By Walker Karraa, PhD (www.walkerkarraa.com)
(APA Division of Trauma Psychology, 2014 Program Co-Chair; Perinatal Mental Health Contributor, Science and Sensibility; American College of Nurse-Midwives)
In 2010 a crowd gathered at the United States Capitol to celebrate the passage of the Melanie Blocker Stokes MOTHERS Act—legislation dedicated to comprehensive federal research, education and voluntary support services for postpartum depression. The MOTHERS Act was heralded as a landmark moment in the national discourse on the mental health of women in postpartum period. Yet despite the inclusion into the Affordable Care Act, despite the advocacy of hundreds of professionals, researchers and policy makers, the United States still fails to implement actual preventive measures that safeguard women from perinatal mood and anxiety disorders.
Case in point, on October 3, 2013, the US Capitol was the site of another landmark event in raising awareness for perinatal mood and anxiety disorders. Miriam Carey, an unarmed 34 year-old African American woman drove past a White House barricade. A subsequent car chase ended near the Capitol, where Miriam was shot and killed by police officers. Her infant daughter was in the car, but she survived, unharmed. While details are still emerging about Ms. Carey’s mental state, her mother has stated that she suffered from depression after the birth of her daughter and police records show a history of mental illness.
And as the news media looked to professionals for insight, there was mass confusion as to what to actually call “it”. Psychosis? Depression? The only common denominator was the word, “postpartum”. Sadly, despite the passage of the MOTHERS Act, the uncomfortable struggle for words in the aftermath of Miriam Carey’s death speaks volumes. While mood disorders around childbearing have been recorded since Hippocrates, providers and society have yet to agree upon a word, or collection of words that defines diagnoses, much less a differential one. Look no further than the DSM51 to find the lack of language describing perinatal mood or anxiety disorders in our current classification of psychological conditions.
As an experiment, I searched the American Psychiatric Association’s DSM5 website and entered the search words “postpartum psychosis”:
“No results matching your search were found.
- Check your spelling. Are the words in your query spelled correctly?
- Try using synonyms. Maybe what you’re looking for uses slightly different words.
- Make your search more general. Try more general terms in place of specific ones.
- Try your search in a different scope. Different scopes can have different results.”
When I did the same search in Google, this came up: Miriam Carey: Capitol Hill Chaos Puts Postpartum Psychosis in Spotlight: What set mom on rampage?
When society has more access to rampage than reason, it is little wonder why confusion ensues.
Just consider that, in the main diagnostic manual for psychiatric disorders, the word, “postpartum” is only used as an onset specifier applied to, manic, or mixed episode in major depressive disorder, bipolar I, bipolar II, brief psychotic disorder if the onset of the episode is within 4 weeks postpartum. However the postpartum-onset specifier may not be used to denote a hypomania, or less prominent mania2.
There are truly no words to diagnose “it”. How are providers to know the differences between fact and fiction when our diagnostic manuals struggle with words, their meaning, and application? The confusion of words breeds stigma, feeds myth, and creates barriers to care for women AND professionals. The lack of language creates the cracks through which too many women fall.
What do the experts say?
I asked Jane Honikman, founder of Postpartum Support International and author of recently published Community Support for New Families shared:
“The ‘language barrier’ will continue so long as we ignore the stigma of mental illness” (J. Honikman, personal communication, October 8, 2013).
The stigma of mental illness creates a powerful obstacle to care that must be addressed by providers.
Lisa Catapano, MD, PhD, Assistant Professor, and Director of the Residency Training Program at the George Washington University Department of Psychiatry offered:
“Clearly, there is still a significant stigma surrounding all mental illnesses; arguably the stigma relating to postpartum depression/psychosis is even stronger than for other mental illnesses. Motherhood, and its associated joy and fulfillment, is considered sacred in our society; for a new mother to admit to feelings of sadness, apathy, anxiety, incompetence, hopelessness, and certainly suicide or infanticide is to admit that she is not enjoying the blissful experience of parenthood that she was told to expect, and that others expect of her. Many women in this situation interpret their negative feelings as evidence of their bad mothering, rather than recognizing them as symptoms of an illness” (L. Catapano, personal communication, October 9, 2013).
Furthermore, could the word “postpartum” itself create stigma through association with powerful social constructs of madness in motherhood found in media rhetoric such as “What set mom on rampage?”
Julia Frank, MD, Professor of Psychiatry and Behavioral Sciences at the George Washington University School of Medicine and Health Sciences offered:
“I think it is unfortunate that any mental disorder in the mother of a very young child is termed ‘postpartum depression’ in popular writing. Being a mother does not protect someone from developing a psychiatric disorder, and childbirth is not, itself, always a cause. The disorders that come on in the immediate postpartum period (within three months, sometimes within days or weeks of giving birth) are highly treatment responsive. Calling an apparently severe episode in a mother of one year old child “postpartum” may alarm women who have the more typical –and far more common– postpartum difficulties.” (J. Frank, personal communication, October 5, 2013)
And for women of color, these issues are even more pressing. There is a paucity of research specifically dedicated to women of color and postpartum mood or anxiety disorders3. The data that does exist reveal higher prevalence due in a large part to an ontological divide in lived experiences between needs and preferences of women of color with postpartum mood disorders, and mainstream psychological paradigms of treatment.
For example, a 2010 nationally representative study of (n = 3,051) pregnant women determined that “non-white and Hispanic women without a history of mental health were less likely to report poor antepartum mental health”4. Other studies have suggested ethnic underrepresentation in mental health research (5-7), less satisfaction with services received (8), or negative beliefs about treatment (9, 10) contribute to prevalence underestimates for minority women in the United States.
Segre, O’Hara, and Losch (11) examined race/ethnicity as a risk factor for depressed mood in late pregnancy and early postpartum period, reporting that African American women were significantly more likely to report depressed mood, yet less likely to obtain care. Most recently, Goodman (3) and colleagues determined that African Americans prefer social support and psychotherapy as opposed to psychopharmacology.
Clearly, we have work to do. Somehow our struggle to give language to mental illness around the childbearing period must be addressed. Further research and discussion about the mechanisms of stigma as experienced by women of color who experience postpartum mood or anxiety disorders is critical to the advancement of prevention, assessment, and treatment. Moreover, in the wake of Miriam Carey’s death, reviewing and refining our terminology regarding maternal mental health should give providers and women a common language of wellness and wellbeing.
Given the stigma, misinformation and professional confusion regarding postpartum mental illness it is important to identify and differentiate the full spectrum of perinatal mood and anxiety disorders – from the most prevalent and benign ‘baby blues’ to the most rare and severe postpartum psychosis. The material that follows is an overview and list of resources that may serve to dispel myths and offer access to resources.
Definition of Terms
Postpartum blues presents mild, time-limited, transient symptoms of depression such as irritability, mood swings and tearfulness occurring soon 3 to 5 days after childbirth and resolving within 10-14 days following childbirth (12). Postpartum blues are reported to occur from 50% to 80% of mothers following childbirth (13; 14; 15). Postpartum blues usually resolves without treatment (14) but may also be a risk factor for the more severe PPD (12; 13).
According to the DSM51 postpartum depression refers to “nonpsychotic depressive episode that begins in the postpartum period” (p. 160), that includes symptoms intense feelings of sadness, hopelessness, guilt and dramatic changes in sleep or appetite and suicidal ideation. Postpartum depression is more common, with prevalence estimates range from 10% to 25% for all new mothers in United States (16-19). More information regarding postpartum depression can be found through APA’s Public Interest directorate.
Postpartum psychosis is a psychiatric emergency that requires immediate medical attention (13). Postpartum psychosis affects 1-2 women per 1,000 births globally, and while rare, it is an extremely severe postpartum mood disorder (20; 21). Postpartum psychosis occurs in all cultures, affecting mothers across socioeconomic, racial/ethnic, and religious communities (22). Women who have a history of bipolar disorder or previous postpartum psychosisor a first-degree relative with bipolar disorder, or are at increased risk of developing postpartum psychosis (23). Contrary to popular beliefs, postpartum psychosis is often the result of either bipolar disorder or major depressive disorder with psychotic features, and there is little frequency of postpartum psychosis caused by reactive psychosis or schizophrenia (24).
Symptoms are sudden in onset, usually occurring within 48 hours to 2 weeks following birth (25), and include waxing and waning delirium and amnesia (26; 27)
- Cognitive disorganization/psychosis that includes
- Disturbances of sensory perceptions such as auditory, tactile, visual, and olfactory hallucinations(28)
- Intrusive thoughts of suicide or infanticide which are ego syntonic–experienced as real or reasonable (27; 28)
In postpartum depression or anxiety disorders, intrusive thoughts of self-harm or harming the baby are known as ego-dystonic and are common (41%-57)29, and are experienced by the woman as abhorrent, as she recognizes that they inconsistent with her personality and fundamental beliefs30.
In contrast, for a woman experiencing postpartum psychosis, the intrusive thoughts or ideations, of harming self or other are ego–syntonic—intrusive thoughts are experienced as reasonable, appropriate and are “associated with psychotic beliefs and loss of reality testing, with a compulsion to act on them and without the ability to assess the consequences of their actions”27.
Resources for Women and Their Partners
- APA’s Postpartum Depression Brochure
- Mother to Baby (formerly Organization of Teratogen Information Specialists), *Spanish language available
- National Suicide Prevention Lifeline
- Postpartum Support International (PSI), *Spanish language available
- Royal College of Psychiatrists: Postpartum Psychosis: Severe mental illness after childbirth
- The Marce Society
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed). Arlington, VA: Author.
- Sharma, V., & Burt, V. K. (2011). DSM-V: modifying the postpartum-onset specifier to include hypomania. Archives of Women’s Mental Health, 14(1), 67-69.
- Goodman, S. H., Dimidjian, S., & Williams, K. G. (2013). Pregnant African American women’s attitudes toward perinatal depression prevention. Cultural Diversity and Ethnic Minority Psychology, 19(1), 50.
- Witt, W., DeLeire, T., Hagen, E., Wichmann, M., Wisk, L., Spear, H., . . . Hampton, J. (2010). The prevalence and determinants of antepartum mental health problems among women in the USA: A nationally representative population-based study. Archives of Women’s Mental Health, 13, 425-437.
- McGuire, T. G., Alegria, M., Cook, B. L., Wells, K. B., & Zaslavsky, A. M. (2006). Implementing the Institute of Medicine definition of disparities: An application to mental health care. Health Services Research, 41(5), 1979-2005.
- U.S. Department of Health and Human Services. (n.d.). Healthy people 2020: Determinants
of health. Retrieved from http://www.healthypeople.gov/2020/about/DOHabout.aspx
- Wang, P. S., Berglund, P., Olfson, M., Pincus, H. A., Wells, K. B., & Kessler, R. C. (2005). Failure and delay in initial treatment contact after first onset of mental disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 603.
- Diala, C. C., Muntaner, C., Walrath, C., Nickerson, K., LaVeist, T., & Leaf, P. (2001). Racial/ethnic differences in attitudes toward seeking professional mental health services. American Journal of Public Health, 91(5), 805.
- Cooper, L. A., Gonzales, J. J., Gallo, J. J., Rost, K. M., Meredith, L. S., Rubenstein, L. V., & Ford, D. E. (2003). The acceptability of treatment for depression among African American, Hispanic, and White primary-care patients. Medical Care, 41(4), 479-489.
- Miranda, J., & Cooper, L. A. (2004). Disparities in care for depression among primary care patients. Journal of General Internal Medicine, 19(2), 4.
- Segre, L. S., O’Hara, M. W. & Losch, M. E. (2006). Race/ethnicity and perinatal depressed mood. Journal of Reproductive & Infant Psychology 24(2), 99-106.
- O’Hara, M. W., & Segre, L. S. (2008). Psychological disorder of pregnancy and the postpartum. In R. S. Gibbs, B. Y. Karlan, A. F. Naey, & I. Nygaard (Eds.), Danforth’s obstetrics and gynecology (10th ed., pp. 504-514). Philadelphia, PA: Lippincott, Williams, & Wilkins.
- Beck, C., & Driscoll, J. (2006). Postpartum mood and anxiety disorders: A clinician’s guide. Sudbury, MA: Jones & Bartlett.
- Moses-Kolko, E., & Roth, E. K. (2004). Antepartum and postpartum depression: Healthy mom, healthy baby. Journal of the American Medical Women’s Association, 59, 181-191.
- World Health Organization. (2004). Promoting mental health: Concepts, emerging evidence, practice. Retrieved from http://www.who.int/mental_health/evidence/MH_Promotion_Book.pdf
- Gavin, N., Gaynes, B., Lohr, K., Meltzer-Brody, S., Garlehner, G., & Swinson, T. (2005). Perinatal depression: A systematic review of prevalence and incidence. American Journal of Obstetrics and Gynecology, 106(5, Pt. 1), 1071-1083.
- Gaynes, B., Gavin, N., Meltzer-Brody, S., Lohr, K., Swinson, T., Gartlehner, G., & Miller, W. (2005). Perinatal depression: Prevalence, screening accuracy, and screening outcomes: Summary, evidence report, and technology assessment (No. 119). Rockville, MD: Agency for Healthcare Research & Quality.
- Knitzer, J., Theberge, S., & Johnson, K. (2008). Reducing maternal depression and its impact on young children: Toward a responsive early childhood policy framework. New York, NY: National Center for Children in Poverty.
- Wisner, K., Sit, D. Y., McShea, M. C., Rizzo, D. M., Zoretich, R. A., Hughes, C. L., . . . Hanusa, B. H. (2013). Onset timing, thoughts of self-harm, and diagnoses in postpartum women
with screen-positive depression findings. Journal of the American Medical Association/
Psychiatry, 70(5), 490–498. doi:10.1001/jamapsychiatry.2013.87
- Kendell, R., Chalmers, J., & Platz, C. (1987). Epidemiology of puerperal psychosis. British Journal of Psychiatry, 150, 662-673.
- Munk-Olsen, T., Laursen, T., Pederson, C., Mors, O., & Mortensen, P. (2006). New parents and mental disorders: A population-based register study. Journal of the American Medical Association, 296(21), 2582-2589. doi:10.1001/jama.296.21.2582
- Kumar, R. (1994). Postnatal mental illness: A transcultural perspective. Social Psychiatry and Psychiatric Epidemiology, 29, 250-264.
- Dorfman, J., Meisner, R., & Frank, J.B. (2012). Prevention and diagnosis of postpartum psychosis. Psychiatric Annals, 42(7), 257-261. doi:10.3928/00485713-20120705-05.
- McGorry, P., & Connell, S. (1990). The nosology and prognosis of puerperal psychosis: A review. Comprehensive Psychiatry, 31, 519-534.
- Sit, D., Rothschild, A. J., & Wisner, K. L. (2006). A review of postpartum psychosis. Journal of Women’s Health, 15(4), 352-368.
- Spinelli, M. G. (2004). Maternal infanticide associated with mental illness: Prevention and promise of saved lives. American Journal of Psychiatry, 161(9), 1548-1557.
- Spinelli, M. G. (2009). Postpartum psychosis: Detection of risk and management. The American Journal of Psychiatry, 166(4), 405-408. doi: 10.1176/appi.ajp.2008.08121899
- Wisner, K. L., Peindl, K., & Hanusa, B. H. (1994). Symptomatology of affective and psychotic illnesses related to childbearing. Journal of Affective Disorders, 30(2), 77-87. doi: 10.1016/0165-0327(94)90034-5
- Brandes, M., Soares, C. N., & Cohen, L. S. (2004). Postpartum onset obsessive-compulsive disorder: Diagnosis and management. Archives of Women’s Mental Health, 7(2), 99-110. doi: 10.1007/s00737-003-0035-3
- Kleiman, K., & Wenzel, A. (2011). Dropping the baby and other scary thoughts: Breaking the cycle of unwanted thoughts in motherhood. New York, NY: Routledge/Taylor & Francis Group.
Walker Karraa, PhD is a perinatal mental health researcher, advocate and writer. She is currently regular perinatal mental health contributor for Lamaze International’s Science and Sensibility, Giving Birth With Confidence, and the American College of Nurse-Midwives (ACNM) Midwives Connection. Walker has interviewed leading researchers, clinicians, and advocates such as Katherine Wisner, Cheryl Beck, Michael C. Lu, Karen Kleiman, Pec Indman, Liz Friedman, and Katherine Stone. Walker was a certified birth doula (DONA), and the founding President of PATTCh, an organization founded by Penny Simkin dedicated to the prevention and treatment of traumatic childbirth. Walker is currently the Program Co-Chair for the American Psychological Association (APA) Trauma Psychology Division 56. She is writing a book regarding her grounded theory study on the transformational dimensions of postpartum depression. Walker is an 11 year breast cancer survivor, and lives in Sherman Oaks, CA with her two children and husband.