The postpartum depression aftershock

You’ve made it out of the darkness. You’re feeling good. But then it happens.

You wake up one day and notice how the walls around you are written with what they saw. They mock you: “We know what you did…” The gun safe glares at you from the closet, reminding you of the impulses you fought. You wake up every morning and walk past the spot where you had that horrible thought, to go and wake up your children that you had the horrible thought about. You feel like you’re walking within the heavy footprints of the woman you were in the darkness; the tracks of a monster. You realize that there’s no escaping your trauma. You will wake up each morning and care for the personifications of your guilt. It seems, so certainly, that it will haunt you here forever. 

Postpartum depression treatment plans will get you through the immediate suffering of PPD, but there is no referral to a marriage counselor, a child psychologist for older siblings, a life coach to help you adjust back to “you” again. There is no talk of how it will feel to look back after you step out of the darkness. How the pain, guilt, shame all stick to everything around you like pitch. You rearrange furniture, you put inspiring art of the walls, but the pitch still seems to seep through. 

I wonder if it’s time to sell the house. I wonder if getting rid of everything we own and starting fresh will erase the trauma from our lives. I wonder and wonder and wonder until I realize: It’s time for a new treatment plan.  

A condition that causes THIS MUCH wreckage for an entire family should certainly be recognized by the American Psychiatric Association (APA), no? The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), which has been referred to as “‘the bible of diagnostic criteria’ for mental health professionals and researchers, is used to determine whether a cluster of symptoms is recognized as a disorder, according to the APA.” (1) For the first time ever, in 1994, with the third edition of the DSM, major depression with postpartum onset was written into the manual. That’s right mama, not “postpartum depression”, but “major depression with postpartum onset.” The cluster of symptoms associated are all those listed for major depression, with a few stipulations:

MAJOR DEPRESSIVE EPISODE(DSM-III):

The essential feature of MDE is a period of at least 2 weeks during which there is either depressed mood or loss of interest or pleasure in nearly all activities. In children and adolescents, the mood may be irritable rather than sad. The individual must also experience at least four additional symptoms drawn from a list that includes: changes in appetite or weight, sleep and psychomotor activity, decreased energy, feelings or worthless or guilt, difficulty thinking, concentrating or making decisions, or recurrent thoughts of death or suicidal ideation, plans or attempts. To count toward a Major Depressive Episode symptoms must either be newly present or must have clearly worsened compared with the person’s preepisode status. The symptoms must persist for most of the day nearly every day for at least 2 consecutive weeks. The episode must be accompanied by clinically significant distress or impairment in social, occupational, or other important areas of functioning

Notice that only children and adolescents are allocated the symptom of irritability. Also notice that most the additional symptoms listed describe new motherhood, with or without depression.

Conditions qualifying an episode “with postpartum onset” were: “defined as within four weeks of delivering a child.” It was noted that this specifier could be applied to current or most recent Major Depressive, Manic or Mixed Episode of Major Depressive Disorder, Bipolar I Disorder, Bipolar II disorder, or to Brief Psychotic Disorder.” (1) (Note: No change was made to this in the next edition (DSM-IV))

Notice how, in order to be considered depression with postpartum onset, symptoms must present themselves within the first 4 weeks of birth. HOWEVER, we know to be true that PPD can stir up at any point in the first 18 months postpartum, and we don’t screen for PPD until a follow-up at 6 weeks. This also conflicts with the accepted definition of “baby blues” which is often described as “anything” within the first two weeks postpartum.

And now for the most recent edition: the DSM-V:

“ In DSM-5 the diagnosis of depression during the postpartum period still utilizes the onset specifier format. However the specifier has changed it is now titled “with peripartum onset” which is defined as the most recent episode occurring during pregnancy as well as in the four weeks following delivery. This official recognition of depression during pregnancy represents a significant step forward! It is however disappointing that the period following delivery was not extended to recognize that real suffering often occurs during the first year, as PSI and others had lobbied. What happened? As noted by O’Hara and McCabe in a recent review of the status of postpartum depression (2), the DSM-5 mood disorders workgroup did consider extending the four week specifier from 4 weeks to 6 months. In this review they also aptly note that, indeed in clinical practice and research, regardless of the DSM criteria, women with a depressive disorder onset within 12 months of birth are often classified as having “Major Depressive Disorder, with postpartum onset.” Yet, the workgroup decided that ultimately the available epidemiological evidence to support such an extension was not yet compelling.” (1)

So it’s here that I ask: what epidemiological evidence do you need? Because I will offer myself as concrete evidence that postpartum mood disorders are needing of their own classification.

By building a screening tool that measures these differences, we can discover the evidence necessary to make this argument. And by sharing our stories, that quality screening tool can be realized. I’m already on that mission and I hope you’ll all join me.

Resources:

(1) Segre, L.S. & Davis W.N. (2013). Postpartum Depression and Perinatal Mood Disorders in the DSM. Postpartum Support International. https://www.postpartum.net/wp-content/uploads/2014/11/DSM-5-Summary-PSI.pdf

(2) O’Hara, M.W. & McCabe, J.E. (2013). Postpartum depression: Current status and future directions. The Annual Review of Clinical Psychology, 9, 379-407.

(3) DSM-V: https://www.psychiatry.org/psychiatrists/practice/dsm