More on Postpartum Depression

I recently wrote a post on postpartum depression which has generated a certain amount of negative comment.  For this reason, I thought it might be helpful to clarify some points.

DEFINITION AND EXPLANATIONS

The DSM makes no mention of postpartum depression as such.  The closest it comes is major depressive disorder with postpartum onset.  In other words, the APA conceptualizes postpartum depression as ordinary major depression (which can incidentally range in severity from mild to severe) which happens to occur in the postpartum period.  This is in marked contrast to the popular notion that postpartum depression is somehow a function of the postpartum woman’s hormones, and is fundamentally different from other forms of depression.

Despite two decades of very active research, there is no evidence that depression in the postpartum period is caused by a hormonal imbalance, no clearly specified mechanism of action, and no identifiable biological marker.  This is similar to the state of affairs in depression research generally, where several biological theories have been proposed, but none has stood the test of time.  There are some suggestions in the literature of correlations between physiological factors and depression in the postpartum period, but they are not always consistent and don’t establish a causal link.

In my view, the most reasonable way to conceptualize postpartum depression is that – similar to other depression – it is largely a function of adverse life events, coupled with feelings of isolation and hopelessness.  The postpartum period, as I mentioned in the earlier post, is fraught with adverse life events, especially if a mother is poor, young, and single.  This conceptualization of postpartum depression is consistent with the widely replicated finding that the risk factors most heavily associated with postpartum depression are:  low education, low income, being unmarried, and being unemployed.  Deepika Goyal et al (here) found that women with all four of these risk factors were eleven times more likely than women with none of these factors “to have clinically elevated depression scores, even after controlling for the level of prepartum depressive symptoms.”

TREATMENT

No hormone treatment for postpartum depression has been shown to be successful.  In the 1990’s there were some claims that hormone treatment had some efficacy in this area, but the claims have not stood the test of time.  The present Mayo Clinic guidelines for treatment of postpartum depression are not enthusiastic with regards to hormone therapy.

“Estrogen replacement may help counteract the rapid drop in estrogen that accompanies childbirth, which may ease the signs and symptoms of postpartum depression in some women. Research on the effectiveness of hormone therapy for postpartum depression is limited, however. As with antidepressants, weigh the potential risks and benefits of hormone therapy with your doctor.” [Emphasis added]

This is in marked contrast to genuinely biologically-induced depression.  It has been known for more than 100 years, for instance, that hypothyroidism, even at low levels, can lead to depression/psychosis in some people.  Treatment consists of thyroid replacement, and the depression/psychosis usually abates readily.

Antidepressant drugs are routinely given to women with postpartum depression, even though it has long been established that their average efficacy in the short-term is no better than placebo.

It is also well established that the use of antidepressants increases markedly the risk of recurrent episodes of depression in the long-term.

There is also a growing body of evidence which suggests that the use of some antidepressants increases the risk of suicide and serious aggression, including murders.

PREVALENCE

The point prevalence rate for depression in the postpartum period is not significantly different from similarly-aged women generally (Gaynes, BN, et al, Perinatal Depression: Prevalence, Screening Accuracy, and Screening Outcomes.)  In other words – and again, contrary to popular belief – the postpartum period is not marked by a significant increase in depressive episodes.  So even if there is some, as yet unconfirmed, hormone-induced depression, it clearly is not sufficiently prevalent to noticeably swell the ranks of postpartum women with depression.  In this context it is also worth noting that screening tests that are used for postpartum depression are the exact same tests used to screen for non-postpartum depression.  There is no special test for postpartum depression.  In this regard “postpartum depression” is a misleading term and would be more accurately called depression in the postpartum period.

SEVERITY

Much of the criticism directed at my earlier post charged me with minimizing the severity of postpartum depression.  In fact, I had made no mention of severity.  There is a widespread misconception that if one says that depression is not an illness, one is saying either that depression isn’t real, or that it isn’t severe.  That neither of these positions is true should hardly need saying, but let me clarify my position.

Depression is real.  Everybody gets depressed at some time or another.  Sometimes the depression is mild and can be shrugged off without difficulty.  Other times it is severe.   Occasionally – I believe very occasionally – it is primarily a function of a biological factor, but this should not be assumed without clear evidence.  The vast majority of depressionincluding depression in the postpartum period – is a function of adverse life events/circumstances.

THE CONCEPT OF DEPRESSION

An overriding consideration in this discussion, or indeed any discussion of depression, is the widespread assumption that depression is a unified, definable, and measurable phenomenon.  In reality, all of these assumptions are false.  There is a great deal of variation in the way that individuals experience, and respond to, depression.  There is no definition of depression that would meet scientific standards, and measuring instruments that purport to measure depression actually measure what people say about their depression, which isn’t necessarily the same thing. There are, for instance, all sorts of reasons that a person might say he’s “fine” when in fact he’s quite despondent.  And vice versa.

The point here is not that we shouldn’t discuss depression, but rather that when we do have discussions of this kind, there is great potential for confusion.

INDIVIDUAL PRESENTATIONS

At the risk of stating the obvious, everybody is different.  Different people react to situations and circumstances in different ways.  Some people do indeed become extremely despondent in the postpartum period and at other times.  How individual people conceptualize their problems and what they choose to do about them are clearly their own choices, and it is certainly no business of mine to challenge people in these regards.

The purpose of this website is to challenge what I believe are spurious and destructive tendencies in modern psychiatry, and my challenges are based on logical analysis, research findings, and common sense.  Some people agree with what I write.  Others do not.  We can agree to differ.

AN APOLOGY

In my original post I mentioned the websites Postpartum Depression and Postpartum Support International, and recommended that they be “viewed on an empty stomach.”  This was undignified and inappropriate, for which I apologize to the writers.  I have removed the sentence.  It is still my contention, however, that the sites be viewed with a critical eye.

  • Jane

    We can agree to disagree when you’re not doing harm to women. In this instance you’re just wrong.

  • Jane

    We can agree to disagree when you’re not doing harm to women. In this instance you’re just wrong.

  • Louise

    Jane, inherent with disagreeing with someone is the belief that the other person is wrong, so I’m not sure what your point is. But I am curious to see the peer-reviewed research that supports your position. I think that sometimes all of us are prone to ignoring science when it doesn’t support our own beliefs. But science doesn’t care what our opinions are. And I’m also curious as to how pointing out the details in terms of the research that has been done on hormones and PPD could be harmful to women?

  • Louise

    Jane, inherent with disagreeing with someone is the belief that the other person is wrong, so I’m not sure what your point is. But I am curious to see the peer-reviewed research that supports your position. I think that sometimes all of us are prone to ignoring science when it doesn’t support our own beliefs. But science doesn’t care what our opinions are. And I’m also curious as to how pointing out the details in terms of the research that has been done on hormones and PPD could be harmful to women?

  • Phil_Hickey

    Jane,

    Thanks for coming in. I appreciate your input. You don’t specify the part of my post that you disagree with, so it’s difficult for me to respond.

    As these are important issues, I would very much appreciate if you could come back and be more specific. It may be that I am wrong, and I would certainly be willing – indeed happy – to review any information or argument that you send my way.

    Best wishes.

  • Phil_Hickey

    Louise,

    Thanks for coming in. It is widely assumed that women in the postpartum period become depressed because of “hormones.”
    Personally, I think this assumption is actually prejudicial towards
    women, in that it assumes that there is something weak or flawed about the female condition. Even if there were no evidence one way or the other, it seems to me from an evolutionary point of view that it would be more likely that postpartum hormones would have positive rather than negative effects. The notion of the postpartum woman stricken helpless by her own hormones is, in my view, a very negative and potentially destructive stereotype.

    Once again, thanks for coming in, and best wishes

  • Lucy Johnstone

    I wanted to add to the debate speaking as a woman, as someone who has had 2 children and could probably have met the criteria for ‘postnatal depression’ at various times, and as a psychologist who has worked
    with many women in the same situation. I am puzzled about the strength of
    feeling behind some of the comments. As I understand it, Phil is not in any way denying the reality of the distress that women suffer. He is simply pointing out that the evidence does not support the claim that this very real distress is best understood as an ‘illness’, that is, as a condition with identified and primarily biological causes such as hormonal dysregulation, ‘biochemical imbalances’ and so on. That is just a fact, and I don’t think many psychiatrists would dispute it – we simply do not have that kind of
    evidence. And furthermore, I think Phil is right to say that this kind of model
    leaves women vulnerable to all sorts of drug-company-driven interventions that may well not be helpful – indeed may be actively unhelpful (which is not the same as saying that drugs are of no use at all.)

    I agree that there are multiple good reasons why women may feel desperately low, even suicidal, after childbirth. These include, as Phil says, poverty, lack of support and so on – but also the impossible expectations that are put on motherhood by society as a whole, not to mention the wholly artificial isolated nuclear family set-up in which we are expected to bring up babies, generally without having had the previous experience of this kind of caregiving that you might get within a more traditional extended-family societal structure. I know from my clinical experience that childbirth often has particular meanings for individuals as well – eg it can re-activate memories of abuse, or make women more aware of a painful lack of
    care from their own upbringings, which leaves them struggling to meet their
    infant’s needs.

    A mother’s role is in the wrong – the whole institution of motherhood is fraught with guilt and mixed messages that, on the one hand, leave women more liable to depression and perhaps, on the other hand, induce such a sense of failure for not ‘coping’ perfectly that we cannot bear to be challenged in our insistence that it is an ‘illness.’ That belief seems to let us off the hook, and perhaps saves us from (quite unjustified) self-recrimination. We all have a right to choose our preferred explanation. But this one is not, as far as we know, accurate, and in the end, it may not help us to recover, or to look at the wider reasons that make motherhood emotionally challenging for many women.

  • Lucy Johnstone

    I wanted to add to the debate speaking as a woman, as someone who has had 2 children and could probably have met the criteria for ‘postnatal depression’ at various times, and as a psychologist who has worked
    with many women in the same situation. I am puzzled about the strength of
    feeling behind some of the comments. As I understand it, Phil is not in any way denying the reality of the distress that women suffer. He is simply pointing out that the evidence does not support the claim that this very real distress is best understood as an ‘illness’, that is, as a condition with identified and primarily biological causes such as hormonal dysregulation, ‘biochemical imbalances’ and so on. That is just a fact, and I don’t think many psychiatrists would dispute it – we simply do not have that kind of
    evidence. And furthermore, I think Phil is right to say that this kind of model
    leaves women vulnerable to all sorts of drug-company-driven interventions that may well not be helpful – indeed may be actively unhelpful (which is not the same as saying that drugs are of no use at all.)

    I agree that there are multiple good reasons why women may feel desperately low, even suicidal, after childbirth. These include, as Phil says, poverty, lack of support and so on – but also the impossible expectations that are put on motherhood by society as a whole, not to mention the wholly artificial isolated nuclear family set-up in which we are expected to bring up babies, generally without having had the previous experience of this kind of caregiving that you might get within a more traditional extended-family societal structure. I know from my clinical experience that childbirth often has particular meanings for individuals as well – eg it can re-activate memories of abuse, or make women more aware of a painful lack of
    care from their own upbringings, which leaves them struggling to meet their
    infant’s needs.

    A mother’s role is in the wrong – the whole institution of motherhood is fraught with guilt and mixed messages that, on the one hand, leave women more liable to depression and perhaps, on the other hand, induce such a sense of failure for not ‘coping’ perfectly that we cannot bear to be challenged in our insistence that it is an ‘illness.’ That belief seems to let us off the hook, and perhaps saves us from (quite unjustified) self-recrimination. We all have a right to choose our preferred explanation. But this one is not, as far as we know, accurate, and in the end, it may not help us to recover, or to look at the wider reasons that make motherhood emotionally challenging for many women.

  • Kristen

    Lucy – Thank you for that. You hit the nail on the head.

  • Phil_Hickey

    Lucy,

    Thanks for coming in. I agree with everything you say. I think family size is also a factor. I was the second of six siblings, and routinely helped my mother with baby care matters for my younger siblings. Rather I thought I was helping her. In reality, I suspect that she was training me for future responsibilities.

    And to guard against misunderstandings, I’m not advocating a return to large families. I’m just pointing out that a natural training experience of the past is no longer available to most people.

  • I think the objections to the original article had to do with the comment that “what mothers suffering PPD need is a cup of tea and help with chores.” That really does generalize and minimize. Many mothers need intense therapy, some even need impatient treatment. Whether you call it a disease or not, your comment sounded dismissive to people with real suffering.

  • Phil_Hickey

    story3girl,

    Thanks for coming in. It wasn’t intended that way, but the remark does come across as flippant, and I will remove it.

    Thanks.

  • Francesca Allan

    I don’t have children so I might be criticized for commenting but I’m wondering if post partum depression is similar to the post marriage depression that I experienced. I was readjusting to a very new way of life (at the relatively advanced age of 35) and everybody kept telling me how happy I was. The subtle but still palpable pressure of my friends’ and family’s expectations in this regard had a dampening effect on my mood.

    I certainly don’t think it harms women to look at the post partum diagnosis and treatment paradigm with some skepticism. In fact, I think it helps them because more information is always helpful. I sense a lot of defensiveness in some of the comments here.

  • Phil_Hickey

    Francesca,

    I think there’s a profound general truth in here also: that a lot of unhappiness stems from trying to live up to other people’s expectations. It’s often difficult to spot, because the “other people” are often loved ones who are “only trying to help.”

    Babies are great, but in those first few months they can be extraordinarily draining and burdensome.

  • cledwyn bulbousons

    “In my original post I mentioned the websites Postpartum Depression and Postpartum Support International, and recommended that they be viewed on “an empty stomach”. This was undignified and inappropriate.”

    I disagree. It should be viewed on an empty stomach.

    The problem I have with the diagnosis of depression, and its many subcategories, is, apart from its being a complete load of unmitigated bollocks, is the notion that we should be happy and deserve to be happy, or that there is such a thing as a person who is happy, fundamentally built into the concept (many people claim to be happy, but I agree with the ancients who said that one is never aware when one experiences those all too fleeting glimpses of happiness, and that there is an incalculably large, unbridgeable gulf between the belief in one’s happiness and real happiness).

    On the point of man’s belief that he deserves to be happy, man, as soon as he pops out of the womb, develops the notion that he is entitled to happiness, because of his self-love, whereon his claim rests and from whence his self-pity comes at being miserable.

    Yet when you see what it is a man’s nature is composed of, it boggles the mind that he could entertain such a notion, as much as it perplexes when men talk of an afterlife because, in truth, the average man (and perhaps even the very best of us) is no more worthy of salvation in some celestial sphere than he is the sublunary bliss he presumptuously and without justification thinks is his due.

    In truth, man is the least deserving of happiness, which is why so many religions have framed human suffering as an atonement for the corruption of his nature (which is not to say that human suffering, in its more extreme forms, is justified, especially the suffering visited upon one man by another, merely that we don’t deserve to be happy).

    It is only in man, for example, that you find schadenfreude. It is only in man that suffering is inflicted purely for the pleasure of it, whereas the other animals, in inflicting suffering, are entirely concerned with the procuration of that upon which they depend for their subsistence. It is only with the man that the notion of rights and the state needed to be invented to protect each man, especially the weakest, from the predations of his fellow men.

    Then there is the hypocrisy of man, his vanity, the morbid delectations he entertains, his irresponsibility, his vengefulness, his lust for power, and his avarice.

    Nevertheless, to the self-help movement and the mental health movement, self-esteem and self-love are the supreme good, then again, people in whom at least many of the foregoing peculiarities, peculiarities which render our claims to happiness so fraudulent, have attained to their highest degree and fullest concentration, that is, the kind of person one regularly encounters in the aforesaid movements, people such as these would believe that, because if it wasn’t for the fact that they possess these in such great abundance, the shame they should feel would submerge them.

    As usual, it is we depressed people who are closer to the truth. I mean, people try to pathologize my misery, saying that my belief that good things rarely happen to me is a symptom of my unproven illness, yet the belief amongst depressed people that good things don’t happen to them is not a symptom of illness but part of that person’s intuitive and discursive understanding of the world, himself and life, both of which rests upon the foundation of a man’s experience of life and and those he comes into contact with, experience which has imparted to him the knowledge that for most people the things they desire never happen, and that which they desire not to happen, does happen, because of which, many of us rightly live without hope, which is a much safer bet than to live with it, because hope is little more than the guarantor of future disappointment and disillusionment, whereas hopelessness is insurance against them.

    These industries preach self-esteem and self-love (which, by the way, are not unconditional goods, but at the root of our culture of entitlement and its corollary, human irresponsibility, as well as so much conflict and violence), as if we should love ourselves, regardless of how much we betray each other, how much we use each other, how much we demean each other, how much we lie to each other, and how despicably we live our lives.

    Picking up the thread of my original point, no, we don’t deserve to be happy. That we believe this to be the case is a mere symptom of the prelapsarian delusions we entertain, of our blindness to our own nature.

    Indeed, it perhaps could be said that the degree to which we deserve happiness and the extent to which we believe we deserve happiness stand in inverse ratio to each other, that they are like two scales in a balance. You see this all the time. Bad people are the quickest to bemoan their fate (which has usually been merciful to them in a way that it rarely is to good people), to take refuge in self-pity, whereas good people, no matter how good they are, flagellate themselves for the simple sin of being human always, the shame of which magnifies their misery, because behind his self-pity, there is the belief that, given who we are, and the lives we lead, we deserve no better.