March 27, 2009

Postpartum Depression: Andrea opens my eyes

I met Jabrea for the first time when she was about an hour old. Her mother, Andrea, was in the delivery bed, exhausted but smiling broadly. Her husband and sisters and parents were all huddled around me as I did my exam. "What does Jabrea mean?" I asked her.

"Nothing," she said, "I just liked the way it sounded."

"I have a suggestion for you. People will ask her and you about it her whole life. Tell them it means 'beautiful princess.'" She liked this idea. Now, 8 years later, sometimes her parents call her 'BP,' though it's usually when she doesn't clean up her room.

Andrea was a happy and healthy young woman, with a supportive family and husband. I wasn't worried about her or the baby. She was a middle child, and her younger sister was still in school. Her older sister already had 2 young children.

She brought the baby to me for follow-up shortly after leaving the hospital. The baby was adorable and everybody in the office fawned over her. We went into an exam room and I asked, "How are things going?" Immediately, she burst into tears. "Everything's going great," she said, crying. I asked all the usual questions--breastfeeding, sleep, poop, rashes, breathing, eye contact, and so on. She answered them all without any cause for concern. While crying loudly. Eventually, I did ask her why she was crying. She said, “I don’t know.” I told her in the most convincing manner I could that the baby looked great and that I thought she was doing a great job. The baby was 2 days old. The next usually-scheduled visit was at 2 weeks of age.

That visit was more difficult, though the baby continued to look great, was gaining weight well, and seemed developmentally normal in every way. No matter how confident I tried to appear, Andrea kept crying. The visit was scheduled for 15 minutes (some clinics schedule 10 minutes), but I couldn’t move to the next patient. There was something here that I had to understand. I had to try and make things better. A long time ago, I was taught to approach complex problems in physics by breaking the problem down into more comprehensible pieces. Not having any idea or training in any other method, I tried this. I asked her about every detail of her life with the baby. She told me, after a lot of very specific questions, that she had stopped breastfeeding. She did this because she wasn’t a good mother: her body couldn’t do it, her breasts hurt, she could never do the things that her older sister could do so effortlessly, she could never do what came so easily to every mother she heard about or read about in baby books. Worse than this, her completely innocent baby would suffer from her incompetence. She would lose the benefits of breastfeeding, she would lose the better immune system and better nutrition and now she has doomed her daughter to having serious illnesses and eating disorders. Worse still, she would never bond with her mother and always know that her mother didn’t care enough about her to live with the pain. Andrea knew this to be true because the baby no longer wanted her, and was rejecting her. The baby clearly knew that her mother didn’t have want she wanted and needed. The baby didn’t need her for anything, and neither did anybody else.

What was I actually observing? In the little exam room, there was a pervasive sadness and feeling of despair and failure. Andrea had no history of psychiatric problems, and it didn’t occur to her to seek professional help. Indeed, she didn’t think anything was wrong with her. She was simply a concerned and observant parent who wanted to be sure her baby was OK. She didn’t think of herself as depressed. She acknowledged that she cried an unusual amount, and she said that her husband was frustrated because he was unable to cheer her up. She didn’t think he understood the baby as well as she did and would only let him take care of her when she was there to supervise closely.

I bought a book. Beyond the Blues by Shoshanna Bennett and Pec Indman.

Every day in my practice, I was seeing mothers with newborns. I started asking a question I had never before asked. “How are you feeling?”

Postpartum depression had never been mentioned in the psychiatry section of medical school. It had never been mentioned in my pediatric residency. Maybe I had heard the term but now, looking back, I don’t think I ever thought about it. Apparently, it is at least mentioned in the training of Ob/Gyn doctors, I guess when they aren't doing surgery. They typically see the woman for follow-up 6 weeks after she leaves the hospital.

Maybe it’s obvious that if you don’t ask a question, you probably won’t find out an answer. There’s an unspoken secret in some areas of medicine, however. Sometimes there’s information a doctor doesn’t want to know, and questions the doctor doesn’t want to ask. Asking about how the patient feels is likely to evoke an answer that will take a lot more time to deal with in a competent way that if the patient is never asked. Some doctors and clinics go so far as to spell it out. They tell the patient that each visit deals with one problem. So it’s either the rash or the headache, not both. The questions they ask for each problem are extremely specific. This helps manage the limited visit time in an optimal way for the institution, not for the patient. The patient’s time, indeed the patient’s health, is not the most important factor in this model of care.

Because so much of postpartum depression isn’t noticed by anyone in the medical field and because many of those suffering with it don’t report it or seek treatment for it, we really don’t know how common it is. But it’s common. Maybe as high as 15% or 20% in some published sources.

Nobody I knew had a clue about this. I felt like I had discovered an underground epidemic, which was everywhere I looked, hidden in plain sight, right in front of me all the time. I decided to learn more.

Next Post: Andrea, getting help and getting sleep.

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