"It's horrible to say," said Christina*, reflecting on her depression following the birth of her first child, "but here I had this beautiful new baby, and I just didn't care about her. The feelings of love just weren't there. All I could think about was how meaningless everything seemed. I managed to feed her and change her, but that was about it."
Stories like Christina's, unfortunately, are all too common -- a situation that has prompted the U.S. House of Representatives this week to authorize spending $3 million to pursue studies of postpartum depression and to carry out a national campaign to increase awareness of the issue.
Postpartum literally means "after birth," and this period is a time when women, who suffer from depression at twice the rate that men do, are especially vulnerable.
A study in this month's American Journal of Psychiatry of more than 4,000 pregnant women showed that more than 10 percent of them suffered from major depression after giving birth. This study, from the Centers for Disease Control and Prevention, also found substantial, though lower, rates of depression in women just before and during pregnancy.
Crying Out for Causes
How does a time of such beauty and hope become so dark and desperate?
Can we blame it all on hormones? The female hormones estrogen and progesterone are obvious suspects, as they rise to several hundred times their normal levels in pregnancy and then drop suddenly after delivery. However, no consistent differences in hormone levels or functioning have been found between postpartum women with and without depression.
One study, however, did suggest that the change in hormone levels plays a critical role for some women. A group at the National Institute of Mental Health showed that a subset of women with a history of postpartum depression had a recurrence of depressive symptoms when high levels of estrogen and progesterone induced by medication in an experimental setting were precipitously dropped.
Several studies have shown that postpartum depression runs in families. A group from the United Kingdom found that among women with a family history of depression -- those whose sisters had experienced depression -- had a 42 percent chance of experiencing postpartum depression in their first deliveries.
Another group, led by Dr. Douglas Levinson of Stanford University, found that women with a family history of postpartum depression were more than three times more likely to experience it themselves compared with women without this history.
And a third study, conducted by Dr. Jennifer Payne of Johns Hopkins University and others, similarly found an increase in risk for postpartum mood symptoms in women with bipolar disorder who had a family history of these symptoms.
These results suggest a genetic contribution to postpartum depression risk. One study of twins reported that 38 percent of the risk is in the genes. Scientists are busy tracking down potential genes that might be culprits. Risk genes could be those that are turned on or off by changing levels of estrogen or progesterone.
But other factors may also play a role. Stress hormones, which could be activated by the stress of caring for a newborn, might play a role in triggering depression. And the sleep deprivation that new mothers experience might further fan the flames of smoldering depression.
Putting Out the Postpartum Fires
What is unusual about the treatment of postpartum depression is that the impact of the illness and its management on the baby need to be factored into the equation along with the impact on the mother herself, according to Payne, who reviewed the management of postpartum depression in the American Journal of Psychiatry last month.
On the one hand, there is the potential risk of treatment -- exposure of babies to antidepressant medication -- while on the other hand, there are the risks of no treatment, which include the risk of depression to the mother, poor bonding between mother and child, and possible effects on IQ, language and development in a child whose mother is depressed.
Antidepressant treatment during breast-feeding is often the best choice, although the baby will be exposed to the antidepressant in breast milk. In general, studies have not found high rates of problems in babies exposed to antidepressants, although the long-term outcome of this exposure is unknown.
Mothers can minimize their baby's exposure to the highest medication levels by taking the antidepressant immediately after breast-feeding. Mothers should be educated about potential side effects of any medication prescribed during breast-feeding. Involvement of the pediatrician can help in monitoring the baby for problems such as sedation, changes in sleep or feeding, and irritability.
Approaches that do not involve medication, such as the "talk" therapies, especially cognitive behavior therapy and interpersonal psychotherapy, may also be useful in patients with postpartum depression and should be considered part of the treatment plan.
*Name changed for confidentiality
Dr. James Potash is an associate professor of psychiatry and co-director of the Mood Disorders Program (http://www.hopkinsmedicine.org/moods) at the Johns Hopkins School of Medicine in Baltimore. If you have questions or comments, please e-mail at firstname.lastname@example.org. To participate in our studies, call 877-MOODS-JH.