The Truth About Postpartum Depression

Why Does No One Talk About Long-Term Postpartum Depression?

Artwork: Aburrida, Bruno Berthier, 2023.

I went all out for my son’s first birthday: Custom party invites, a balloon garland, and of course, the perfect cake. As a pandemic mom who had spent most of the previous year inside, I hadn’t had many opportunities to celebrate. I kept myself busy with party planning but there were telltale signs that all was not well; I was struggling to get out of bed, simple tasks like grocery shopping felt impossible, dread consumed me. It rained the day of the party, and while guests stood beneath their umbrellas watching my son’s chubby fists destroy a frosted cake with rainbow sprinkles, I knew without a doubt that my depression was back.

When we think about postpartum depression (PPD), most people imagine something that takes place the weeks or months following a birth. The DSM-5 defines postpartum depression as depression that begins during pregnancy or up to four weeks following birth. Research shows that one in eight women will experience symptoms of postpartum depression, but the time of onset may be later than you think.

Like many moms, I experienced the baby blues, but I wasn’t diagnosed with postpartum depression until four months after I had my son. An unplanned C-section and ongoing struggles with breastfeeding meant my fourth trimester (the 12 weeks after giving birth, which many experts now believe is as crucial to a mother’s health as their first three trimesters) was filled with unexpected challenges. It took me months to process my disappointment over how my birth had happened, and the aggressive pumping and feeding plan I had been advised to follow in order to give my son as much breastmilk as I could, led me to a breaking point.

In the depth of my PPD, I was lucky to receive care from BC Women’s Reproductive Mental Health Program, a treatment facility in British Columbia that is part of the larger BC Women’s Hospital. Despite the DSM-5 classification, the facility offers specialized services to mothers and their families for up to 12 months after birth. (I should assert at the outset, that as a Canadian, I have access to publicly funded healthcare, including dedicated postpartum support.) Through therapy, psychiatric care, medication, and time, I began to recover. It was the holiday season when the fog of my depression slowly started to lift, and I soaked up every moment of my son’s first Christmas. I was no longer breastfeeding, and felt at peace with my decision. I finally felt like myself again.

But, despite having received this treatment, when my postpartum depression returned on my son’s first birthday, I felt confused, isolated, and ashamed. Shouldn’t I have gotten over this by now? I watched other toddler moms going back to work, hiring nannies, even getting pregnant with their second babies, while I hid in bed, too humiliated to admit I was in a dark place again.

Navigating PPD for a second time looked a lot different. Without being eligible for postpartum mental health care, I had to refer myself to a psychiatric assessment and support center. Because the clinic was so overrun, general practitioners were no longer able to submit referrals, so I sat on hold after calling them for what felt like an eternity, then answered a series of intake questions: Are you having thoughts of harming yourself or your son? Do you have a plan to do so? Are you hearing voices? The questions made me uneasy, and I felt unsure that this was the right place for me. I said yes to the earliest appointment they offered because my options were limited, and I knew I needed help.

I was too shaky to drive, so my dad took me to the center the next morning. I stared out the window wondering if my son had settled for his nap and how I had gotten here, driving to an emergency psychiatric appointment on a cloudless summer day. My dad dropped me off and I sat nervously in the cold lobby waiting for my name to be called until a young female psychiatrist brought me to her office. Knowing that I had a history of mental illness and postpartum depression, she used the Edinburgh Postnatal Depression Scale, a widely-used screening tool, to assess me.

At the time, I wasn’t thinking about why my psychiatrist was approaching my care through the lens of postpartum depression—all I wanted was to get better. But, as I started to recover, I began to consider the gray areas that exist within these diagnostic tools and the labels inherent to them. Are there more women out there, like me, who have experienced some form of PPD far beyond the timeframe in which we consider it to be “normal”?

Dr. Deirdre Ryan, Medical Director of the Reproductive Mental Health Program at BC Women’s Hospital says the program’s decision to cease specialized postpartum care at twelve months “is about the fact that we have limited resources.” “This is the most vulnerable time in any woman’s life to develop depression and anxiety. There are huge hormonal shifts going on, there is sleep deprivation and pressure to breastfeed. By one year a lot of those pressures have changed,” explains Ryan. But for me, those pressures were replaced with an onslaught of new obstacles like adjusting to my husband’s paternity leave ending, finding childcare and achieving the ever-elusive work/life balance.

I have struggled with anxiety and depression since my early twenties, which puts me at greater risk for postpartum depression and a repeat episode. According to Ryan, the fact that I had already suffered one bout of PPD made me more at risk for developing it again at some point in my postpartum period: “When you have major depressive disorder in the postpartum period,” Ryan says, “you can have a relapse with the return to work or other psycho-social stress.” Doctor Lori Brotto, Registered Psychologist and Executive Director of the Women’s Health Research Institute at BC Women’s Hospital stresses the importance of patient history when forming a treatment plan for the postpartum period.

But, what exactly is the postpartum period? “That four-week window is just not long enough” says Diane Putnick, a Developmental Psychologist and Peer Researcher at the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NIH). “Health care providers don’t screen for [postpartum depression] past six months, and women are going without treatment,” explains Putnick. In a longitudinal cohort study, Putnick and a team performed assessments for depressive symptoms in mothers at 4, 12, 24 and 36 months postpartum. The study showed that one-quarter of women had elevated symptoms of depression at three years postpartum. “It’s a continuity of care issue—you have extensive care during pregnancy, then you have a baby, then you have a six-week postpartum appointment with your ob-gyn and then you’re on your own,” says Putnick.

The official time frame for diagnosing postpartum depression seems absurd when you consider the monumental transition of becoming a parent. “At the root of this is what you believe causes postpartum depression,” notes Putnick, “if you believe it’s purely triggered by the hormonal shift that occurs during pregnancy and after birth, then it’s reasonable to think this will be done by four weeks, but that’s not what is driving the depression we are seeing amongst mothers. It’s a renegotiation of everything in their life, their relationship, finances, health and independence. It’s a series of stressors that all occur at once.”

At three years postpartum, I’m still uncovering new ways that becoming a mom has altered my identity and tested my capacity. Motherhood has humbled me, clarified my priorities and helped me bring more compassion and patience to everything I do. Nevertheless, the challenges of parenting persist, and I know I’m not alone in that. In the absence of resource constraints, Putnick, Ryan, and Brotto advocate for extending screening and specialized care to at least three years postpartum.

When it comes to postpartum depression, language holds weight. Removing the qualifier of postpartum to a case of depression after four weeks can not only influence the type of treatment a woman receives, it also denies a fundamental part of her experience. “If you take that away from mothers, you’re showing them that this period doesn’t hold special importance in their lives. The postpartum period presents some of the most unique challenges women can face, and that should be acknowledged,” says Putnick. When telling people about this time in my life, I never hesitate to use the label of postpartum depression. It’s a part of my story and I want everyone to know that this transformational period cannot be confined to an arbitrary timeline.

The other day I went to a fitness class with a friend catered towards new moms. Before we began, the teacher reminded us that wherever we are in our motherhood journeys, we’ll always be postpartum. Her simple advice had resonance for me: I’m forever postpartum—in my body and my mind.

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