When the Blues Arrive with Baby
Santa Maria CA USA
From: NEW BEGINNINGS, Vol. 21 No. 3, May-June 2004, pp. 84-88
The birth of a baby is generally regarded as a time of great happiness. Mothers and fathers see the child they hold in their arms as the long-awaited fulfillment of their dreams.
However, new parenthood may bring emotions that are the opposite of bliss and contentment. Some experts estimate that 50 to 80 percent of women are affected by some degree of depression following childbirth (Komaroff 1999). They may feel sad, tired, and anxious. Some of this may be due to hormonal changes following childbirth. The realities of caring for a helpless infant, which include lack of sleep and a loss of control over one's own life, also play a role. For most women, these "baby blues" last only a short time, and they emerge from their postpartum haze fully able to cope with the demands of mothering.
Some women, however, find themselves enveloped in an inexplicable and unrelenting sadness. They may be experiencing postpartum depression. Symptoms include feelings of helplessness, mood swings, anxiety, inability to sleep, and a lack of interest in life (see Box #1). These feelings do not go away. They persist for weeks, and the mother seems unable to help herself get better.
Postpartum depression is but one of several mood disorders that may manifest itself following the birth of a baby. "Mood disorder" is a term psychiatrists and psychologists use to describe problems with feelings of depression, anxiety, and fear. It can also describe inappropriate "high" feelings defined as "mania." As science has learned more about the brain and how it functions, mental health professionals and the general public have come to recognize that depression and other psychological disorders are not, as was once thought, the result of character weakness or a lack of will power. Depression and other mood disorders are caused by physical factors in the brain interacting with a person's life experiences.
Depression is a fairly common illness. One in five adults will experience a major depression in his or her lifetime. The physical and emotional stresses of pregnancy, childbirth, and new motherhood can trigger depression and other mental health problems in vulnerable individuals. Postpartum depression occurs in about 10 percent of new mothers in the first year after giving birth (ACOG 1999). Other mood disorders, such as bipolar disorder (in which periods of deep depression alternate with manic periods of hyperactivity and elation), often make their first appearance during young adulthood. Thus, depression and other mood disorders affect a significant number of women during the time they are caring for and breastfeeding their babies.
Effects of mood disorders range from mild disruptions in life to severe disability and incapacitation. While the mother may often be acutely aware of something being wrong, family members are sometimes the first to notice. Some women feel persistently sad, anxious, and unhappy with motherhood. At the other end of the spectrum, women with severe symptoms may have hallucinations or delusions and a distorted view of reality.
Research has shown that a mother who is struggling with depression will have trouble being a good mother to her baby. The baby's development depends on having a responsive caregiver. Babies' brains develop their many networks of nerves and information in response to the myriad daily interactions between the mother and baby. Babies learn social behavior, language, and a great deal more from eye-to-eye contact with mother, from her animated facial expressions, vocal responses, and the like. A mother who has no energy to get out of bed or to engage her baby in "conversation" is unable to meet these needs. At the same time, the depressed mother is robbed herself of the day-to-day happiness of mothering her baby and other children.
This is why it is important to treat postpartum depression and other mood disorders promptly. The welfare of both the mother and the baby are at stake.
Treatment of postpartum depression and other mood disorders will vary according to the needs of the individual. In many cases "talk" therapy is very effective. A psychotherapist can help a mother replace false messages she gives herself ("I am the worst mother in the world") with a more realistic appraisal of herself and her situation. This type of therapy is called cognitive behavioral therapy; its goal is to help people recognize their false beliefs about the world and themselves and learn to think in new ways. Professional counseling can also help an individual build better support systems for herself and find ways to get her own needs met.
Sometimes depression is also treated with medication, which can provide excellent relief of symptoms within a relatively short period of time. It can be unwise, however, to only use medications to treat postpartum depression. Medications may help an individual feel better within a few weeks, but therapy can help that person make the life changes that can result in long-term wellness.
Caring for mothers with postpartum mood disorders presents unique challenges to health care providers, including mental health providers. Health care providers who treat mental illness include psychiatrists and other physicians who may prescribe antidepressant medication, and psychologists, counselors, or therapists who provide "talk" therapy. When they treat mothers of young infants, they have two, rather than the usual one patient to concern themselves with. Mother and baby are interdependent, especially if they are breastfeeding. They are a "dyad," meaning two units that are regarded as one. Treatment of the mother's illness must support both the mother and baby.
Many health care providers do not have training or experience in devising a treatment plan that includes the needs of both members of a breastfeeding dyad. Consequently, it is very common for mothers to be told at the outset that they must wean in order to pursue treatment of their depressive illness. Physicians may tell the mother she must stop breastfeeding because of concerns about the baby's exposure to medication through the mother's milk. Therapists may also advise weaning, believing that if other family members could give the baby a bottle, the mother would be able to rest and relax. Many health care providers share the bottle-feeding mentality that is still the norm in Western cultures. A mother who insists on her "lifestyle" choice of breastfeeding in the face of challenges will often be viewed as making a foolish and possibly detrimental decision. Family members who are often frightened and worried by the mother's illness, may not be able to assist the mother in challenging treatment advice that includes sudden weaning.
One mother, after recovering from a manic episode during which her doctor insisted that she wean immediately because of the medication she was taking, said later:
People don't realize how desperate you and your husband feel to get help and be well. We didn't know who to listen to, as often three or four health care providers gave conflicting advice. The psychiatrist didn't see the baby as his problem and the pediatrician felt helpless to advise me. I feel a lot of sadness about weaning my baby, especially now as we are facing surgery to place tubes in the baby's ears because of frequent ear infections.
A close look at weaning, however, reveals potential risks for both baby and mother that may outweigh any of the expected benefits. Some of these risks are especially pertinent in situations where a mother has a depressive illness or other mood disorder.
Painful breasts. Most women experience engorgement, including the risk of breast infection and abscess, in the face of sudden weaning. A mother who stops breastfeeding will need to take steps to relieve her engorgement. This many involve acquiring an adequate pump or learning to hand-express milk, as well as using ice-packs and watching for symptoms of breast inflammation and infection. Some drugs used to treat mental illness may have a galactogogue effect, i.e., they cause the breasts to produce more milk. This can intensify the pain of engorgement and slow the process of getting the breasts to stop producing milk.
Hormonal shifts. Sudden weaning brings sharp changes to maternal levels of estrogen, progesterone, and prolactin. The result may be mood swings and exacerbation of the mother's depression. A breastfeeding mother's mood is positively affected by the oxytocin released into her blood whenever she nurses the baby; sudden weaning deprives a depressed mother of this mood-boosting hormone.
Additional burden of baby care in the long-term. Family and friends rally to the aid of the mother in crisis, and they are ready and willing to bottle-feed the baby so that the mother can get some rest. But this support is often short-lived as the demands of life require the helpers' attention elsewhere. When the helpers are gone, the mother finds herself with the additional burden of cleaning and preparing bottles and other feeding paraphernalia, where previously, breastfeeding meant that she could luxuriate in the opportunity to sit down and simply cuddle her baby to her breast.
Expense. The costs of weaning include not only the additional cost of buying formula, but also the expense of more frequent illnesses in baby. Bottles and other feeding paraphernalia may need to be purchased. This financial burden will fall on a young couple who likely can ill-afford it.
Return of fertility. The possibility of another pregnancy is an important concern for a family already struggling to cope. Weaning the baby will cause the mother's fertility to return, so she must consider contraception. This can be an added cost. In families who choose not to use contraception, lactation amenorrhea provides an important child-spacing mechanism.
Disruption in bonding. It's not unusual for mothers who are depressed to find themselves unable to make the effort to play with their children, cuddle their babies, and so forth. When breastfeeding, the baby is assured of some loving contact with mother several times a day. The "mothering hormones" associated with breastfeeding foster the mother's attachment to the baby. If bottle-propping becomes an option for feeding the baby, the mother may not spend as much quality time with her infant.
Feelings of helplessness. Generally speaking, mothers with mood disorders are feeling out of control, powerless, and hopeless. Breastfeeding may be one thing that helps a mother to feel good about herself and her mothering. Telling her to stop breastfeeding delivers one more message of inadequacy. If others take over the baby's care, her inadequacy and powerlessness are confirmed. It's not unusual for mothers to experience tremendous grief, as well as hostility toward care providers even decades after an enforced weaning.
The younger the baby, the greater the risk for allergies and other nutritional problems. Substituting formula for human milk has significant health risks for infants, including increased risk of allergies, Type I diabetes, obesity, Crohn's disease, and much more.
More frequent and serious illness. Breastfeeding protects babies against infectious disease. Babies who are formula-fed have more frequent colds, ear infections, diarrhea, and gastrointestinal upsets. Not only is weaning risky for the baby's health, it also creates parenting challenges. Sick babies need and demand more attention around the clock.
Attachment trauma. A baby who is denied access to the breast for food and comfort may be grief-stricken. Separating mother and baby for prolonged periods of time may have lasting effects. The research is clear on the desperate need of mother and baby to be together for babies to experience normal growth and development. When they are unable to interact, there is evidence that lifelong depression may begin forming in the infant. One study of rat pups who were weaned and separated from their mothers for one 24-hour period during the neonatal period demonstrated both elevations in stress hormones and disruption of the hypothalamic-pituitary-adrenal system, which helps to regulate mood (Schmidt 2002). The distress a baby experiences with sudden weaning is real and should not be ignored or minimized by health care providers or substitute caregivers.
The breastfeeding dyad that is struggling because of the mother's mood disorder may be particularly vulnerable to the effects of sudden weaning. If hormonal shifts and negative messages cause the mother's mood to spiral downward, she becomes less able to effectively mother her baby. If baby becomes more sickly because of stomach upsets or allergies, he presents a bigger challenge to her mothering skills. A baby who is more difficult to comfort can make a mother feel even more inadequate and helpless. And, since many experts believe that there is a genetic component to mental illness, it stands to reason that the disrupted attachment inherent in sudden weaning may predispose the baby to mood disorders in the future.
What Is the Answer?
In many situations, it is possible for a mother to continue to breastfeed while being treated for postpartum depression or other types of mood disorder. She will need the support of family and friends, as well as health care providers, as she continues to care for her baby and to attend to her own recovery. It is important for everyone assisting her to recognize and respect her needs and those of the baby.
The support and practical assistance of loved ones is crucial to a positive outcome. Many mothers who are depressed experience feelings of inadequacy and marginalization. Additionally, those caring for her may manipulate or coerce her into agreeing to a treatment plan that does not acknowledge what is important to her—breastfeeding and mothering her baby. This sometimes occurs as a result of the fear that loved ones feel when they see the mother having such a hard time. The fact is that, despite her illness, she is often quite capable of making decisions.
That being said, mothers would do well to discuss the importance of breastfeeding with family members before a crisis (of any kind!) occurs. Mothers should share their feelings about their relationship with the baby, breastfeeding goals and desires, and hopes for the future with their partners and other loved ones. When family and friends understand the importance of breastfeeding through the mother's eyes, perhaps they will not suggest weaning as a first recourse. Having this knowledge will also prepare these individuals to advocate for the breastfeeding mother and baby in the event of a crisis. Educating her family about breastfeeding could include sharing her LLL Leader's phone number and the names of some LLL friends.
Finding a mental health care provider who understands the concept of the breastfeeding dyad is also crucial to the mother's treatment. The mother will oftentimes be seeing both a psychiatrist and a psychotherapist, as they have different roles in the treatment. She will need support from both if at all possible.
The psychiatrist should be willing to explore treatment options that allow the mother to continue breastfeeding. This may involve seeking out information about the effects of various medications on breastfeeding and the infant. It is important to know that many of the drugs being used to treat these problems are compatible with breastfeeding. In other cases, a safer substitute drug that is also effective may be used to treat the mother's disorder. Information on specific drugs may be obtained from various sources, including La Leche League's Professional Liaison Department and written materials such as Dr. Thomas Hale's Medications and Mothers' Milk. This information can then be shared with health care providers as appropriate.
When physicians make decisions about drugs, there are factors to consider besides the drug's presence in the mother's milk. Whether or not a drug is harmful will depend on the amount of the medication that gets into the milk as well as the age of the baby and how much the baby is nursing. The risks of the baby receiving a small amount of the mother's medication in her milk must be weighed against the risks of formula-feeding. While using some drugs, it may be advisable to monitor the baby's blood levels and to watch for an adverse reaction. The mother's physician can consult the baby's physician on issues related to monitoring possible drug reactions in the baby.
A good therapist should be willing to listen and learn about the family's specific needs, including the value the mother places on her breastfeeding relationship. This caregiver would be willing to talk with other health care providers (with the permission of the mother). Rather than advise the mother to wean, the therapist would listen to the mother's feelings about her breastfeeding relationship with her baby, and whenever possible, not only support it but advocate for it with other health care providers.
One of the immediate issues in situations where a mother has a depressive illness is whether she is able to care for her baby and for other children in the family. If the mother is deemed able to care for the baby on her own, then certainly breastfeeding would make her task easier! If she needs assistance, her helpers can take over household responsibilities, or care for older children, leaving the mother to concentrate what energy she has on the baby. A woman with a severe mood disorder, whose symptoms or distorted perception of reality prevent her from safely caring for her baby or even herself, may need friends and family to take turns being with her and the baby. This would allow for continuing attachment between the mother and baby while at the same time ensuring safety for both. This mother could continue to breastfeed even if her helpers must physically assist her with getting the baby to the breast.
In the event of an unavoidable hospitalization, the family could see about bringing the baby to the mother regularly, as well as arranging for a breast pump and assistance with using it. It's likely that, in many institutions, the idea of supporting continued breastfeeding would be new and therefore possibly viewed with suspicion or even scorn. Again, it becomes crucial for loved ones to advocate for the mother if she has trouble standing up for herself.
Fortunately, effective treatment is available for postpartum depression and other mood disorders. These illnesses do not carry the stigma that they have in the past, and treatment need not compromise any further a mother's attachment to her breastfed baby. When the mother, her partner, friends, and other family members work together with health care providers, solutions can be found that will enable the mother to continue to breastfeed as she recovers from her mood disorder. Both she and her baby will benefit.
American College of Obstetricians and Gynecologists (ACOG). Answers to Common Questions about Postpartum Depression. Washington DC: ACOG, 2002.
Hale, T.R. Medications and Mothers' Milk, Eleventh Edition. Amarillo, Texas: Pharmasoft Publishing, 2004.
Kendall-Tackett, K.A. The Hidden Feelings of Motherhood. Oakland, California: New Harbinger Publications, 2001.
Komaroff, A.L., ed. Harvard Medical School Family Health Guide. New York: Simon and Schuster, 1999.
Mohrbacher, N. and Stock, J. THE BREASTFEEDING ANSWER BOOK. Schaumburg, Illinois: La Leche League International, 2003.
Schmidt, M. et al. Maternal regulation of the hypothalamic-pituitary-adrenal axis in the 20 day-old rat: consequences of laboratory weaning. Journal of Neuroendocrinology 2002; 14(6):450-57.
Taj, R. and Sikander, K.S. Effects of maternal depression on breast-feeding. Journal of Pak Med Assoc 2003; 53(1):8-11.
A mother with postpartum depression may suffer from any or all of the following symptoms, although the most severe symptoms occur only rarely.
If these symptoms intensify rather than fade, and last longer than about two weeks, the mother may be suffering from postpartum depression. It is important that a mother attempt to overcome her postpartum depression, because it not only affects the mother and her relationship with her baby. Untreated postpartum depression can also affect a baby's physical and social development.
Source: Mohrbacher, N. & Stock, J. THE BREASTFEEDING ANSWER BOOK. Schaumburg, Illinois: La Leche League International, 2003; 570-75.
Tips for Family Members
For more information about mood disorders, see the following sources:
The National Women's Health Information Center
Depression after Delivery
Postpartum Support International
Postpartum Stress Center
Kathleen Kendall-Tackett, PhD