It’s delicate terrain for women struggling with their mental health during the trials of new motherhood. In some cases, psychiatrists suggest drug-based intervention is the safest option.
A new mother’s life is a minefield of chaos and conundrums she must navigate with much less energy, sleep, and patience than she’s likely ever had before. Her body transforms and her social life is turned completely on its head. Routine is thrown out the window. Tasks that appear simple on the surface — like assembling a formula bottle — become insurmountable obstacles. And then there’s the pressing issue of keeping a tiny, helpless human alive.
With so many major changes taking place at once, it’s no wonder postnatal depression (PND) is difficult to detect, not only for the mother, but for health professionals too. While many mothers attribute symptoms they are experiencing, such as tiredness, to other parts of their lives, health professionals can also struggle to recognise when normal transitional adjustments tick over into PND. This is just the first hurdle for women to face before they can get started on a treatment journey.
Symptoms of PND include, but are not limited to, anxiety, inability to cope, negative and obsessive thoughts, crying, feelings of guilt and inadequacy, and a loss of confidence and self-esteem. To experience any combination of these symptoms would be devastating for anyone at any stage of life, but for a new mother who is trying to meet the demands of her new around-the-clock role, it is incredibly debilitating.
What’s causing this?
PND can strike during pregnancy (antenatal depression), suddenly after birth, or in the weeks, months, or year after birth. It can happen after miscarriage, stillbirth, normal or caesarean delivery. And it can occur after any pregnancy, though first child is most common. Pregnancy is the common factor, and with 1 in 7 women in Australia developing PND, the questions beg to be asked: what is happening in a woman’s body during pregnancy that affects the brain in such a profound manner? Why are pregnancy and depression so intimately linked?
“Fluctuations in circulating oestrogen and progesterone can cause marked effects on central neurotransmission, specifically serotonergic, noradrenergic and dopaminergic pathways,” said perinatal psychiatrist Dr Juliana Lo Ming.
While serotonin is the neurotransmitter involved in maintaining mood balance, dopamine is important for motivation, decision-making and working memory, and norepinephrine plays a role in learning, sleep, memory and emotions.
Literature has long maintained that sex hormones affect neurotransmitters during hormonal transition periods, making women more predisposed to depression than men. With pregnancy comes elevated levels of both oestrogen and progesterone to develop and tolerate the foetus respectively, but soon after birth, the levels of both these hormones plummet to enable the production of the baby’s first meal: colostrum.
With oestrogen involved in the synthesis of both serotonin and dopamine, it is not difficult to see how a new mother’s neurotransmitter levels can be thrown off-kilter, creating optimal conditions for depression to set in.
However, whether a mother actually develops PND does not depend solely on this biological and hormonal interplay. Dr Lo Ming explained that PND is born of multiple factors including psychological state, genetic vulnerability, and social/environmental circumstances.
Some women with PND are advised by their doctor to take medication to relieve their symptoms. According to Dr Lo Ming, the most commonly used drugs are selective serotonin reuptake inhibitors (SSRIs), which block the uptake of serotonin back into the brain cells, subsequently preventing the neurotransmitter from being inactivated, which in turn increases the amount of serotonin available in the brain. Fluctuating levels of oestrogen impacts the production of serotonin, so treating this issue at the fundamental level with a drug that “reduces the recycling of serotonin,” as Dr Lo Ming put it, is an effective way to address symptoms.
While Dr Lo Ming conceded that drugs are not the be all and end all when it comes to treating PND, she believes that there are specific signs that signal a mother would benefit from a drug-based intervention.
“The core issues would be a prolonged period of illness with no response to psychotherapy or cognitive behavioural therapy; a risk to the mother or baby, for example, increasing suicidal or infanticidal thoughts; an inability to work or care for the child; poor self-care; and relationship decline between mother and child.”
Many mothers Dr Lo Ming sees are motivated to nip their depression in the bud, and will do what it takes to do so. However, there is another group of women who are hesitant to take the drugs that would help them manage their situation. On the surface this might seem strange — after all, sufferers of high blood pressure take ACE inhibitors to widen arteries and lower blood pressure. Diabetics inject insulin, and coeliacs avoid gluten. But when it comes to mental illnesses like PND, sufferers are stalling. Why?
Dr Lo Ming claimed that the hesitant camp is split into two. On the one hand there are women who have limited knowledge about medication. They worry about the drugs harming their baby in utero (if they are suffering from perinatal depression), passing through to their baby during breastfeeding and causing neurocognitive effects, becoming addicted to the drugs, or having to remain on drugs for life. The second camp is slightly more complicated.
“Society has increasing expectations of mothers to be able to care for their families and children, work, remain emotionally intact, and be a ‘perfect mother’. As women, we also place some of these pressures on ourselves. This can limit a parent's capacity to engage in and agree with drug-based treatment, as often stigma and society's expectations can make a mother feel it is her own fault for not being able to stay happy and be a ‘good’ mother,” Dr Lo Ming explained.
These perceptions lead to medication during pregnancy being feared or shunned, which isn’t helpful — not only for those who are in need of a drugs-based intervention, but also for those who are already taking an antidepressant or other psychotropic medication. In fact, mental illness can be so detrimental to a mother’s (and therefore her baby’s) wellbeing that in many cases an expecting mother will be advised to stay on medication, despite potential risks to her unborn baby. Dr Lo Ming backed this course of action.
“It does depend on the individual's illness, but illnesses like depression, schizophrenia, and bipolar can have a significant impact on one's life. Some individuals disengage with their support network, or become suicidal when unwell. Patients who clearly relapse when untreated and have a clear history of becoming very unwell should try their best to remain on a known treatment,” Dr Lo Ming said.
Society has a lot to answer for when it comes to the mental health of our mothers. One aspect of the issue is the way motherhood is portrayed: as an intuitive, natural and fulfilling role, which is not true for everyone. The other aspect is the pressure society puts on mothers to cope. As a result, when women do not automatically and inherently know what to do as a new mother, and do not meet expectations on how they should feel as a new mother, they perceive themselves as failures.
Not only should we be deconstructing these dangerous mothering myths, it is Dr Lo Ming’s belief that our responsibility extends to supporting new mothers too. She pointed out that in many third world countries, generations of families live under the same roof, support each other and care for each other, while in Australia young families travel to larger cities for work opportunities, leaving the mother isolated, with only her working partner for support.
“In an ideal world there would be paid parental leave, taking the pressure off mothers to return to work, and instead spend time caring for their children and becoming familiar with parenting. There would also be flexible working hours for men, and a supportive working environment to allow access to alternative working conditions for mothers,” said Dr Lo Ming.
At the very least mothers should feel comfortable seeking the help they need, whether it be drug- or talk-based. However, this will only happen when the social constructs of motherhood are expanded to show women that mothering is not the same for everyone.
There are mothers who radiate joy, and mothers who do not. When one considers that biology, genetics, psychology, and environment — complex factors in themselves — differ from mother to mother, then this is to be expected. A depressed mother is just another type of mother — another type of normal.
As a community, we have a responsibility to overcome idealised notions of motherhood and standards of perfection beyond the reach of most mothers. Media campaigns are pivotal in targeting mothering myths and overcoming stigmas attached to seeking help.
In a world that is becoming increasingly obsessed with the ‘dangers’ of medical science, it is important to remember that, in some cases, drugs are actually helping us mum, and society should accept that if drugs are what a mother needs, they are precisely what she should get, along with respect, support and no judgement.
As Dr Lo Ming said: “If you look at mothers being the carers of our future generations, then taking care of them is a societal responsibility. Our future society will be made up of our children, and so raising them is an important job, isn't it?”
Edited by Deborah Kane, and supported by Elia Pirtle.