How Postpartum Depression is like Onions
We all remember the loveably crotchety ogre, Shrek. Crass, perpetually sarcastic, he walks through a field in the first film trying to get Donkey to understand why he is the way he is: “Ogres are like onions. They have layers.” Moms are like ogres too, not in the crotchety way, but in the layered like onions kind of way. Postpartum depression (PPD) is a lot like Shrek too: poorly understood, layered, and willing to explode at a moment’s notice.
Having a baby is no joke. It doesn’t matter how you have one: vaginal birth, C-section, adoption, whatever. You learn who you really are and what you really stand for in the process. People talk a lot about meeting someone new, but they aren’t always referring to the baby. YOU will be that someone new. You will have feelings and thoughts you didn’t think were possible. And that doesn’t mean there’s anything wrong with you, it just means you’ve uncovered another layer.
There is a period of time after birth in which the euphoria goes away, and you feel a little “blue.” Someone affectionately termed this the “baby blues.” Due in part to the drastic changes in hormonal expression that occur during pregnancy, birth, and breastfeeding, this should dissipate after about 2 weeks. However, for many people, it does not and becomes something far more serious. Miraculously, the American College of Obstetrics and Gynecology (ACOG) changed their guidelines in 2018 to move the post-natal visit from 6 weeks post birth to 3 weeks (THANK YOU!). If you have used a midwife or doula, your support network will be checking in on you MUCH sooner than that!
Depression requires five or more of the following symptoms to be accurately diagnosed, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM):
depressed mood
diminished interest or pleasure in activities
change in body weight (more than 5% in one month)
insomnia
psychomotor agitation or retardation
fatigue or loss of energy, feelings of worthlessness
excessive or inappropriate guilt
decreased ability to concentrate
recurrent thoughts of death or suicidal ideation
According to the DSM, for these qualities to classify as “post-partum” they must occur during pregnancy or within the first four weeks following delivery. Really?? 4 weeks??? Are you F******* kidding me?
I look at this list and I am confounded by the amount of thoughts and feelings I had during my pregnancy and after the birth of our son:
depressed mood (Well, I’m bloody exhausted, I’m wearing panties that look like something that belongs on an Asian pear, I’m terrified to take a shit, so yeah, my mood isn’t great)
diminished interest or pleasure in activities (I am so effing tired I can’t remember if I brushed my teeth today, so how would I know if I still like to workout or go for a walk, or read)
change in body weight (more than 5% in one month) (UMMMM HELLO!!! Just created a human, thanks.)
insomnia (What is sleep? This guy is up every 30 minutes)
psychomotor agitation or retardation (My hormones are all over the place. I am exhausted. I think I just put cereal in the fridge and the milk in the pantry.)
fatigue or loss of energy, feelings of worthlessness (See items above: exhaustion. I can’t even remember to do the laundry or cook dinner. Literally I’m a milk machine. Perhaps that’s all I’m good for)
excessive or inappropriate guilt (I seem to have forgotten how to be a wife?! You want to have sex? No freaking way buddy. Nothing is going near my Asian pear panties. I need a break from my baby. But I miss him the minute I give him to someone else. Wait, I’m supposed to be the one feeding him. What if he gets nipple confusion? I feel so guilty for not being able to cook my own meals. How can I take care of myself? There is another human who relies solely on me for survival right now.)
decreased ability to concentrate (See cereal example above).
recurrent thoughts of death or suicidal ideation (Gratefully, I didn’t have any of these thoughts until later, but that’s another blog post).
Environmental factors, such as previous trauma, a history of depression and anxiety, cultural norms and expectations, community support, and coping strategies all play a role in whether a person will develop PPD. Turns out that more than just the environment can contribute to PPD. Turns out that your upbringing, your hormonal expression, and your neurophysiology, that is, literally how your brain works to process information, play a role in the development of PPD. Most specifically, the hypothalamic pituitary adrenal (HPA) axis contributes to PPD development and progression beyond just the “baby blues.” The HPA axis is like the outer shell of the onion. Just like as we peel an onion and the fumes make us cry, the outer peel has to be removed to “trigger” the fumes. Corticotropin releasing hormone (CRH) is secreted by the hypothalamus in response to a threat, which then triggers the pituitary gland to make adrenocorticotropin hormone (ACTH). This hormone acts on our adrenal glands which sit just on top of our kidneys. At this point, we’re full on crying, not just due to exhaustion and the new demands of parenthood, but because we’ve peeled the outermost layers of the onion and the fumes are UNREAL. This signals cortisol to be secreted and we are in full fight, flight, or freeze mode. Interestingly, the last few weeks of pregnancy are when cortisol levels rise the most, reaching levels that are up to three times more than those of women who are not pregnant. Perhaps this is our primitive brain preparing us to protect our new offspring. REMEMBER: our goal as humans is to reproduce. This is ingrained at a primitive level and our hormones will stop at nothing to keep the bloodline going.
So what are we doing about this? I’ll tell you that in my experience, it was NEVER discussed in any of ante- or post-natal appointments. By the grace of God, I was trained formally in pregnancy and postpartum physical therapy, so I had some modicum of knowledge as to what to look out for. It took a solid community and some really brave people to point it out to me, though. I could explain away all of the physiology, but not stare my PPD in the face and truly FACE it.
If you or someone you know thinks you might have PPD, the Edinburgh Postnatal Depression Scale is a great place to begin. If you’re not sure that you might be having more than just the “baby blues,” please fill this out and call your doctor or someone you trust. You can also contact the SAMHSA National Helpline 24 hours a day, 7 days a week, 365 days a year in both English and Spanish.
Having a baby and a family is the most beautifully rewarding thing in this world you can do. There are people who love you, support you, and will help you. I am one of them, even if I don’t know you.
https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/05/optimizing-postpartum-care
Eberhard-Gran, M., Esklid, A., Tambs, K., Objordsmoen, S., et al. 2001. Review of validation studies of the Edinburgh postnatal depression scale. Acta Psychiatr Scand, 104, 243-249
Garcia-Leal, C., De Rezende, MG., Corsi-Zuelli, FM., De Castro, M., Del-Ben, CM. 2017 The functioning of the hypothalamic pituitary adrenal (HPA) axis in postpartum depressive states: a systematic review. Expert Rev Endocrinol Metab, 12, 341-353.
Payne, JL and Maguire, J. 2019. Pathophysiological mechanisms implicated in postpartum depression. Front Neuroendocrinol, 52, 165-180. doi: 10.1016/j.yfrne.2018.12.001
Soma-Pillay, P., Nelson-Piercy, C., Tolppanen, H., Mebazza, A. 2016. Physiologic changes in pregnancy. Cardiovasc J Afr, 27, 89-94.
