Rates of postpartum depression (PPD) in the United States have been estimated to be between 6% and 9% across African American, Hispanic and white female populations (Yonkers et al., 2001). Suicide risk for the mother in the first postnatal year is increased 70-fold (Appleby et al., 1998). In a review of maternal mortality in Sweden, suicide was found to be the leading cause of postpartum maternal death after malignancy (Hogberg et al., 1994). Despite increased awareness of PPD, too many women are still suffering and dying from it. The seriousness of this disease is highlighted by the recent case of Andrea Yates.
Case HistoryMs. A, a 28-year-old woman, was admitted to our inpatient unit for PPD following the birth of her first child. She had no prior psychiatric treatment, but history revealed a probable long-standing anxiety disorder with some avoidant traits. Her symptoms began toward the end of her pregnancy and got markedly worse after the birth of her son, when she had fantasies of running away and leaving the baby and her husband behind forever. She was new to the area, with no friends or relatives in the vicinity. She did not have the kind of relationship with her own mother, an alcoholic, that would have enabled her to call for support or advice.
This being her first child, she had little idea how to care for him and read numerous books on child care, only to find that each book had a different prescription for the best care, often proffering conflicting advice. She interpreted one such book as saying she should never put her child down, so she spent nearly every waking moment with him in her arms and kept him in her bed all night. Although nursing was not going well, she felt that to stop would deprive her son. She persisted despite distress to herself and her baby.
Given this picture of isolation and sleep deprivation, in addition to her premorbid personality and anxiety, it is not surprising that she developed symptoms of depression. She was started on a selective serotonin reuptake inhibitor in the hospital, and her symptoms began to improve over the next several days. More importantly, numerous recommendations were made by the treatment team about restructuring her home environment. She was told to stop breast-feeding, a decision made easier for her by the presence of medications. The family had the financial resources to hire a nanny to help her. She was connected with a mothers' group that met weekly, and her husband began spending more time at home. Finally, she was seen in weekly psychotherapy sessions, where the focus was issues of identity and motherhood, particularly in reference to her own mother who could not serve as a model for her. She did very well in subsequent weeks and is now virtually symptom-free.
DiscussionThis case highlights the importance of targeting psychosocial aspects of recovery in PPD treatment. We know that predictors of PPD, in addition to prenatal depression and anxiety, include child care stress, marital relationship and self-esteem (Beck, 2001). With the help of a nanny and her husband's greater involvement at home, Ms. A was able to markedly reduce her daily stress level and simultaneously improve her relationship with her husband. As an added bonus, her husband began to form a closer relationship with their son.
Also vital to Ms. A's recovery was an ongoing discussion of her conception of herself as a mother in the world. For Ms. A., motherhood meant being different from her own mother; yet this goal left her with no road map to follow and a terrible fear of repeating her mother's mistakes. As a result, she lost faith in her ability to be a good parent and, in the context of depression, felt her only recourse was to flee. She had convinced herself that her son was better off with no mother than with her, a belief that can -- in some cases of postpartum depression -- lead to maternal suicide. The not uncommon corollary to that is a mother's belief that her children are somehow defective or developing improperly, which can -- in cases -- lead to infanticide. Fortunately, Ms. A received treatment before she reached that level of psychopathology.
In our increasingly fractured society, mothers face the complex problems of social isolation, lack of role modeling and discontinuity through the generations. In this context, it is crucial for psychiatrists to prescribe, in addition to medications, ways to restructure the home environment that can improve the mental health of the entire family. Psychiatrists treating women with PPD should, when possible, also use psychotherapy to explore symbolic representations of motherhood, with its hidden layers of meaning and potential sources of identity confusion.
