I recently wrote a post on postpartum depression which has generated a certain amount of negative comment. For this reason, I thought it might be helpful to clarify some points.
DEFINITION AND EXPLANATIONS
The DSM makes no mention of postpartum depression as such. The closest it comes is major depressive disorder with postpartum onset. In other words, the APA conceptualizes postpartum depression as ordinary major depression (which can incidentally range in severity from mild to severe) which happens to occur in the postpartum period. This is in marked contrast to the popular notion that postpartum depression is somehow a function of the postpartum woman’s hormones, and is fundamentally different from other forms of depression.
Despite two decades of very active research, there is no evidence that depression in the postpartum period is caused by a hormonal imbalance, no clearly specified mechanism of action, and no identifiable biological marker. This is similar to the state of affairs in depression research generally, where several biological theories have been proposed, but none has stood the test of time. There are some suggestions in the literature of correlations between physiological factors and depression in the postpartum period, but they are not always consistent and don’t establish a causal link.
In my view, the most reasonable way to conceptualize postpartum depression is that – similar to other depression – it is largely a function of adverse life events, coupled with feelings of isolation and hopelessness. The postpartum period, as I mentioned in the earlier post, is fraught with adverse life events, especially if a mother is poor, young, and single. This conceptualization of postpartum depression is consistent with the widely replicated finding that the risk factors most heavily associated with postpartum depression are: low education, low income, being unmarried, and being unemployed. Deepika Goyal et al (here) found that women with all four of these risk factors were eleven times more likely than women with none of these factors “to have clinically elevated depression scores, even after controlling for the level of prepartum depressive symptoms.”
No hormone treatment for postpartum depression has been shown to be successful. In the 1990’s there were some claims that hormone treatment had some efficacy in this area, but the claims have not stood the test of time. The present Mayo Clinic guidelines for treatment of postpartum depression are not enthusiastic with regards to hormone therapy.
“Estrogen replacement may help counteract the rapid drop in estrogen that accompanies childbirth, which may ease the signs and symptoms of postpartum depression in some women. Research on the effectiveness of hormone therapy for postpartum depression is limited, however. As with antidepressants, weigh the potential risks and benefits of hormone therapy with your doctor.” [Emphasis added]
This is in marked contrast to genuinely biologically-induced depression. It has been known for more than 100 years, for instance, that hypothyroidism, even at low levels, can lead to depression/psychosis in some people. Treatment consists of thyroid replacement, and the depression/psychosis usually abates readily.
Antidepressant drugs are routinely given to women with postpartum depression, even though it has long been established that their average efficacy in the short-term is no better than placebo.
It is also well established that the use of antidepressants increases markedly the risk of recurrent episodes of depression in the long-term.
There is also a growing body of evidence which suggests that the use of some antidepressants increases the risk of suicide and serious aggression, including murders.
The point prevalence rate for depression in the postpartum period is not significantly different from similarly-aged women generally (Gaynes, BN, et al, Perinatal Depression: Prevalence, Screening Accuracy, and Screening Outcomes.) In other words – and again, contrary to popular belief – the postpartum period is not marked by a significant increase in depressive episodes. So even if there is some, as yet unconfirmed, hormone-induced depression, it clearly is not sufficiently prevalent to noticeably swell the ranks of postpartum women with depression. In this context it is also worth noting that screening tests that are used for postpartum depression are the exact same tests used to screen for non-postpartum depression. There is no special test for postpartum depression. In this regard “postpartum depression” is a misleading term and would be more accurately called depression in the postpartum period.
Much of the criticism directed at my earlier post charged me with minimizing the severity of postpartum depression. In fact, I had made no mention of severity. There is a widespread misconception that if one says that depression is not an illness, one is saying either that depression isn’t real, or that it isn’t severe. That neither of these positions is true should hardly need saying, but let me clarify my position.
Depression is real. Everybody gets depressed at some time or another. Sometimes the depression is mild and can be shrugged off without difficulty. Other times it is severe. Occasionally – I believe very occasionally – it is primarily a function of a biological factor, but this should not be assumed without clear evidence. The vast majority of depression – including depression in the postpartum period – is a function of adverse life events/circumstances.
THE CONCEPT OF DEPRESSION
An overriding consideration in this discussion, or indeed any discussion of depression, is the widespread assumption that depression is a unified, definable, and measurable phenomenon. In reality, all of these assumptions are false. There is a great deal of variation in the way that individuals experience, and respond to, depression. There is no definition of depression that would meet scientific standards, and measuring instruments that purport to measure depression actually measure what people say about their depression, which isn’t necessarily the same thing. There are, for instance, all sorts of reasons that a person might say he’s “fine” when in fact he’s quite despondent. And vice versa.
The point here is not that we shouldn’t discuss depression, but rather that when we do have discussions of this kind, there is great potential for confusion.
At the risk of stating the obvious, everybody is different. Different people react to situations and circumstances in different ways. Some people do indeed become extremely despondent in the postpartum period and at other times. How individual people conceptualize their problems and what they choose to do about them are clearly their own choices, and it is certainly no business of mine to challenge people in these regards.
The purpose of this website is to challenge what I believe are spurious and destructive tendencies in modern psychiatry, and my challenges are based on logical analysis, research findings, and common sense. Some people agree with what I write. Others do not. We can agree to differ.
In my original post I mentioned the websites Postpartum Depression and Postpartum Support International, and recommended that they be “viewed on an empty stomach.” This was undignified and inappropriate, for which I apologize to the writers. I have removed the sentence. It is still my contention, however, that the sites be viewed with a critical eye.