What are perinatal mood disorders?

Advocates of industrial androgyny say pregnancy is not an illness. Well, neither is busting a femur or ripping open a scrotum on a fishhook, but that doesn't mean it's not a good idea to keep still for a while afterwards.

Emma Tom

During pregnancy many women experience at least some depressive symptoms and around 10 per cent are at risk of developing a clinical 'syndrome'. A similar number of women are affected during the postnatal period, too. Following the birth, and particularly in the next days or months, women are vulnerable to fluctuating moods, including:

• the baby blues

• depressive reactions brought on by adjustment difficulties

• non-melancholic depressive syndromes, that is, as later depressions brought on by the stressful situation rather than caused by a chemical imbalance in the body

and several more biological conditions (that is, those caused by chemical imbalances rather than stress, although they can still be be worsened by stress), including:

• melancholia or melancholic depression

• puerperal psychosis (or psychotic depression)

• bipolar disorder.

Postnatal depression (PND) is usually non-melancholic (that is, caused by stress rather than a chemical imbalance) but in about 10 per cent of cases is melancholic (for more, see 'Postnatal depression' below). Postnatal disorders can, while present and if severe, interfere with the bonding and attachment of mother and her baby and impose strains upon the parents' relationship, as well as cause distress to the new mother herself. A depressive episode is also marked by decreased confidence, which can create secondary problems, and may also drive feelings of irritability and anger. All such mood disorders — apart from the baby blues and puerperal psychosis — can occur at other times of life and display the same clinical features, but doctors will tailor their treatment choices differently when a woman is pregnant or breastfeeding.

The following 'map' of the perinatal mood disorders may help you determine whether you're in the territory of perinatal mood disorders or not. The geography of motherland seems deceptively familiar until you get there.

THE TERM 'PERINATAL'

In this book we use the term perinatal to refer to the time from the start of pregnancy to the end of the baby's first year.

The strict definition used for statistical purposes by the Australian Institute of Health and Welfare classifies the perinatal period as starting at 20 completed weeks of gestation and ending at 28 completed days after birth.

DEPRESSION: AN OVERVIEW

One day I was at home alone with the kids. I was exhausted and on the verge of tears. My 3-year-old climbed onto my lap and took my face in his chubby little hands and said, 'Don't worry, Mummy.' It was my awakening. At last I could admit to myself that I had a problem.

Zara

'Depression' is a word that is used loosely. It is used to describe everything from mood states to economic recessions, so a diagnosis of depression is diffuse and liable to variable interpretation and misinterpretation. Depression is, in essence, a term more comparable with 'pain'. It is a marker of superficially similar but actually quite diverse entities. When the term 'depression' is used to describe a mood state it needs to be more closely defined. For instance, it is important to differentiate between 'normal' depression (or everyday temporary unhappiness) and clinical depression — in the same way a dermatologist would be expected to distinguish a benign mole from a melanoma — as it influences the type and success of treatment.

Signs and symptoms of depression

Someone with depression feels down and hopeless, helpless and pessimistic, but one key symptom is a drop in self-esteem and, correlated with that, an increase in self-criticism. This decline in self-regard distinguishes depression from other conditions such as grief, sadness or anxiety.

Grief is the distress felt following usually irretrievable loss and separation, when an attachment bond is broken. While grief can be severe and disabling, it is not accompanied by a drop in self-esteem. Sadness is an emotional reaction to losses or disappointments, a feeling of being down and unhappy, that dissipates within days and self-worth is rarely diminished. Anxiety is essentially a state of insecurity or fear and hyper-arousal. People with depression (including PND) are frequently anxious (and anxiety can set the stage for depression), and some people who are grieving will later develop depression, but clarifying the primary emotional state is the best way towards effective treatment.

The Edinburgh postnatal depression scale (EPDS; see Chapter 3) is a widely used screening instrument for postnatal depression. As the instrument includes anxiety as well as depression items, a percentage who score positive will do so due to having a primary anxiety rather than a primary depressive condition during the postnatal period.

ANXIETY AND PANIC ATTACKS

A new mother has to traverse some very unfamiliar territory, which can be more than somewhat overwhelming. Many women already have lifelong anxious tendencies, but when anxiety becomes more prevalent than feelings of wellbeing, something else is going on. As many of our essayists attest, a baby provides a focus for intense worry and anxiety-based preoccupations.

Most people never experience a panic attack, although they would recognise the symptoms, which are the feelings people experience when they're frightened or under threat — the so-called 'flight or fight' response. A panic attack seems to come from nowhere, though. Feelings of panic and terror build up and intensify to such a degree that the sufferer may feel like they're having a heart attack or a stroke or like they're literally going to die. Symptoms include tightness in the chest, chest pains, a racing heart, dizziness and breathing too fast, tingling all over, numbness, weakness, sweating and muscle cramps. A panic attack is so unpleasant that it can create a feedback loop, where feelings of panic increase the feelings of panic. Nevertheless, people can have panic attacks and not recognise them as being a symptom of a mood disorder. They think they're going mad or have some terrible physical disorder but don't consider the attack as indicating that something is...