support.
Statistics closer to home show that some 60 per cent of women who give birth in hospital experience depression, as opposed to only 16 per cent of those who give birth at home (Special Delivery, winter 199: 12-13). A high rate of depression is also associated with emergency caesareans.
Besides an unhappy experience at birth, depression can result from the social isolation of mothers and the often impossible task of integrating the many conflicting emotions and impulses which a new mother feels. In a review of several research studies on postnatal depression (Journal of Reproductive and Infant Psychology, 8, 2: 147-59), the author concludes, among other things '. . . the downside of the birth of a new family member remains hidden ... from medically orientated professionals who cannot visualize the psychological concomitants of birth which could result in psychodynamic change sufficient to produce depression. This lack of insight into the possible meaning of the event leaves such professionals convinced that all postnatal-onset psychiatric disorder must be hormonally caused ... [which wins over audiences] while preserving their happy images of happy motherhood.'
The antidepressant drugs which are all too freely recommended do not help. These drugs work on the emotional centres of the brain, dulling a woman's feelings to the point where confusion, memory problems, disorientation, palpitations, sweating, shortened attention span, fatigue and lower libido become chronic.
Of the older-style tricyclic drugs, desipramine has proved highly toxic. Patients treated with this drug are 51 per cent more likely to attempt suicide than those taking more modern medication such as fluoxetine (JAMA, December 23/30, 1992). Yet questions have arisen about the new 5-HT antidepressants and a possible link between them and violence and suicidal behaviour (GP, 17 July 1992).
While there is very little to show that antidepressants taken in 'normal' doses will penetrate into a mother's milk, a safe dose has not been established. A depressed mother, in any case, will usually be told to wean her baby to 'save her energy', thus breaking the one bond she desperately needs to strengthen in order to feel more confident in her new role. Weaning also deprives her of the blissful sedative effects of the prolactin released into her system while nursing.
One area almost ignored in postnatal depression is diet. Certainly a depressed woman will be advised to keep her sugar levels up, as hypoglycaemia can make symptoms worse. But what about diet as a means of prevention or even cure? Nutritional specialist Dr Stephen Davies says published evidence shows that postnatal depression can be due to a lack of vitamin B, calcium and possibly magnesium.
A woman looking to the Association for Post-Natal Illness for advice on prevention is advised that there are two types of treatment. One involves high doses of progesterone during and after labour - a new method which has yet to be proved safe or successful (see WDDTY vol 4 no 7). The other involves the use of antidepressants in late pregnancy. As the Association noncommitally notes, 'Many doctors feel that exposing the baby to antidepressants, even in late pregnancy, is dangerous. However, some feel that the benefit to the mother outweighs the risk to the baby.'
A depressed woman feels she cannot do for herself, and the advice that she should let others do for her usually only aggravates the problem. Having to take drugs - more help from the outside - can be the last straw. Depressed women need to be pointed in the direction of self-help in the form of counselling or therapy. Talking about feelings in a safe space is the best form of self-help because it gives her back responsibility for getting well.
Pat Thomas is a journalist and psychotherapist, who works with pregnant women.