After months or even years of anticipation, most pregnant women and their partners are certain that taking care of their babies will be a blissful if tiring experience.
But for a minority of parents, the period after birth can be a nightmare called postpartum depression (PPD) that suddenly pounced on their joy like a bird of prey.
It isn’t the “baby blues” – feelings of restlessness, anxiety and irritation accompanied by occasional tears that affects between half to 80 percent of new mothers and usually disappears untreated after a week or two. PPD, which is moderate to severe depression, does not fade away by itself and must be treated. International studies estimate the prevalence at between 5% and 25% of mothers and even some of the fathers. This should not be confused with an even-rarer phenomenon (one or two per 1,000 births) of postpartum psychosis, which is a separate psychiatric disorder with symptoms such as hallucination, disturbed thoughts, delusions or disorganized behavior or speech and which usually attacks those who already suffer from mental illness.
PPD is a universal phenomenon to which no society – including the most primitive – is immune. In Malaysia, for example, the traditional culture includes a belief in a “spirit” that lives in the placenta and fluid filling the uterus and feeding the fetus; after birth, when the spirit is “angry,” it causes the mother to cry, have difficulty sleeping and lose her appetite. A shaman is brought in to hold a seance to force this Asian-style dybbuk to flee.
But PPD is real, and it can be very painful and destructive to the family. As the phenomenon is still in many cases hidden under the covers in Israeli society, the Knesset Health Lobby headed by Kadima MK Rachel Adatto recently initiated a meeting on the disorder. The two-hour session was attended mostly by women activists, mental health experts and a smattering of MKs and government officials.
“I am a gynecologist by profession,” Adatto said, “and I have treated women with PPD. The subject of postpartum depression makes headlines from time to time, and then it disappears. For example, some speculated that PPD was involved in the case of the twins who reportedly suffered from shaken-baby syndrome. I decided raise the issue more seriously at this meeting to increase awareness,” Adatto said.
“I have dealt with such patients too,” said Hadash MK Afou Agbaria, a Russian-trained Israeli surgeon from Umm el-Fahm.
“Family doctors and tipat halav [family health] centers must be more alert to the problem.”
“Postpartum depression is regarded as a woman’s problem” added Dr. Leonid Eidelman, chairman of the Israel Medical Association, which co-sponsored the event. “It is a public issue, a quiet enemy and sometimes a silent killer. People want to distance themselves from this problem. But PPD has to be treated; there is treatment! Families should know. It is not only hormones.
Everybody has to work to help the victims.
If we can save women who hear about this conference and seek help, we have carried out our mission,” Eidelman said.
HADAS, A 43-year-old modern Orthodox woman with a headcover and a skirt down to the floor, was introduced as someone who had struggled with PPD. When she spoke, she mesmerized the audience.
“I was overweight as a child,” she recalled. “My teachers said I had ‘organization problems,’ that I was slow and needed to go to special education classes. They insisted I had problems connecting with people.”
But Hadas nevertheless earned her high school matriculation certificate, did her national service, studied special education at Bar-Ilan University, married and gave birth to a baby girl.
“I was very happy. I received a teaching degree and then had another baby girl. But when we moved to Beit Shemesh, I had problems getting settled. My elder daughter didn’t make good connections to other children, so the experts recommended that she go to special education. It turned out she suffered from PDD [pervasive development disorder, a mild form of autism].
Then I became pregnant again with our third daughter. The baby refused to breastfeed.
I felt weak and anxious, and I thought of causing myself harm. I decided to tell the family doctor about the problem. And he sent me to a mental health clinic.”
There, Hadas was told that she couldn’t be given medication because she was breastfeeding.
“But I stopped that and got pills. The problem was that they didn’t help,” she said.
Her symptoms got so bad that she was willingly hospitalized in a mental health center.
“I was constantly crying because my newborn baby wasn’t allowed to remain with me. The psychiatrists gave me more diagnoses and drugs. I suffered terribly from side effects. I wrote then in my diary that ‘I feel heavy, don’t find my place, am enveloped in darkness. What will happen to me? I miss my girls and want to be with them. When will this nightmare end? Maybe I will drown.’ I was hospitalized there for a whole year. My husband was torn between me and the kids, and he still had to support the family.”
Finally, said Hadas, she was discharged, not because she had recovered but because the institution suffered from a staff shortage.
She didn’t feel well after returning home.
“We were greatly helped by our religious community; the neighbors volunteered to make meals and mind the kids. But the situation became worse, and I was in and out of the psychiatric hospital. I was sent for diagnosis of organic and other problems; even a neurosurgeon saw me. I received other medications. I was referred for living in a hostel, and I went home from time to time. I was scared to do things after years of not doing anything. I was afraid of hurting myself.”
One day, a physician asked about her menstrual cycle.
“He said he had noticed that I had depressive symptoms usually around the same date in the month. I was diagnosed as having premenstrual syndrome and that it was involved in my depression. I was treated, and a Filipina caregiver was hired to help me at home. Then I got pregnant again with our fourth daughter, and my father died suddenly. I had a cesarean section. It was hard. I was hospitalized again for depression. But things have much improved. Five years have passed. I am better.”
Hadas urged that doctors, nurses and social workers in the system be trained on PPD to become more aware of the problem.
She also bemoaned the fact that there are no inpatient psychiatric facilities where the mother and her baby can stay together under supervision.
“It makes it even worse if the baby is taken away and raised at home. This could shorten hospitalization and rehabilitation. There must be a pleasant place in the hospital where the family can get together.”
"Dr. Boris Nemetz, a member of the Israel Psychiatry Society and director of the Beersheba Mental Health Center’s psychiatric department and depression clinic told the participants that women and men equally suffer from depression, but females often get it at different stages in life – usually at younger ages – than males. Often, depression is connected with life events such as menstruation, pregnancy and menopause". boys and girls equally suffer from depression, but women to men as 2:1" The age of depression becomes younger" instead of "but females often get it at different stages in life – usually at younger ages – than males "
“It was once thought that pregnancy protects against depression,” Nemetz said.
“But the opposite is true. Data show that pregnant women are more liable to suffer depression, with 7% during the first trimester, 12% in the second and 17% in the third.”
After giving birth, mothers can be screened for PPD using the Edinburg Postnatal Depression Scale, but “it is not enough just to look at the score. A good clinical person has to diagnose it,” Nemetz continued.
Along with a sad or depressed mood, symptoms of PPD include agitation or irritability; appetite changes; feelings of worthlessness or guilt; feeling withdrawn or unconnected; lack of pleasure or interest in most or all activities previously enjoyed; loss of concentration and energy; negative feelings toward the baby; significant anxiety; trouble sleeping; and thoughts of death or suicide.
A mother with PPD may also be unable to care for herself or her baby; be afraid to be alone with the infant; and either be extremely worried about the baby or have little interest in him or her.
“The natural decline in hormone levels after delivery does not cause depression. If not, every woman would develop it,” said Nemetz. “One has to have a tendency for it.”
Other non-hormonal factors in PPD are bodily changes, sleeplessness, worries about one’s ability to function as a mother, changes in work and social relationships and having less personal freedom and time for yourself.
Treating depression in pregnant women and afterwards in those who breastfeed is difficult, said the psychiatrist, because some drugs can cause harm to the fetus and to the baby. But some of the medications are safe. A combination of talk therapy and medication is most effective, he said.
His institution studied Beduin women in the Negev and surprisingly found that of 104 who gave birth, 42% had PPD.
“There is a lot of unnecessary suffering. Intervention is needed,” he said.
Treatment includes talk therapy and medications. Having good social support from family members, friends and colleagues is also helpful and may reduce the severity of PPD, but it is unlikely to prevent it, experts say.
THE US government has invested $18 billion in recent years to help women at risk for PDD. Although early detection by the Israeli health authorities and intensive support for affected women have been slow in coming, the Health Ministry and others have become aware of the fact that this pays off.
Mira Honovich, the chief supervisor in public health, described a program operated through tipat halav centers. There are 160,000 deliveries per year in Israel. About 70% of pregnant women come to the centers for followup of their pregnancies rather than to health fund or private obstetricians/ gynecologists.
“The centers were set up to take care of newborns for health checks and vaccinations, but they expanded into mother-and- child stations and then to family health centers,” she said. “Once the baby is born, attendance at the centers is almost universal. Public health nurses today are experts in holistic care, including pregnancy, breastfeeding, vaccinations, home safety, vaccinations, family violence and physical and social problems. Not only the baby is examined, but the woman is, too.
If PDD is suspected and intervention is needed, the nurse refers her to the mental health authorities.”
A pilot program to diagnose PPD has been set up by the ministry, with voluntary organizations like Em Le’em Bakehila (Mother to Mother in the Community) promoting personal connections. Experienced mothers are matched up with families with PDD, supplementing them and making regular home visits to provide much-needed support. Social work experts have urged that this program – developed in Boston – be implemented all over the country.
Another sector besides the Beduin that has high rates of PDD or hides it is the haredi community. Dr. Rina Bina, who heads the health section at the voluntary organization Ezer Mizion and lectures at Bar-Ilan, said her research n 804 such women has shown 8% had PDD. “But they usually don’t go or treatment,” she said.
As childbearing is recognized as the wife’s most important role, those with psychological problems after delivery tend to be ashamed. As families are so large, the pressures are multiplied.
Stigma, concluded Dr. Gadi Lubin, head of the ministry’s mental health department, “is difficult to cope with. So this meeting is helpful to raise awareness. Our programs through tipat halav are vital. We recently did a course for 30 women who will give support to mothers. This network will help give support and reduce the number of women who suffer and don’t seek help.”