Because I had to take a break from blogging while moving (which, may I say, is such a HUGE, FREAKING NIGHTMARE!!), I missed out on sharing with you a few more letters written to Timemagazine by some amazing advocates for women with PPD. So I must share them with you now, because their voices are so important. Still waiting to see if Time prints any of our letters to the editor, or if they ignore the issue completely ...
Dear Editors at Time Magazine:
As a maternal-newborn clinical nurse specialist, coordinator of a Postpartum Emotional Support Program, and most importantly as a mother, the article "Postpartum Depression: Do All New Mothers Need Screening?" hit several nerves. As a nurse and educator in my role I am compelled to shed some light on the facts that were overlooked by this recent article. As a mother and advocate for women suffering from postpartum depression, I feel the need to jump up and down to get people to start paying attention to the fact that perinatal mood disorders have a strong biologic component, place an enormous strain on the family unit and have the potential to be lethal.
The Maternity Center at Elliot Hospital in Manchester, New Hampshire, does about 2200 births per year. We help women achieve their dream of becoming mothers and transform couples into families. We have a level 3 NICU, can manage the most noninvasive natural labors to the more high-tech delivery of multiples and obstetric complications. We have formed multidisciplinary workgroups to implement simulation training and communication processes to make certain that as a team we are functioning like a well-oiled machine. The guidelines, algorithms and policies under which we function serve as a "safety net" or contingency plan for when labor and birth do not follow the expectations of a normal, uncomplicated delivery. Yes, we operate with our life preservers on, not that we always need them, but they sure come in handy if we start to enter choppy seas.
But this is only the first step in making a mother. We forget that as we launch these new mothers into the world, they are often quite unprepared for what comes next. There isn't always a safety net in place for the reality of how challenging the transition to motherhood can be. While our society gets caught up in the perfect stroller, diaper bag, crib and baby room decor, no one talks about the chaos that comes after we send this new family home. Trust me, it is less than perfect. Parenting is not a perfect science, and here's a secret: there are no "perfect mothers".
After birth there is a dramatic drop in the hormones of pregnancy. This, along with the cumulative effects of countless sleepless nights can cause a shift in the brain chemistry and may contribute to mood swings, anxiety and/or depressed mood. There are a number of psychological factors that go along with becoming a mother. Mom is learning, the baby is learning and it takes time to adjust to this new role and bond with the baby. This is all met with the normal life stressors of finances, job concerns, family issues and/or a lack of family and friends who live nearby to help. When one is trying to juggle it all, along with learning how to care for a newborn (or balance a newborn in the context of meeting the needs of OLDER children), this can feel very overwhelming.
Over 80% of women will experience the "baby blues", which are a normal period of high and low emotions during the first several weeks following birth. Postpartum depression or other mood and anxiety disorders occur at least 20% of the time, and can occur anytime in the first year after birth. Constant, intense feelings of sadness, worry, nervousness and emptiness that lasts 2 weeks or more, and affects areas of the mother's life like sleep and changes in eating habits, is an illness that requires medical help. Some women with PPD also have recurrent, disturbing thoughts that can lead to a high level of anxiety and is called postpartum obsessive compulsive disorder. Postpartum psychosis is rare, affecting only ~1 in 1000 women and occurs most often during the first four weeks after delivery. These women are severely impaired and may have paranoia, mood shifts, or hallucinations that command her to hurt herself or others, and usually requires immediate hospitalization. Women suffering from PPD often need medication to treat the biology in the brain, talk therapy to discuss some of the changes in feelings they are having, and support from new moms groups or PPD support groups to have a safe place to share what they are going through with other mothers in similar situations.
I find it outrageous that the interpretation of the MOTHERS Act by Catherin Elton is to assume that this bill would simply support prescriptive proactive or psychotropic drugs and "lead to an increase in mothers being prescribed medication unnecessarily" and "simply contribute to the potentially dangerous medicalization of motherhood." The goals of the MOTHERS Act are similar to many other preventative initiatives such as those developed by Healthy People 2010 from the U.S. Department of Health and Human Services.
Are the disease prevention and health promotion objectives for obesity, diabetes, asthma, cancer and heart disease and stroke ALL based in pharmacologic management? Absolutely not! Physical activity, nutrition, risk-taking behaviors, and smoking cessation are components of the care plan and preventive strategies for these diseases. A healthcare provider who would simply prescribe a lipid-lowering agent and a beta blocker for a patient with high cholesterol and a previous myocardial infarction without providing counseling on a diet, exercise, and referral to a nutritionist and cardiac rehab would be amiss in providing a comprehensive treatment plan.
Any of the experts in the field of perinatal mental health will tell you that you can't rely on just one type of intervention to treat postpartum depression. Pharmacology is just one piece of the puzzle. A healthy dose of endorphins from daily exercise, relaxation/meditation, light therapy, fish oils, a balanced diet, counseling, support groups and avoidance of caffeine and alcohol are just a few of the various interventions that can be beneficial in treating PPD. Popping a pill every day is not going to help the new mother if she does not have a good sleep hygiene schedule or can't ingest adequate nutrients secondary to her diminished appetite. Nor will aerobics classes or yoga and meditation around the clock "will away" the guilt of scary, intrusive thoughts the mother might be experiencing. Each individual is going to respond to a healthy mix of more than one type of interventionaddressing the areas of biological, psychological and social support for PPD. The MOTHERS Act supports the research and education of clinicians and families in ALL of these areas.
The national governing organizations for perinatal nurses and OB-GYNs also support the objectives promoted by the MOTHERS Act. The Association of Women's Health Obstetric and Neonatal Nurses' (AWHONN) position statement on "The Role of the Nurse in Postpartum Mood and Anxiety Disorders" states that "Health care facilities that serve pregnant women, new mothers and newborns should have routine screening protocols and educational mechanisms for staff training and client education related to postpartum mood and anxiety disorders."
On May 6, 2009, Gerald F. Joseph Jr. MD of Louisiana became the 60th president of the American College of Obstetricians and Gynecologists (ACOG). Dr. Joseph announced that postpartum depression is the theme of his presidential initiative. He emphasizes the need to develop evidence-based guidelines for ACOG members in the areas of screening, identification, counseling, treatment, referral to specialists and development of community-based resources for women suffering from PPD. He, too, is taking a multifaceted approach to addressing the multidimensional needs of perinatal mood disorders. Nowhere do I see it suggested that we develop a recipe book of SSRIs and anxiolytics to be distributed to healthcare providers as a quick fix to treat this problem.
Our organization recently implemented an Inpatient Postpartum Depression Risk Assessment. An 11-item questionnaire is distributed to EVERY new mother who delivers, and screens them into a risk category for developing PPD. This screening tool identifies risk factorsand does not indicate that a woman will definitely experience PPD. Just like someone who smokes, is obese, has high blood pressure and a family history of cardiac disease is at higher risk for a heart attack, these PPD risk factors simply indicate that one might be at a higher risk for the illness. The "at-risk" moms view a PPD video, receive more in-depth PPD education, get follow up phone calls at home, are offered Visiting Nurse visits and are invited to attend weekly New Moms Groups and the Postpartum Depression Support Group. In our first month of screening, we had patients screen out as 46% low risk, 21% moderate risk, 30.5% high risk and 2.5% immediate risk. More than HALF of all of the new mothers who delivered had some increased risk for PPD. I don't believe that is something that can be ignored.
When screening for depression in the healthcare setting is based on clinical observation alone, 50% of women suffering from depression are missed (Wilen and Mounts, 2006). We cannot rely solely on clinical judgment. Obstetric providers are encouraged to screen for current symptoms of depression with a validated tool such as the Edinburgh Postnatal Depression Screening Scale during follow-up visits. Our intention is to help moms become aware of the factors that can potentially make them vulnerable to PPD so they can mobilize their support network and make use of available resources. By screening universally, we hope to reduce the stigma of perinatal depression by encouraging healthcare providers to take about it as a common complication of childbirth.
PPD is very treatable. Many women do not want to admit that they are having a hard time after having a baby. It is supposed to be a happy time of their lives! In reality it is also a major time of change and role adjustment to essentially the most difficult and important job that anyone can do. If you had diabetes you would see an endocrinologist, take insulin and no one would tell you to "snap out of it". Your brain is an organ. We shouldn't treat the mind any differently. The process we have initiated at our organization is our way of providing the family with their own life preserver, and letting them know that they are not alone as they embark on those unchartered seas called "parenting". Time, I'm sorry to say you missed the boat on this very important issue.
Alison Palmer, RN, MS, WHNP-BC
Maternal-Newborn Clinical Nurse Specialist
Postpartum Emotional Support Program Coordinator
Manchester, NH
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