My 6 week postpartum follow-up appointment with my OB was scheduled for the day that should have been my estimated due date. It was a short appointment. She oohed and ahhed over my baby, did a quick physical exam to confirm everything had healed correctly, and then I was asked a couple of quick questions like “Are you crying for no reason?” and “Have you been feeling sad for no reason?” I answered these questions truthfully with “No.” And with that I was pronounced healthy and sent on my way not to be seen again for another year.
Of course, it turned out everything wasn’t fine. 8 weeks later when I returned to work my postpartum depression surfaced fully enough for my husband to notice and say something. However, what I have realized over the past few years was that there were signs, mostly of my anxiety, early on that could have been caught at my 6 week visit with the right questions. And I don’t blame my OB for not asking the right questions because the reality is that most providers are not trained to probe very far when it comes to screening for postpartum depression, much less the anxiety or other mood disorders that can accompany the depression.
It wasn’t until 2016 that the US Preventive Services Task Force (USPSTF) included depression screening for pregnant and postpartum women as a recommended preventive service, and it wasn’t until this recommendation that the American Medical Association (AMA) also recommended screening. The American College of Obstetrics and Gynecology was a little ahead of the USPSTF and AMA in making screening a recommended practice, but only by one year.
So, it took until well into the 21st century, but in the United States the major professional organizations for women’s providers now finally recognize the reality of postpartum depression, and the importance of screening all women for it. This is progress, agonizingly slow, but progress. But the next issue to address is the screening itself. The recommended, evidence based, screening tool is the Edinburgh Postnatal Depression Scale (there is also a tool called the Postpartum Depression Screening Scale, but it is not available to view online, so I cannot review it). I highly recommend taking a look at this 10 question screening tool, and let me know if see the issues with it. Yes, I understand it has been tested and shown to be evidence based, but tell me, how many women with a new baby will be able to provide an accurate answer to a question like: “I have been so unhappy that I have had difficulty sleeping.” I know I would have looked at that and said, “well I have a newborn baby that eats every few hours, so that’s why I’m not sleeping.” And the most relevant question for the anxiety I experienced early on, “I have been anxious or worried for no very good reason,” I would have answered that no because to me I of course had a very good reason! I was terrified of dropping my baby and her skull cracking open on the floor, that seems like a pretty good reason to be anxious or worried! That, “for no very good reason” language is the biggest problem I see with this tool. For a new mom the mere presence of a newborn will make all irrational, depressed, anxious, obsessive compulsive thoughts seem to be happening for a very good reason.
So what do we do? It took much longer than it should have for screening to become an actual recommendation for providers, and the evidence based tool that is recommended seems inadequate. We do what women have always had to do, we take charge! We start informing ourselves about the symptoms of postpartum depression, the fact that it can present anytime within the first year after a birth and it can last longer than a year, and the signs of co-occuring issues such as anxiety or obsessive compulsive disorder. Then we help inform our providers, when only 9-12% of OB/GYNs report routinely asking patients about depression or using a screening tool, and when I hear firsthand stories – as recently as a week ago – of a woman being told by her therapist that she doesn’t have postpartum depression because she doesn’t resent her baby, it is clear that our providers need to be educated as much as we do. And then, we work to help inform and create better evidence based tools.
If you are in the United States or Australia, and if you have an iPhone, you can participate in active PPD research by downloading the PPD Act App. This is an App launched by Postpartum Progress in collaboration with the University of North Carolina School of Medicine, the Queensland Brain Institute in Australia, the National Centre for Mental Health at Cardiff University in the United Kingdom, Apple, and the National Institute of Mental Health. The App will have a questionnaire for you to answer, and your answers will help create a database of information about postpartum depression for researchers to use to better understand the condition, and to hopefully develop better screenings and treatments. Phase 2 of the study will include genetic data collection to help determine if there is a genetic link to postpartum depression which may lead to even better and earlier screenings.
When more than half of pregnant women and non-pregnant women experiencing depression are going undiagnosed, and therefore most likely untreated, we have to acknowledge that we haven’t come nearly far enough in society. Motherhood is hard, really really hard, motherhood with an undiagnosed and untreated mental health condition is dangerous. Having postpartum depression does not make you a bad mother, it makes you human. You should never feel like you can’t admit what you’re really feeling or experiencing. The more we talk about our postpartum experiences, the more we will be able to help each other. If you need information or resources about postpartum mood disorders, including links to specialists and support groups, check out the Postpartum Progress website. Please feel free to share your PPD experiences or questions in the comments, this is a completely judgment free zone.