And why it’s damaging for mothers when we conflate the two
When Karen Papajohn first came home from the hospital with her infant son, AJ, she felt numb.
“I kept wondering why I didn’t feel the same ‘joy’ and ‘happiness’ of welcoming this precious gift into my life as my husband did,” she wrote in a survivor story on Jenny’s Light, a perinatal issues website. Amongst other things, Papajohn was sleep-deprived, overwhelmed, and exhausted.
But she wasn’t depressed—instead, Papajohn was suffering from postpartum depression, a condition that is distinct from major depressive disorder. While the many of the symptoms are similar (sad mood, restlessness, poor concentration), PPD isn’t merely an extension of depression, as a recent review published in Trends in Neurosciences confirms. It involves distinct changes to the brain, which suggest that PPD is a separate biological disease, and may even require distinct treatment.
And only by better understanding those differences, says behavioral neuroscientist Jodi Pawluski, the first author of the review, will we be able to help prevent and treat maternal mental illnesses—conditions that affect not only the mother, but the child as well.
PPD, MDD, and the brain
Pawluski explains that some research has shown that the amygdala—a part of the brain that plays a role in maternal caregiving, social behaviors, and emotion—is less active in postpartum women with PPD than in postpartum women with no mental illness. But for people with MDD, the amygdala is actually more active than in people with no mental illness. This could indicate that in women with PPD, there’s actually some downregulation of the amygdala in the parental caregiving system, Pawluski says. In other words, women with PPD may be less responsive to certain infant cues than both the regular population and sufferers of MDD.
Of course, Pawluski cautioned, the brain doesn’t work in isolation; it functions as a circuit, so changes in one area may point to changes in another. More research is needed to understand exactly how the brains of PPD and MDD sufferers differ, and how this may impact treatment.
“Studies are only beginning to address that question,” maternal-fetal psychiatrist Dr. Tamar Gur says. Dr. Gur is an assistant professor of psychiatry and behavioral health, neuroscience, and obstetrics and gynecology at The Ohio State University Wexner College of Medicine. She noted that researchers believe that, while PPD shares many symptoms with MDD, it might actually be a biologically distinct disease. And understanding PPD is essential, Dr. Gur said, given that it affects not only the mother, but also the infant and rest of the family in a critical period of the infant’s development.
However, research is extremely limited right now—only around 20 published studies address the neurobiology of postpartum mental illness, despite the fact that it affects about 10 to 20 percent of women.
Just baby blues?
Part of the difficulty in dealing with PPD is a lack of awareness—not only by the patient, but also by the people around her. Unlike MDD, which can strike at many different times, PPD comes at a specific period in a woman’s life. People around the new mother may simply assume that her exhaustion and unhappiness is a normal part of motherhood, standard fare for someone going through a major transition, and that she just needs time to adjust.
But many women with PPD don’t understand how others don’t recognize their intense suffering and, in turn, start to second guess their own feelings.
Papajohn went through this: At her four-week checkup with her obstetrician/gynecologist, she broke down in tears after the doctor didn’t ask how she was faring emotionally. She left confused, thinking that perhaps her reaction was normal and part of the “baby blues” that most new mothers experience.
According to Dr. Gur, baby blues is a fairly common occurrence among new mothers. Some research suggests it can affect around 60 to 80 percent of them. The onset can happen the day after giving birth or a few days later, and generally last up to a week. Women often feel overwhelmed and sleep-deprived after having gone through a major life event, she said. They may feel like they’re not doing a great job of taking care of their baby, and even may be anxious about simple tasks like taking the baby out of the house.
But if the baby blues don’t lift after about two weeks and, instead, become more severe and entrenched, it becomes something more serious: postpartum depression.
“You really feel like you’re drowning,” Dr. Gur said. “It’s omnipresent, throughout the day.”
Indeed, this is how Papajohn felt as the weeks went by. She suffered from insomnia and exhaustion, and the smallest task—like going to the grocery store to buy milk—seemed monumental. She began to resent her husband for leaving every morning to go to work and started avoiding all of her friends.
“I thought that if I was dead, everything would be so much better for my husband and my son,” Papajohn wrote.
Thus, in a way, PPD can be even more invisible than MDD. People may normalize women’s feelings and explain them away as an inevitable part of motherhood. Or worse, they may conclude that these women are just bad moms, or unprepared mothers, Dr. Gur said, noting that this is one of the biggest misconceptions. PPD, she emphasized, is a disease and not a choice, and women cannot just “snap out of it.”
Responding to PPD
Just as PPD is a unique disease, it requires a unique response—one that involves all hands on deck, Dr. Gur said.
“I see a lot of benefit to immediate social intervention,” she said. “It’s really the time to circle the wagons. That’s when you want your mother to come from across the country, for a neighbor to help with dinner.” Given how crucial it is for the mother and child to bond immediately after birth, families need to make sure they are doing their best to offer support for mothers afflicted with PPD.
And don’t be afraid of offending a mother who may be suffering. “I’ve heard from more moms than I can count that they felt invisible when no one commented,” Dr. Gur said, adding that women felt more hurt when people seemed to pretend that everything was fine, which only invalidated their feelings. Instead, neighbors can offer to take older kids out for a playdate, family members can show up with dinner, spouses can escort mothers to doctors appointments for important treatments, which can include medication.
For Papajohn, her story changed when she spoke to a nurse practitioner about her feelings. That nurse referred her to a doctor who specialized in postpartum mood disorders, and over time—with the help of therapy and antidepressants—Karen began to feel better.
“The ‘dark glasses’ I had been wearing for the last while had started to become brighter,” she explained. “Today, my son is almost 4 years old. I love him with all my heart and I can’t imagine my world without him.”