Tina Merritt, now 39, of Virginia Beach, Va., had heard of postpartum depression when she was pregnant seven years ago. But when she gave birth to her son, Graham, she expected nothing but joy as she and her husband welcomed the baby boy who would be the first grandchild on both sides of their families.”It took me a while to get pregnant, and it was a huge deal for everyone,” Merritt says.”I worked right up to the end of my pregnancy and felt great. I’d planned so long for this baby, I really thought everything would be wonderful.”

Of course she did, says Michael Silverman, PhD, assistant professor of psychiatry at the Mount Sinai School of Medicine in New York City. “Most women have bought into the belief that when you give birth to a child, you immediately feel love like you’ve never experienced. [But] for many women, that’s not reality. They feel that they’re defective, that something’s wrong, and they can’t talk to anyone about it.”

Instead of the picture-perfect motherhood she imagined, Merritt found herself terrified of taking care of her new son, worrying she would make a mistake. She describes the first year or more of his life as a big fog. “I don’t remember much at all. I don’t remember how old my son was when he crawled, don’t remember him taking his first steps or eating solids for the first time.”

It wasn’t that she didn’t want to care for her son, Merritt says — she just didn’t feel that she could. “I thought my husband or my mother-in-law could do it better, that I was supposed to be this perfect mother but I couldn’t be,” she recalls. Merritt’s husband took on most of the child care, and she returned to work when Graham was 6 weeks old. “That was the one thing I could do right. I could work. Before that, my husband would come home from the office, and I’d be in the chair in my pajamas holding the baby — exactly where I’d been when he left. I was so afraid to be alone with my son. He was 2 before I even took him to the grocery store by myself.”

Perinatal Mood Disorders

To the 800,000 women who develop one of several types of perinatal mood disorders each year (that’s about 20% of new mothers), Merritt’s story is painfully familiar. Postpartum depression is often used as a catch-all description, but in fact, perinatal mood and anxiety disorders include a lot more than just classic depression — and they can start before or well after delivery. New moms can develop:

Depression: This can include the typical signs, such as sadness and crying, as well as anger and irritability.

Anxiety and panic disorder: Like Merritt, mothers might feel anxious and fearful about their ability to take care of their baby and worry they will do something wrong. Some suffer debilitating panic attacks and feel unable to go out in public.

Obsessive-compulsive disorder: Women with postpartum depression can be plagued by constant worries about germs or intrusive thoughts about harming their baby. Others are obsessed with doing everything “perfectly.”

Posttraumatic stress: If something went wrong during birth — a medical complication or an emergency cesarean — a mother might have anxiety attacks with flashbacks.

Postpartum Depression: a Hidden Epidemic

Although perinatal mood disorders are common, more than half of all cases are unrecognized and untreated. Some doctors attribute them to the “baby blues,” a short-lived state of intense emotion that comes on and disappears quickly. In some cases, women don’t confess their symptoms for fear of judgment or stigma. That’s particularly tragic, experts say, because perinatal mood disorders — such as postpartum depression — respond well to counseling, medication, and other treatment.

“Even highly intelligent women don’t recognize what they have, and when they do try to reach out, people just say, ‘Yeah, that’s motherhood. It’s tough,'” says Birdie Gunyon Meyer, RN, MA, CLC, coordinator of the Perinatal Mood Disorders Program at Clarian Health in Indianapolis and president of Postpartum Support International. “Between 1% and 3% of women get gestational diabetes, and we check all women for it. About 20% of women get perinatal mood disorders, and we still don’t routinely screen for that,” she says. (That could change soon; see “The MOTHERS Act” below.)

Causes of perinatal mood disorders are still poorly understood, but researchers speculate that shifting chemicals in the brain during and after pregnancy — such as oxytocin, a hormone related to mood — play a role. It’s more complicated than that, though, because new adoptive parents and fathers — who are never pregnant — can also develop depression and mood disorders.

Baby Blues vs. Postpartum Depression

When Merritt talked to her doctor at her six-week follow-up visit, she told him that she was crying a lot and that things didn’t feel right. “He said ‘Oh, that’s just the baby blues. It’s your hormones; it’ll go away.'”

Her doctor was wrong. The baby blues and perinatal mood disorders are two very different things. Some 80% of women do have the baby blues after delivery, and it’s true some symptoms are the same as for postpartum depression, such as mood swings, sleep disturbances, and loss of appetite. Sometimes the baby blues just involve an excess of emotion — crying often, for no reason.

But the baby blues come and go quickly. “Generally, these symptoms start within several days of delivery and usually go away within a couple of weeks,” says Silverman. At six weeks after delivery, Merritt was well past the baby blues stage.

True postpartum depression, on the other hand, can begin any time in the first year after a baby is born. “The diagnostic criteria for postpartum depression say it’s a depression that starts within the first four weeks after delivery, but it can start later than that — or even before delivery,” says Shoshana Bennett, PhD, a former president of Postpartum Support International and author of Postpartum Depression for Dummies and Pregnant on Prozac: The Essential Guide to Making the Best Decision for You and Your Baby.

That’s why it’s so important during the first few months to pay attention to any sense that things just aren’t right. If you’ve had a psychiatric disorder in the past or a perinatal mood disorder with a previous child, keep an eye out for symptoms.”Trust your instincts,” says Karen Kleiman, MSW, LSW, executive director of the Postpartum Stress Center and author of several books on the disorder. “If you think something isn’t right, it probably isn’t. That doesn’t mean something terrible is going on, but you should get help.”

Start by calling your obstetrician — more doctors are aware of postpartum depression issues now and can refer you for treatment. But if your doctor dismisses your concerns, as Merritt’s did, contact a local or national support group.

Postpartum Depression vs. Postpartum Psychosis

What if you think you’re going to hurt your baby? Christina Garman, 33, of Euclid, Ohio, says she still can’t shake a memory from when her daughter Molly was a baby. She was sitting on her bed breastfeeding, but even as she nursed, Molly was still crying. A frustrated, exhausted Garman, who had struggled with post-delivery abdominal pain and difficulty nursing, had reached her limit.

“All I could see myself doing was throwing her across the room,” she recalls, the horror of the moment still in her voice. “Or shake her. I would never do that, but for some reason those thoughts kept coming into my head. I thought, ‘Who are you, and what have you done with your brain?'”

Garman’s story might remind you of Andrea Yates, the Texas mother who drowned her five children in the bathtub. But Yates had postpartum psychosis, a very different and more rare condition that should not be confused with postpartum depression. It is not an extreme form of postpartum depression but a separate condition in which a new mother has a genuine psychotic breakdown and could harm her children. Garman was eventually diagnosed with postpartum depression obsessive-compulsive disorder.

About one in every 1,000 new mothers develops postpartum psychosis, compared to the one in five who goes through other perinatal mood disorders. It comes on “very shortly after delivery, within the first 72 hours to the first couple of weeks,” says Gunyon Meyer. “Often the first sign is that the mother is speeded up, not sleeping, and yet she feels great. Then she’ll be having these unusual thoughts about harming the baby or ‘protecting’ the baby from evil by harming him or her. Sometimes these thoughts will wax and wane a little, so she thinks it’s going away and doesn’t tell anyone until she has a true psychotic break.”

Both women with postpartum depression and women with postpartum psychosis have thoughts about hurting the baby, but the difference is that women with postpartum depression, like Garman, are horrified by these thoughts, while women with postpartum psychosis think they’re normal. With postpartum depression, “acute depression and anxiety develop in ways that make women feel as if they’re going mad,” Kleiman says. “They don’t realize that having these thoughts doesn’t mean they’re going to act on them. The thoughts are horrible and scary, but the good news is that they do scare you. Women with postpartum depression don’t hurt their children. In fact, they’ll go to extreme lengths to protect their children, even hurting themselves to avoid harming their child.”

Treating Postpartum Depression

True postpartum psychosis requires intensive treatment and often hospitalization. But most women with postpartum depression and other perinatal mood disorders can find relief relatively quickly with treatments that usually include some combination of medication and counseling. In therapy, women learn specific techniques to quell persistent anxiety and rid themselves of intrusive thoughts about harm coming to their baby.

Women are also encouraged to find a way to take care of themselves, not just the baby. “You’re a pitcher of water, and if you’re always giving, you’re going to be empty. How do you fill back up?” Gunyon Meyer asks. “Make sure you’ll have time to go to the gym or even just the grocery store alone.”

Antidepressants are another element of treatment for some women. Many worry about taking antidepressants, especially if they are nursing, because medication does get into breast milk. But most experts say those fears are generally exaggerated. “Though nothing is ever 100% risk-free, we do have studies that show no long-term adverse effects from taking antidepressants while breastfeeding,” Gunyon Meyer says. On the other hand, she points out, numerous studies show how being severely depressed or anxious while pregnant or breastfeeding can have a negative effect on the baby.

Garman and Merritt, much like most of the women who come to the support group Gunyon Meyer runs, took medication in addition to counseling. Garman benefited from a program developed by her health insurance company, Medical Mutual. When a routine follow-up call the company makes to check on moms revealed signs of postpartum depression, the insurer alerted Garman’s doctor, who called to intervene. She spent three months on a low dose of an antidepressant and had weekly calls with a social worker provided by her insurance company.

Healing From Postpartum Depression

It took Merritt much longer to find help. It was only after Graham, then 2½, broke his leg falling out of his crib that both Merritt and her husband felt so guilty they pursued counseling. That’s where they learned that Merritt’s strange detachment from Graham was due to postpartum depression and anxiety. She started taking antidepressants and continued with counseling, and within several months her anxiety began to wane. “They’d give me goals: ‘You’re going to go do this with your son by yourself this week,'” she recalls.

For Garman, in retrospect, there were warning signs that she might be at higher risk for postpartum depression. “I had dealt with anxiety on and off when I was younger, and took medication for it,” she says. “I’d even seen one of my close friends go through postpartum depression. But in myself, I just couldn’t see it.” Even during treatment, Garman struggled with feelings of guilt. “I kept asking my social worker, ‘Why do I feel like this?’ And she’d say, ‘Christina, it’s not you.’ I really had to learn to forgive myself for feeling that way.”

Merritt says her son was about 3 before she really felt confident caring for him. She says the transition to parenthood is so rough that almost every new mom could benefit from therapy. “Becoming a parent is a life-changing experience,” she says. “It changes your marriage, your career, everything. People don’t get it. Even though I was fortunate and had a lot of people helping me, no one really understood what was going on.”

“There’s nothing that’s not stressful about bringing a new baby into your home,” Silverman says. “For many women, it helps just to know they’re not alone. Remember those pictures of Brooke Shields when her first daughter was born? She looked like the glowing mother, but now we know, because she shared her story, that she was miserable. So if you’re miserable, too, it doesn’t mean you’re defective. You’re not crazy. It’s OK that you feel crappy, and it’s OK that you don’t feel this instant bond. But it can get better, and it will — if you get help.”

Creating a Postpartum Wellness Plan

Even if you’re not at risk for postpartum depression, it’s a good idea to create — in advance — a comprehensive wellness plan to follow after the baby is born. “This can actually help prevent postpartum depression,” says expert Shoshana Bennett, PhD. Key elements of the plan include:

Sleep:
Sleep deprivation can induce or worsen postpartum depression. Even if you’ll be breastfeeding, designate someone else to share nighttime duties. Consider pumping so that someone else can feed the baby on occasion, and you can get a few full sleep cycles.

Support: Who’s going to help out? How will you take a break? When will you get out of the house? Line up friends and family or consider hiring a doula, a professional who helps guide women through delivery and bringing baby home. Research shows that women who have labor and postpartum doulas reduce their risk of developing postpartum depression. But be sure that people who sign up to help know what you need. “Some people who think they are ‘helping’ aren’t,” Bennett says. If your mother’s idea of helping is holding the baby while you make lunch — and that’s not the kind of help you need — be prepared to explain what you really want. “Don’t worry too much about hurting people’s feelings. It’s more important to take care of yourself and your baby.”

Exercise: What you can do physically might depend on your recovery after giving birth. Even a walk around the block with baby in a stroller or sling gets you moving in the fresh air. It might not seem like a workout, but it’s a start. Hit the mall for a stroll if weather doesn’t cooperate.

Food and water: A plan for nutrition and hydration might sound obvious, but many new moms are so busy caring for the baby that they don’t eat right. Not getting enough water and protein, especially if you’re breastfeeding, can leave you depleted and vulnerable. Drink at least half your body weight in ounces of water per day (if you weigh 150 pounds, that’s about nine 8-ounce glasses), and nibble on high-protein snacks such as nuts, hard-boiled eggs, and yogurt throughout the day.

Realistic expectations: Make a list of motherhood myths you won’t buy into, such as “I’m not a good mom if I can’t breastfeed,” “I should be madly in love with my baby from the second I see him,” and “I should lose all the pregnancy weight and look like Heidi Klum before my baby is six months old.”

Help for Depressed Moms: The MOTHERS Act

When Melanie Blocker Stokes gave birth to her daughter, Sommer Skyy, in 2001, she seemed to have it all: a successful career, a devoted husband, and a beautiful, healthy baby. But by the time Sommer was a month old, Stokes was crippled by depression so severe that she stopped eating and drinking. Plagued by paranoid thoughts, she was put on a series of antipsychotic drugs, but eventually jumped to her death from the 12th floor of a Chicago hotel.

Stokes had postpartum psychosis. In her name, the Melanie Blocker Stokes MOTHERS (Mom’s Opportunity to Access Health, Education, Research, and Support for Postpartum Depression) Act was introduced in Congress in January 2009. The legislation is aimed at improving research, screening, and treatment for perinatal mood disorders.

Sponsored by Sen. Robert Menendez (D-N.J.) and Rep. Bobby Rush (D-Ill.), the bill funds grants that help health care providers recognize, identify, and treat perinatal mood disorders. It also encourages the Department of Health and Human Services to conduct a national public awareness campaign around perinatal mood disorders and orders the department to study the benefits of screening for postpartum depression and postpartum psychosis.

The MOTHERS Act, supported by a broad coalition of groups ranging from the American College of Obstetricians and Gynecologists and the American College of Nurse-Midwives to the National Alliance on Mental Illness and the Suicide Prevention Action Network USA, passed the House of Representatives by a nearly unanimous vote in March. The legislation is awaiting action in the Senate, where it has broad support but has been stalled by the objections of one senator. You can urge your senator to support the MOTHERS Act, S. 324, by calling 202-224-3121.