The Debate about Causes of Postpartum Depression

(Written on the last day of Women's History Month)

Pregnancy is in the news with the announcement that Kate Middleton is expecting a baby and that maybe she even let it slip that its sex is female.

Pregnant women and new mothers are supposed to feel happy, since after all, this is what we women are allegedly born to do: Give birth and nurture.

But also in the news are some recent studies of postpartum depression, the very term telling us that it's not all sunshine and smiles.

About 35 years ago, when I started thinking about what became Don't Blame Mother: Mending the Mother-Daughter Relationship (first worked on it in the late 1970s, first edition published 1989, THE NEW Don't Blame Mother published in 2000)*, I was troubled that the talk about postpartum depression always seemed based on the notion that women's hormones somehow made them "go crazy" after they gave birth. Why did that trouble me? Because I had myself been through the fears and anxieties that so many women go through during pregnancy -- Will the baby be healthy? How in the world will I know how to be a good mother? How can I protect the baby and growing child from the physical dangers and the many heartaches the world can bring? -- and the huge sense of responsibility of being a new mother, when we realize that being female does not automatically give us all the answers about how to be a good mother.

Consciously or not, both women and men in this country and many others know that if anything goes wrong with one's baby, child, teenager, or even adult offspring, the mother will almost invariably be blamed, whether or not she is at fault. In fact, after I raised concern about mother-blame at the clinic where I was working and was told my the psychiatrist who was my team leader that he thought I was just imagining how common it was, and that that was because I was a woman, a mother, and -- horrors! -- a feminist, I decided to put my training as a researcher to use, to see if he was right. With Ian Hall-McCorquodale, I did a systematic study of mother-blame in major clinical journals and found that it was even more rampant, unwarranted, and horrific than I had feared.** Despite the glorious aspects of having a child, it is damned hard to know every moment that you will be blamed for virtually every problem the child might have, and that anxiety -- no, more appropriate to call it fear, even terror, because nothing less than your child's welfare is at stake -- plagues so many mothers. In fact, just a few days ago, I was a guest on a radio show on which another guest said repeatedly that if anything goes wrong, it is right to blame the mother, because her relationship to the child is closer than that of anyone else. Whether or not you believe that her statement about closeness is true -- and it certainly is not true of some mothers, and of course some fathers are as close to or even closer to their children than are the children's mothers -- there simply is no epidemic of father-blame that remotely approaches the pervasiveness of mother-blame.

Mothers, as I wrote in 1989/2000, raise their children in a world permeated by motherhood myths, some of which set standards so high that no human could reach them (mothers are 100% nurturant 100% of the time, good mothers never get angry, mothers instinctively know everything they need to know about raising healthy children) and some of which urge us to take even good things that mothers do (e.g., being close, loving, and caring) and transform them into "proof" that mothers are bad (e.g., mothers' closeness is smothering).

There is in addition the terrible isolation that many mothers feel. The isolation stems partly from demographic changes in recent decades, leading to the geographic isolation of mothers from family members and/or frequent moves to new communities in search of employment, leading to geographic distance from close friends. The isolation also stems from the pressure on women to be happy and serene as mothers, even as brand-new mothers whose bodies may be physically depleted from pregnancy and/or labor and delivery. In fact, it struck me in the late 1970s how positively absurd it is to expect that the very person whose body has just been through the physical demands of pregnancy, labor, and delivery is the one person who is expected to be ready, able, and delighted to do the lion's share of caring for the newborn. If someone told us that a neurosurgeon who had just been on her feet doing brain surgery for 72 hours straight was about to operate on someone we love, we'd ask for a better-rested surgeon.

Still another cause of social isolation is this: Given that a new mother is supposed to feel simply elated, fully competent, and even calm, many women are mortified when they feel terrified, clueless, and exhausted, and the last thing they need is for anyone to find out about these "inappropriate, unmotherly" feelings. They assume something is wrong with them for not simply having the emotions depicted on greeting cards about new babies.

When I think about my own experience, I know -- have always known -- how privileged I was as a new mother, because despite all of the concerns, fears, and insecurity I felt, I did not at the time have to worry about whether I would have enough money to support a child. And as a white woman, I was not subjected to racism. I was not a battered wife. If any of that had been different, how much more reason would I have had for anxiety and despair.

Should we surprised, then, by a recent report*** that at one obstetrical hospital, 14% of the women "screened positive for depression"? In fact, I am surprised that that percentage is not higher. But let's look further at that report. Rather than being a study of the kinds of factors described above and how they affect new mothers, this one was designed as a "psychiatric" investigation: Their orientation was to call upset in new mothers psychiatric disorder instead of understandable responses to the intense pressures and isolation of these women. It's a simple matter to classify their fear, insecurity, and even despair of being able to measure up to the impossible motherhood standards as psychiatric disorder. In fact, that is literally all it takes: Note these feelings, and label them mental illness, which is how "postpartum depression" is often classified. Then the new mother has an additional burden: Her totally understandable feelings have been classified as sickness, and she feels even more than before that she is defective, that the fault is simply her own. She becomes alarmed that her alleged mental illness is now something else that will put her baby at risk. And too often, another consequence of labeling postpartum upset and suffering as mental illness is that the woman is put on psychiatric drugs that, as always with such drugs, can sometimes help some people, at least for awhile and maybe for longer, but on balance do more harm than good.**** Furthermore, in new mothers, taking psychiatric drugs can seriously harm the baby through breastfeeding, which therefore must be stopped.

It is alarming that calling postpartum depression a mental illness takes the focus off the many social changes we need to make to reduce the burdens on new mothers, such as providing more social support and practical help, providing better healthcare for mother and baby, and working hard to expose the myths about motherhood and reduce the mother-blame that put unnecessary and enormous burdens on mothers.

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Another new study scheduled for future publication***** reveals that -- surprise, surprise! -- when new mothers feel that they have more social support from their families, the rate of postpartum depression declines. They say that this is the case for women from "diverse socioeconomic and ethnic/racial backgrounds." The authors of this study also report that that social support dampened the mother's "corticotropin-releasing hormone" during pregnancy and that that helped reduce postpartum upset. It is important to know that that hormone is a response to what is euphemistically and vaguely called "stress" but that I prefer to call intense emotional and social pressures. Unlike the unfounded claims that what gets called "mental illness" is caused not by what happens to people in their lives but rather by abnormal neurochemistry or "broken brains," there is now this proof the cause-effect relationship is the reverse: Lack of social support causes a physiological change, and it is known that problems with stress hormones can cause or intensify exhaustion, the last thing that a new mother needs. So in the absence of adequate social support, it makes sense that the rise in this hormone intensifies the new mother's exhaustion, which understandably increases the chances that she will feel despair about the prospect of being able to provide adequate care for her newborn. All the more reason to provide more support of various kinds for new mothers, rather than assuming they have mental disorders and moving immediately to drug them. And as shown in this new study, the earlier that that support is provided, the more effective it is in reducing problems for the mothers.

One final thought is about that word "depression." The brilliant David Jacobs and David Cohen challenge us to think about how freely, vaguely, and variously it is used.****** Their argument about its lack of specificity is so compelling that it has made me realize that when someone tells me they are "depressed," I know little other than that they are feeling badly somehow. I have adopted the practice of asking people who use that word to answer the following question: "If you were not going to use the word 'depressed,' what word or words would describe what you feel?" And I have been amazed by how much more clearly the person is able to specify what they feel and how much easier it is for me to understand -- and relate to -- what they then say. Usually, their response includes one or more of the following: sad, grief-stricken, lonely, helpless, hopeless, wistful, nostalgic, longing, or despondent. I conclude this essay by suggesting that for women experiencing postpartum emotional problems (as for anyone else who is suffering emotionally), we try to help them understand more specifically what they are feeling, because if they come up with any of the words in the list above, it is easier both for them and for us to know what might help.

*Caplan, Paula J. The New Don’t Blame Mother: Mending the Mother-Daughter Relationship.
New York: Routledge, 2000.
**Caplan, Paula J., & Hall-McCorquodale, Ian. Mother-blaming in major clinical journals. American Journal of Orthopsychiatry, 55, 1985, 345‑353; and Caplan, Paula J. & Hall-McCorquodale, Ian. The scapegoating of mothers: A call for change. American Journal of Orthopsychiatry, 55, 1985, 610‑613.
***Postpartum Depression: Surprising Rate of Women Depressed After Baby. 2013, March 13. http://www.sciencedaily.com/releases/2013/03/130314124618.htm
****Whitaker, Robert. Anatomy of an Epidemic. 2010.
*****Hahn-Holbrook, Jennifer; Dunkel Schetter, Christine; Arora, Chander; & Hobel, Calvin J. Placental corticotropin-releasing hormone mediates the association between prenatal social support and postpartum depression. Clinical Psychological Science. 2013.
******Jacobs, D. H., and Cohen, D. (2010). The make-believe world of antidepressant randomized controlled trials---An afterword to Cohen and Jacobs (2010). The Journal of Mind and Behavior 31, 25-36.

©Copyright 2013 by Paula J. Caplan All rights reserved