Postpartum depression -I know these are only words, medical words, I suppose: descriptors. Language. But for all we’ve done with these particular words, what little attention we seem to have paid to them, they are still only words. And yet they describe a condition that has dogged us for millennia: the darkness that follows pregnancies like a silent shadow. Creeping quietly in the background, it bides its time, stalks its prey. Camouflaged, it is visible only if you look carefully along the trail, study the subtle indentations where it hides, part the branches of its lair. It’s always there. Lurking. Waiting. And given the opportunity -a gift of circumstance perhaps, a melange of genes, a naivety of observation- as the brilliant light of birth is slowly extinguished, it rises suddenly from the shade and pounces like a hungry cat.
It bothers me that we pay it so little heed until it strikes; that we read the cover of its book so well and then, seduced by the play of colours on the top, miss the message written clearly not so deep within. We act as if it were a surprise that things are not always as they seem; that we all have shadows if we dare to look behind.
There are quite a few tools -questionnaires, by and large- that have been designed to help doctors and midwives anticipate most perinatal problems long in advance. The problem, of course, is in according depression sufficient importance. We are too often focused on measurements in pregnancy: weight, blood pressure, the amount of protein in the urine sample, fetal heart rate, growth of fetus, position of baby –real things, objective things. Important things to be sure. Most of us feel more comfortable in writing numbers and words in their proper columns and following the trend; understanding and charting the ongoing fetal development: Ontogeny recapitulates Phylogeny as they taught us in medical school. There’s a certain comfort in the dispassionate assessment of what we take to be an objective, measurable reality. There are rules.
Emotions on the other hand are mysterious; we hardly understand ourselves, let alone the vagaries and vicissitudes of the moods, coping mechanisms, or even guiltily-expressed thoughts of our patients -their words on exhibit, but weeks apart on consecutive visits. On some of those occasions they’ve had a hard time at work, or have argued -are maybe even arguing in the office- with their partners; they’re polite, but only on the surface. Other times they’re all smiles -or all questions… Sometimes they never even get a chance to speak- just the partner. But I think that these are clues to an observant midwife, or doctor -even if the various screening strategies (such as the Edinburgh Postnatal Depression Scale, for example) have not been utilized. They are certainly helpful in gauging the amount of anxiety the woman is feeling, the attitude she has to her partner -or vice versa- and the amount of support she is receiving at home… all contributors to possible future problems.
Some of the clues -the postpartum ones at any rate- are revealed by simply asking the mother if she has been feeling down, depressed or hopeless of late, or if she has been finding that she is losing interest or pleasure in doing things. If she answers yes to either, then does she want or need help in dealing with it? The questions are asked sensitively, casually, and with no hint of prejudice or blame. They are not traps to assign the stigma of mental illness, nor to criticize her ability as a mother.
I am fortunate in my center to have a Reproductive Psychiatry program that is interested in assessing pregnant women and their risks for developing adverse postpartum mental health issues. They come up with strategies -not necessarily medication- to help, apprise her of facilities available in the community and ensure that the mother is in the system should there be problems. The woman knows where to go for help if she needs it.
I try to identify the risks both from history, observation, and direct questions as to whether they feel they might benefit from someone as well as me to talk to. I usually stress that it is better to be prepared beforehand than caught unawares. I try help them to understand that it is as much for the baby’s well-being as their own. Once the patient realizes that the referral does not mean that I think they already have mental problems, and that they won’t be pressured into taking antidepressant medications with their possible -yet controversial- effects on the fetus, they usually accede to my concerns. Caring for a person, means more than entering their data in a chart… Words, even in the correct columns, only go so far.
Words are signs, signals in the void that separates us all: little lights… and sometimes they’re really all we have. They’re among the few things that touch us deeper than skin; they often tell us more than we can take in with our eyes. But only if we listen.
Are more than billboard signs,
Along the road;
More than pictures
On a wall.
They can be pretty
As a group,
It is an accident of birth
That any one of them
Has more than a passing flair.
Is a suitcase,