It is said that 70-80% of newly delivered mothers experience some degree of the ‘baby’ blues, a short-lived disturbance of mood and emotion, usually lasting no more than 7-10 days. But as most mothers and their carers do not regard these feelings as unusual, specific treatment is not often asked for, nor required.
The symptoms are not surprising, given the intense and mixed emotions that a mother may suddenly feel on the birth of her baby, especially a firstborn; feelings of overwhelming love and protectiveness; and/or terrifying responsibility and fears for the future. If exhaustion has occurred, then feelings of guilt or inadequacy for not feeling the first of these may arise, only to disappear once she has recovered. If there is no past history of depression or other mental illness, then a positive and supportive cast of family and friends is all that is needed.
The cause or ‘trigger’ here is thought by many to be related to the precipitous drop in the mother’s progesterone level after the separation of the placenta, which is responsible for raising it as much as 50 times its normal value during the pregnancy itself. There is some disagreement about this in different quarters of the medical profession, as oestrogen shows a similar (but less dramatic) fall, and there are other factors also to consider. I will address this further in Part 2 of this article.
Longer lasting, at the next level of seriousness, is PND or Postnatal Depression. This is much less common, occurring in 1 in every 10 births. Although this means that while each family doctor will only see an average of 2-3 cases a year, the total number of women suffering some form of this condition every year in England and Wales is in the region of 70,000! The symptoms are similar to ordinary, everyday depression, but influenced in addition by the particular conditions of the postpartum period. These of course can also lead to depression in a vulnerable husband or partner.
Apart from the misery experienced by these mothers, and the knock-on stress and unhappiness by partners and families, this also creates a serious potential disruption in the bonding process between mother and baby. If she is not fully present mentally or emotionally in the first 9-12 months of the baby’s life, this can lead to problems of self esteem and the ability to relate to others, which in turn has an effect on the child’s future chances of achieving fulfilment in work and love.
In more extreme cases, self-destructive ‘borderline’ and narcissistic personality disorders can develop, with painful consequences for the growing teen and young adult, the family and all that come into contact with them. This is well covered by Dr James F Masterson in his book ‘The Search for the Real Self’. In a way, all the fundamental problems of life start here, with the cycles of difficulties being passed on from one generation to the next.
In addition, symptoms of the mother’s depression may be hidden by a ‘bright’ exterior from family and friends until in the most severe cases the devastating reality of suicide comes like a bolt out of the blue. In the past I have spoken in depth to several women who fortunately failed in their attempt, recovered fully, and were aghast at what they so nearly had done.
On each occasion the pattern was the same: overwhelm, confusion and depression was robbing them of motivation until they seemed to be ‘pulling out of it’ and the family began to relax. But behind the lighter facade there came a point where it became SO clear to them that their lives were of no value, that their husband and even their children really would be better off without them. At this they felt great peace, becoming even more able to hide their very clear intentions.
This seems likely to have been the case in the very sad and well-publicised suicide in 2009 of the ‘exceptional’ London lawyer Catherine Bailey, who 6 months after giving birth, and less than a month after returning to her very demanding work, left behind her husband and three daughters under the age of six. Leaving behind also, no doubt, hearts full of troubling thoughts of ‘what if?’ and ‘if only’.’Tragic’ may have become somewhat diluted by over-use, but these events are indeed tragic, in the very fullest sense of the word.
The third degree of postpartum illness is known as Puerperal Psychosis (from the Latin ‘puerpera’ – woman in childbirth). This is much rarer than PND, occurring in only 1 or 2 mothers per thousand, so an individual G.P. may see only 2 or 3 cases in a working lifetime, out of an official incidence of 700-1400 in the U.K. a year. A tiny proportion of the number of births (0.1-0.2%), but contributing disproportionately to the sum of human pain.
This depression is usually sudden and acute, sometimes immediately after the birth. Persisting anxiety, insomnia and agitation are early signs, followed by suspicion, confusion, bizarre thoughts and sometimes rejection of the baby. In more extreme cases mania or schizophrenia-like symptoms may appear, with paranoia, delusions, hallucinations and an irrational disconnection of thought and feeling. Thus the mother may feel she loves her baby so much she must roast him in the oven. Or she may struggle to resist horrifying thoughts of murder, but never confide these to anyone for fear her child may be taken away. The most extreme form of psychosis may lead not only to suicide, as in PND, but even to the killing of her baby, her partner, family, friends or even strangers. The late Dr Katherina Dalton’s book ‘Depression after Childbirth’, still in print, is a ‘must read’ if you have an interest in exploring this subject more deeply
My first of only two experiences of postpartum psychosis during my time in general practice was of a young mother who, normally gentle, quiet and conscientious, overnight on the 3rd day became first cousin to Linda Blair in the film ‘The Exorcist’, but fortunately without the revolving head and all the green stuff. However she had supernatural hearing and emitted a force that at first had me backing out the front door with my doctor’s bag held out in front of me as a shield. Happily, after two days of progesterone pessaries, she was completely back to her normal self, offering me a cup of tea, and enquiring if I was “alright now”!
Puerperal psychosis is a much more dangerous condition than PND. It is much more difficult for carers and family to deal with. There is always the possibility of violence to self, baby or others, and for these reasons urgent hospital admission is usually the best option. Especially because it is often impossible to be sure of what is going on in the mother’s mind.
When I worked in hospital obstetrics I became very aware of the extremes of possible experience in this field, from joy and elation to deep distress and tragedy. It is a very good thing that the former are much more common. But truly ‘All of Life’ is here in a microcosm.
Next time, in PART 2, I’ll explore the ‘Why?’ of postnatal illness; how it may be prevented and best treated; and I’ll also attempt to make sense of all the conflicting ideas on these topics…