The Globe and Mail

When a woman's world comes tumbling down
Postpartum depression affects not only
mothers, but infants and partners, warns
Dr. Gabor Maté. Early diagnosis is crucial

Dr. Gabor Maté

Tuesday, August 15, 2000

Postpartum depression is thought to have been a factor in last Friday's tragedy in which a Toronto woman, clutching her six-month-old baby, threw herself in front of an oncoming subway train. The condition hardly ever extends to such suicidal and murderous despair, but in its common forms it still takes a toll on women's health, family life, and infants' development.

Postpartum depression is a dark night of the soul that descends on the woman at the very time when she is expected to feel the greatest delight and satisfaction -- during her child's first year of life. The discrepancy between how she feels and the conventional picture of joyful motherhood is confusing. Shame is a hallmark of postpartum depression, and may be one of its first signs. "I have a beautiful baby and a wonderful husband. There must be something wrong with me if I can't be more happy," is the usual formulation of that shame. Such words ought to ring alarm bells in the minds of doctors, spouses and friends. So should other symptoms, which may include insomnia, extreme fatigue, loss of appetite and a depressed demeanor. There may be panic attacks or extreme anxiety around the well-being of her infant.

But despite the fact that the disease occurs in as many as 20 per cent of new mothers, it can be missed. Physicians often lack what in medical language is described as a "high index of suspicion" for the condition -- an alertness to the possibility of its presence. The woman may force herself to show a cheerful face to the world. Or, if the sadness is overwhelming, she may conclude that she is unfit to be a parent. "I tried to return my first kid to the hospital because I was crying all the time and was convinced I couldn't mother him properly," a professional woman in Toronto told me recently.

An almost universal symptom of postpartum depression is the mother's perception that there is no one in the world with whom she can discuss her feelings without being misunderstood or judged. Some fear that their baby will be taken away if the truth were known about how they really feel.

While hormonal changes accompanying childbirth and its aftermath play a role as important triggers, they cannot by themselves explain postpartum depression. More than simply a biological disease of the woman, the condition also represents a problem in the spousal partnership in which she, at that stage in life, is the more vulnerable member.

It was this way in hundreds of postpartum depression cases I have treated. It was this way, too, in the case of our marriage when my wife suffered a severe postpartum depression. I was unable to see then how my own problems contributed to hers.

Whether the couple realize it or not, in many relationships there is a major upheaval in the emotional dynamics between husband and wife upon the arrival of their child. If the couple have not have yet fully matured into autonomous, emotionally differentiated beings (as can be true at any age), the wife may have provided a kind of mothering function, meeting the man's needs for nurturance. When the baby arrives, her emotional energies and nurturing instincts must all flow toward the infant, as nature intends it.

The husband, unconsciously, feels a sense of abandonment. He may be dutiful, but he subtly withdraws. The woman, whose own needs for emotional support are greatly heightened in the postpartum period, suddenly finds herself bereft of adult partnering precisely when she most requires it. Less often, the husband may openly act out, expressing sexual frustration, or throwing himself into work or other consuming activities, or even finding another woman to replace the lost "mother." Whether of the subtle or overt variety, such stress affects the neurotransmitter systems in the woman's brain. In combination with hormonal influences, it can lead to biological and clinical depression.

Because of their sense of guilt, women may have difficulty sensing just how alone they feel. "But my husband is great," one young mother told me. "He's always encouraging me, always telling me that I am strong, that I will beat this." What she needed to hear was not that she was "strong," but that the husband understood just how weak and helpless she felt at that moment, and how much she needed his commitment, empathy, and unconditional acceptance.

It is important for the development of the infant that postpartum depression be recognized and treated as early as possible. A baby's evolving emotional patterns and even brain circuitry are affected by the mother's psychological states. In one electroencephalographic study, six-month-old infants of depressed mothers exhibited predictable differences in the electrical activity of their brains, as compared with the infants of non-depressed mothers. In British studies, maternal depression was associated with diminished attention spans in the infant. While these effects may be reversible later on in life, it's best to prevent such problems rather than have to deal with them in the older child or adult.

Postpartum depression is treated effectively with antidepressant medications, although these are not required in every case. What is always required is counselling and support for the woman and, crucially, for the husband. The new mother needs to know that she is neither guilty nor crazy, the victim of some unnamable, irrational unhappiness. She is not alone in her feelings; thousands upon thousands of other women have experienced precisely what she is going through. She can be helped.

Gabor Maté, a Vancouver physician, is the author of  Scattered Minds: A New Look at the Origins and Healing of Attention Deficit Disorder.