This article originally appeared in Mishpacha/Family First (Issue 425, January 14, 2015).
@Mishpacha Magazine 2015
WHAT HAPPENS IF YOUR NEW BABY BRINGS YOU ANXIETY AND DEPRESSION, INSTEAD OF JOY AND DELIGHT? HOW TO RECOGNIZE – AND RECOVER FROM- POSTPARTUM REACTIONS
“MOMMY, I WANT TO MAKE YOU A BIRTHDAY PARTY,”
Shloimy said, eyes bright.
“Hmm,” Leba mumbled, her head ensconced in a novel.
“You know why, Mommy? Maybe if I make you a party, then you’ll smile.”
An English teacher by profession, Leba Katz was as normal as they come. She was geshikt too: Despite giving birth to her sixth child just months earlier, her family always had fresh suppers, clean laundry, and sparkling floors. Which is why, despite repeated red flags, it never dawned on her that something was wrong.
“My son’s remark should have been a bulletin from Shamayim,” Leba reflects. “But depression was for weirdos. I was Leba Katz, the oldest of a well-known heimishe family from Boro Park.”
It took another alarming incident for Leba and her husband to realize they needed help.
At 11:30 p.m. one night, Leba began walking out the door, wearing only a robe and socks. “Where are you going?” her husband asked incredulously.
“I’m leaving,” she declared. “I’m just going… somewhere.”
“This is crazy,” he said. “We’re going to a doctor.”
A CLINICAL DEFINITION
Leba was suffering from postpartum depression (PPD), a form of maternal mental illness affecting at least one in eight — and as many as one in five — women across the world.
In the past, researchers referred to any post-birth mood disorder as “depression,” but today the medical world talks about postpartum reactions, acknowledging the range of conditions that can result from wildly fluctuating hormones: anxiety, bipolar disorder, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), or a combination.
Not to be confused with baby blues, a short-lived bout of irritability affecting 90 percent of mothers for the first two weeks after birth, postpartum reactions generally do not go away without medical or therapeutic intervention — or an integration of both.
What’s more, a fast-growing body of research indicates that maternal mental illness does not always wait for delivery:
33 percent of women diagnosed with PPD developed the condition in their third trimester. Symptoms can also develop anytime in the baby’s first year of life — not just the first few months.
“With each child, the depression hit later and later,” Sari, a Baltimore mother of four relates. “With my youngest, I was fine until he was five months old. Then it hit.”
What causes maternal mental illness? A complex interplay of genes, stress, and hormones. “Hormones go up more than a hundredfold” during pregnancy, says Dr. Margaret Spinelli, director of the Maternal Mental Health Program in Columbia University, as quoted in the New York Times. After birth, hormones plummet, causing a crash that can “disrupt brain chemistry.”
Some primary risk factors are biological: Women whose moms had postpartum (PP) reactions are highly susceptible, and women who once experienced pregnancy-related depression have a 50 to 62 percent risk of recurrence.
Environmental factors also play a big role: the more stressors in a woman’s life — from financial strain to shalom bayis issues — the more likely she is to get a PP reaction. Experiencing a scare during pregnancy — even if it never materialized — can also trigger PPD.
Internal stressors impact a woman’s risk as well. A woman from a family of high achievers, for example, is at high risk. “She had a baby, she’s more limited, she can’t cope as well — but she’s expecting the same output of herself,” says Dr. Shula Wittenstein, a seasoned psychologist who works at Nitza, the Jerusalem Postpartum Support Network.
Perfectionists are more likely to fall into depression when their birth or after-birth experience does not go as planned, because they aim for “perfect” even in areas they can’t control. “Many women are brainwashed not to take an epidural, or told that a C-section will negatively affect the baby for life,” Dr. Wittenstein notes. “They’re also told nursing is a must. And they feel the powerful societal pressure to have many children in close succession, regardless of circumstance that warrant rabbinic instructions to the contrary.”
The result, asserts the psychologist, is that women aim for these goals even when they don’t have the capacity for them. And when they don’t succeed, they feel like failures.
Chaviva, who suffered from classic PPD, says, “I made myself insane trying to nurse, but it simply didn’t work. It took having three kids and consulting seven lactation consultants for me to accept that this is the way Hashem made me.”
Another internal stressor is the guilt felt when seeking a husband’s help. “The mother is drowning, but she doesn’t want to take away from her husband’s Torah,” describes Dr. Wittenstein. “She valiantly tries managing alone, pushing herself deeper into depression.”
Sari, an almost ten-year-veteran kollel wife, remembers feeling like a horrible Jew. “How could I ask him to stay home? I must have no chashivus haTorah, I’d think. Then I’d get angry at him for not offering to stay, thereby relieving me of the inner turmoil.”
A GLIMPSE INTO DARKNESS
Depression, the most common postpartum reaction, varies significantly in severity. Many affected women report a constant state of sadness and irritability.
Naturally upbeat and optimistic, Chaviva couldn’t find it in herself to smile. “Everything was wrong,” she remembers. “I couldn’t shake the anger.” Chaviva was unable to react to normal life challenges in a balanced way. When minor things went wrong, she would stew in a negative headspace — for days. “If my husband didn’t take out the garbage, he didn’t love me, my marriage was falling apart,” she says.
Other mothers paint a picture of perpetual “overwhelmedness.”
“Taking care of my kids just didn’t end. I felt I was being buried,” says Mindy. “My toddler whining, my baby crying — anything would set me off.” Mindy’s black feelings were exacerbated by a massive cloud of guilt: She had struggled with infertility for years. “G-d gave me these two amazing gifts after all these years — how could I not be happy?”
Rivka, who felt similarly submerged by routine responsibilities, says that in hindsight, she realizes her depression began in pregnancy. When she and her husband would read about their unborn baby’s weekly development, the soon-to-be-Tatty would get excited and emotional. Rivka, in contrast, would be completely detached.
“I kept telling myself: You can’t see the baby, that’s why you’re not feeling anything.” Months later, Rivka had no difficulty loving her sweet infant — she just couldn’t handle even life’s tiniest curveballs. “If I was in a rush and the baby had a dirty diaper, I’d lose it,” she recalls. “I couldn’t make decisions or problem-solve. I felt like I was about to crash — all day long.”
Most difficult to diagnose are cases of milder depression. Here, the woman functions outwardly — cooking and laundering, caring for the baby — but her inner world is in tatters.
“I put on a Broadway show. No one in the neighborhood could have known,” Leba says. “At home, though, I was in a fog. I wasn’t relating to my husband, my kids.”
For Shira, who held a high-powered finance job through several babies — and years of untreated depression — the farcical charade was the scariest part of it all. “I was having awful, awful thoughts: What’s the point? Why am I living? I knew I could do something really bad to myself, and no one would even know to prevent it.”
Years later, in a discussion about that bleak period, Shira’s husband remarked: “If you had stayed in bed for three days straight, I would have done something, gone for help. But you were totally functioning — I assumed you were just in a really bad mood.”
Other widespread postpartum reactions include anxiety, obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD).
“People don’t associate anxiety with birth, but it’s very, very common,” notes Dassy Gordon, coordinator at Nitza. She’s worked with mothers who were suddenly scared to leave the house, enter an elevator, or stay home alone. It’s a vicious cycle: If the anxiety deteriorates into a full-blown panic attack, the woman starts feeling anxiety about having another attack.
Anxiety often centers on the baby: Is she healthy? Happy? Developing right? In severe cases, a form of OCD may develop, where the mother constantly checks her baby’s breathing. Sometimes it manifests only in thought: The mother has to keep telling herself — again and again — “Everything will be okay.”
“Women suffering from OCD know it’s illogical,” Dassy says. “But they feel out of control. Their brains are being manipulated.”
Mindy, whose mother passed away suddenly when Mindy was in her eighth month of pregnancy, suffered from a mix of anxiety and PTSD. Coursing through every diaper change, bath, and bedtime was an underlying worry that she’d die too — leaving her children orphans.
“I was terrified. I was sure I would die, and who would take care of them?”
Birth is a particular trigger for PTSD: Studies suggest that the delivery process revives old stresses. What’s more, many women experience birth itself as a trauma, especially if there are complications.
“Birth can be very frightening,” Dassy observes. “It’s understandable that many mothers have to process this trauma.”
Using hormonal contraceptives after birth may exacerbate — or impersonate — maternal mental illness. While some gynecologists gloss over the side effects, many women experience radical mood swings and mistakenly assume they’re having a postpartum reaction. For others, hormonal treatment aggravates a preexisting condition, introducing new levels of despair.
“I had low-grade PPD for years,” shares Shira. “But it was only under the influence of hormonal treatment that I started having suicidal thoughts.” Shira found viable alternatives quickly.
PPD AT HOME
Maternal mental illness of any kind has a profound effect on the family. “Akeret habayit is not just a cute catchphrase,” says Dassy Gordon. “It’s reality.”
In extreme cases, the household stops functioning: Kids wear dirty clothing to school, hygiene falls by the wayside, the supper table remains empty.
In milder cases, the cogs keep turning, but the inner damage is acute. A mother with a postpartum reaction cannot attend to her children’s emotional needs. Her marriage is severely compromised. And her relationship with her baby can be frighteningly flawed.
“It was the worst at night,” Chaviva remembers. “She’d wake up, again, and I thought I would hurt her.”
Sari remembers thinking, I don’t want to look at this baby.
While most women experiencing such intrusive thoughts never hurt their children, writes Pam Belluck in an extensive New York Times piece on the subject, some take extreme measures to protect their babies. One woman slid down the stairs in a sitting position for months because she’d imagined throwing her baby downstairs, reported Wendy N. Davis, the executive director of Postpartum Support International.
Maternal stress may cripple a woman’s ability to bond with or care for her child, studies indicate. As a result, the child’s emotional and cognitive health may suffer.
Dassy Gordon says passivity is a common fallout. Baby is developing a relationship with this world. When he smiles or cries and doesn’t get reactions, he subconsciously thinks, “Why should I smile or cry? What effect do I have on my surroundings?”
“These babies can become apathetic, lying in the crib for hours each day,” Dassy says. “They may grow into children who recoil from emotional attachment, who can’t build healthy relationships.”
Older siblings can also sustain long-term effects. Struggling with typical new-child jealousy and insecurity, they need extra love and attention. Instead, they might receive copious amounts of screaming and yelling, or feel obliged to take on a protective role, propping up a fragile mother who cries endlessly.
But, Dr. Wittenstein stresses, children are very resilient. If a woman seeks help in a timely manner, her kids will likely make a full recovery.
Beyond the children, the marriage relationship is obviously undermined. Many men — especially first-time fathers — are unfamiliar with postpartum reactions, and their ignorance adds insult to an already difficult dynamic. “You have a young boy who married a beautiful, charming wife,” Dassy Gordon says. “Then she’s sick for nine months straight. When she gives birth, he’s thinking, ‘Finally, I’ll have my happy wife back!’ But the opposite happens.”
Some husbands brush it off as “normal moodiness.” Then the wife starts making demands, and he gets resentful. “He doesn’t understand that he needs to stretch beyond his normal schedule to help her get past this,” Dr. Wittenstein says.
Sari blamed her husband for everything. Unwilling to admit another factor was at play, she attributed her never-ending upset to him: “If only you helped more, I wouldn’t feel this way.” The anger predictably intensified during high-pressure times like Yamim Noraim or Pesach. One Succos, she remembers not speaking to him all Yom Tov.
Shira, whose depression went undetected for years, felt deeply betrayed: She was in a dark pit, and her husband wasn’t pulling her out of it. “Every woman wants her husband to take care of her,” she says. “But I didn’t realize what was happening myself, and my husband didn’t pick up the cues.”
A CULTURE OF COPERS
Whether they suffer from depression, anxiety, or PTSD, frum women experiencing postpartum reactions face unique challenges. In a community that prides itself on large families and masterful juggling skills, mommies who are not managing feel enormous shame. And because of the emphasis placed on the beauty of motherhood (“Eim habanim semeichah!”), the woman who finds herself resenting — even hating — the role feels completely inadequate.
“We are raised with expectations about how happy we’ll be as mothers,” says Rebbetzin Michal Cohen, LCSW, a kallah teacher, social worker, and rebbetzin of Congregation Adas Yeshurun in Chicago. “Then you have a woman who can’t get out of bed, or has thoughts of hurting her baby. What is she supposed to think?”
“I lost my bren for Yiddishkeit,” Chaviva recalls. “Life was about keeping my head above water instead of becoming close to Hashem. I felt like a terrible Jew. I’d been so passionate in seminary, I had so many dreams… what happened?”
Chaviva’s pain was magnified by the fact that no one — not even her husband — validated her pain. When she reached out to mentors, they pooh-poohed her feelings, telling her it was normal to be overwhelmed after birth.
“That was the hardest part: not feeling heard,” Chaviva says.
When she finally went to the psychiatrist, who told her, “You have textbook PPD,” the relief was profound.
Denial of postpartum reactions is unfortunately not the exception. This flawed approach to mental health illness — resulting from community stigma or plain lack of awareness — can cause years of needless suffering, sometimes irrevocable emotional damage.
For Leba, it took six children and ten years of strained shalom bayis to seek help. Her refusal to face reality was part stigma, part ignorance. “My husband had a wife every other year,” she says sadly, adding that he was nothing short of a tzaddik for putting up with her. “I used to tell people: ‘It takes eight full months to recover from birth, you’re supposed to feel yucky!’ Looking back, I realize how abnormal that sounds.”
When Leba’s husband would show concern, wondering why she snapped so frequently at the kids, she’d say, “This is not medical, it’s avodas hamiddos.” When Leba finally made the trip to the doctor — at her husband’s insistence — she put up a tough fight.
“The doctor — who I’d already decided was a quack — recommended a mild antidepressant, and I was like, ‘Are you out of your mind? Do you know who you’re talking to? I’m Leba Katz, I’m normal!’ ”
“If your eyes weren’t working well, would you not get glasses?” the doctor matter-of-factly stated. “You’re missing some serotonin. That’s the whole story.”
The shame associated with therapy and mental health meds causes many frum women to delay treatment until the situation becomes untenable. “We have to be crawling on the floor, gasping our last breaths, in order to seek help,” rues Rebbetzin Cohen. “Why do we do that to ourselves? I wish therapy were one of the Aseres Hadibros: Thou shalt seek help.”
Another factor possibly aggravating PPD incidence in our community is the fact that there isn’t much emphasis on mothers taking care of themselves. Rebbetzin Cohen shares a telling incident: At the first session of a newly launched parenting class, she asked each woman to introduce herself. The questions included name, age, and range of children, and what each woman does to relax or unwind.
“Most of the women could not respond to the last question,” Rebbetzin Cohen reports. “I was floored. If you don’t outfit yourself with the oxygen mask first, your entire family will be comatose!”
Part of being a mother, says Rebbetzin Cohen, is making sure you are mentally and emotionally capable of caring for your kids. A 45-minute exercise routine is just as important — if not more so — than making a fresh supper.
“After all these years, I finally started treating myself to facials,” says Shira. “It sounds silly, but the emotional impact is real. Someone is taking care of you.”
Precisely when families are large, it’s critical that women stay on top of their emotional wellbeing. The larger the family, the more children are affected each time Mommy lapses into a postpartum reaction.
Treatment for postpartum reactions involves a multipronged approach of physical support, emotional support, therapy, and medication.
The first stop for a woman who suspects PPD is her obstetrician, who might refer her to a psychiatrist to evaluate if medication — usually in the form of antidepressants — is necessary. Next, the woman might call a postpartum support network like Nitza, who would refer her to a qualified therapist, hook her up with a support group, or arrange for a “phone friend” — based on her preferences.
Fearful of side effects to their unborn or nursing babies, many women are wary of taking medication (though research indicates the risk is minimal). But the damage of not taking it might be far more serious.
Mindy, whose psychiatrist prescribed a low-dose antidepressant, says the impact was immediate. “Within a week, I saw a difference,” she says. “I was reluctant to take it, but eventually I realized: You take Motrin for a headache, antibiotics for an infection, and antidepressants for mental illness.”
Leba’s results on medication were so positive that she’s continuing to take them, even though her baby is now pushing two. “I’ll get off of them one day. In the meantime, I have to be an effective mother.”
For Chaviva, landing on the right medication and dosage took time. “It’s not an instant happy pill,” she says. “But it did allow me to become grounded again. Life’s ups and downs kept coming, but the downs didn’t send me flying down a staircase anymore.”
Therapy is another critical treatment piece. It often comes in the form of cognitive-behavioral therapy (CBT), a structured, present-oriented psychotherapy focused on solving current problems and recasting negative patterns; or of psychodynamic therapy, a more analytical approach that examines the client’s past to reveal the unconscious intent of his actions or choices,
Therapeutic healing is also essential. This refers to a woman sharing her experience: letting go of the guilt, shedding feelings of inferiority, and internalizing that postpartum reactions could happen to anyone.
These feelings are facilitated when mothers speak openly with each other, normalizing the condition.
“Instead of pretending you have the perfect life,” Dr. Wittenstein urges, “share your story. For every person who courageously shares, so many others are affected.”
Alternative healing methods like reflexology or massage may be beneficial. But, warns Esther Gross, author of You Are Not Alone and moderator of a Williamsburg-based support group, these alone cannot be effective. “It’s like using an ACE bandage for a broken foot,” she says. “I meet women who spend $30,000 a year on alternative healing. I tell them: ‘Stop sabotaging yourself. Go to a doctor.’ ”
The importance of a solid support system in treating PPD cannot be overemphasized: Research indicates that proper social support (regular phone calls, home visits, offers of help, empathy) can reduce symptoms by 50 percent.
Husbands especially must be on board, offering extensive technical help and showing support for the interventions. Chaviva’s husband’s rosh yeshivah unilaterally directed her husband to make himself available both physically and emotionally.
“It’s funny — now that I know he’s available, I don’t need his help as much,” she says. “Knowing he’s there physically is so important to me emotionally.”
In contrast, Sari — who’s endured PPD four times — has developed some coping mechanisms, but she still hasn’t gone for professional help. “I wish my husband would put his foot down and tell me: I’m going to watch the baby and you have to go,” she says. “He’s just not that type.”
But whether or not Husband “gets it,” women like Sari must realize they deserve to take care of themselves. The short-term babysitting technicalities pale in comparison to the potential fallout of non-treatment.
A narrow slice of PPD cases resolve spontaneously within three years. Most untreated cases deteriorate or become chronic. And because depression often occurs with comorbidities like anxiety or PTSD, the depression may diminish while the comorbidity remains.
“A 45-year-old woman may still be suffering from postpartum depression,” says Dr. Wittenstein. “With each year, the impact becomes progressively more severe.” This means that at first, PPD struck an otherwise healthy family. Now, after years of abstaining from treatment, the mother must deal with PPD along with a host of marital and parenting issues that developed as a result.
What’s more, Dr. Wittenstein tells mothers, even if the condition fades away, “Two to three years is a long time to live like this. For you and your family.”
PREPARATION AND PREVENTION
Women who endured postpartum reactions are generally determined to use every means at their disposal to avoid a repeat experience.
“Next baby, I will not leave the hospital before going on medication,” Mindy says. “I will pursue therapy before birth, while I’m pregnant.”
“I will get more help,” Chaviva says resolutely. “No one else can mother my kids, but lots of people can wash dishes, fold laundry, and cook supper.”
“I’m open to bottle-feeding,” Rivka says, recalling the physical pain that plunged her further into depression. “I wanted to nurse so badly, but I’d do anything — anything — to avoid this again.”
On a communal level, reducing the rate and severity of postpartum reactions requires greater awareness and open discussion. Dr. Wittenstein feels strongly that childbirth education classes should include more emphasis on “not-dream births” and associated feelings of inadequacy and shock. Expectant mothers must learn more about PPD and its red flags, in a clear, non-alarming way.
“I assumed every woman with PPD was suicidal,” says Rivka, who suffered from milder depression. “If I’d only known to get help, I could have avoided two years of misery.”
Husbands must be especially prepared, since they are often the only ones in a position to help. Dr. Wittenstein’s dream is for every rosh kollel or rebbi to check in with new fathers every few weeks after birth, asking, “Is your wife getting enough sleep? Is she back to herself? Is there anything you’re concerned about?” Rabbanim should be supportive, lightening the pressure of husbands who may need to spend more time at home. Neighborly nurturing after birth is far-reaching. Besides meals and babysitting, women should try to tune in to the emotional needs of kimpeturin mothers. “Instead of only asking, ‘How are you managing?’ try asking, ‘How are you feeling? Are you happy with the baby?’ ” suggests Dassy Gordon.
Most of all, mothers must validate, validate, validate, scratching out the stigma with every conversation — so that women like Sari feel comfortable seeking help. “Even after experiencing depression many times, it’s so hard to face it,” says Sari. “I’m still convincing myself: If I ignore it, it will go away.”
Meanwhile, women like Leba — who have found relief through medication and support — are continually stunned at how joyful and manageable motherhood can be.
“I am beyond crazy about my baby,” Leba says. “He’s 24 months; I’m still nursing him; I’m hopelessly attached. I feel like he’s my first kid.”
DEPRESSION IN DADS
A little-known cousin of maternal mental illness, paternal postnatal depression (PPND) affects as many as 14 percent of fathers in the US. Experts dub it the “underscreened, underdiagnosed, and undertreated condition,” contending that real incidence is probably much higher, since men are less likely to report symptoms.
Depression in fathers presents differently than in their female counterparts: while men exhibit more traditional symptoms like fatigue, loss of appetite, or low motivation, they are less inclined to cry or show sadness.
Which men are vulnerable? Researchers have found a strong link between maternal depression and PPND, likely due to poor marital satisfaction. Some studies even propose that maternal depression causes PPND. But regardless of the mother’s condition, first-time fathers, unemployed fathers, and fathers of kids with special needs are associated with the highest rates of PPND.
And while the effects of PPND are milder than those of maternal depression, normal child development can still be hampered. Research indicates that children whose parents are not depressed have a 6 percent rate of emotional or behavioral problems. In homes where only the father was depressed, 11 percent of children will develop problems; where only the mother had symptoms, the rate among children was 19 percent.
Alarmingly, a child with two depressed parents has a 1 in 4 chance of having emotional or behavioral problems later in life. So both mothers and fathers should be on the lookout for the telltale signs of depression — and deal with them swiftly.