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Recurrent Postpartum Depression

QUESTION: I've had postpartum depression twice. With my first child, I started having symptoms 20 weeks into the pregnancy and I hit rock bottom six months after my son was born. With my second child, the symptoms started 12 weeks into the pregnancy and I went on Paxil, which prevented me from hitting bottom again. My daughter is now eight months old, and I can still "feel" postpartum depression lingering in the background. I really want to get off the Paxil. Can I do that without losing ground?

ANSWER: Becoming a mother is one of the greatest identity changes that you will ever experience. Yet, the impact of motherhood on women's health remains largely unrecognized in our culture. Postpartum depression is in part a result of the lack of emotional support available for women going through this transition.

Our society simultaneously pressures women to be "good" mothers and devalues the work of nurturing. Though we give lip service to the importance of motherhood, women still experience disrespect for the unpaid work of caretaking. Cultural pressures inherent in motherhood, coupled with "invisibility" of the work being done, is internalized. Is it any surprise that the adjustment to motherhood becomes a breeding ground for low self-esteem and resulting depression?

Women are brought up to defer their needs to nurture others. This is our culture's simple means of differentiating between a "good" mother and a "bad" mother. No wonder so many women, like yourself, do not even notice the early signs of depression. The first step in prevention is to understand your own emotional needs, the forces that exist to forget these needs, and find an appropriate balance which includes self-care.

Women are additionally vulnerable to depression during pregnancy or postpartum because it is also a transition which brings up our personal family history. Let's take a look at several of the most common sources for depression during this life transition. Consider whether any of the following possibilities could be contributing to depression in your life.

The first is cultural gender programming that kicks in when you take on parenting roles in the family. For example, women often lose decision-making power in their marriages when they no longer bring in money. They may unconsciously "defer" to their husband's needs or decisions, rendering them depressed and powerless without realizing it. Or they continue jobs outside the home, without changing their workload inside the home, contributing to work overload and again, depression.

The second reason is past neglect or unresolved family conflict experienced in childhood. Motherhood brings us close to our own experience of our mothers. How did you feel about your mother's role in your family when you were a child? Was she happy, powerful, depressed, victimized? What kind of messages did you absorb about women's experiences of motherhood, pregnancy and childbirth? If positive, do you identify with her or not? If not, why not?

How did you see your mother's position in her marriage to your father? Were they happily married? Unhappily married? Was there a loss through death or divorce in your childhood? Pregnancy, childbirth and early parenthood is replete with unconscious expectation for repeating losses that occurred in childhood. You cannot help but relive the ghosts of the past as you create your own family constellation.

Your depression can in part be a result of unrecognized fears and unresolved experiences that live in your past, but are affecting your current feelings. If so, individual therapy can help you separate yourself from your past and shape your own future more positively. Refer to my book, "An Easier Childbirth" for questionnaires exploring your personal experience as preparation for a healthy adjustment to pregnancy and motherhood.

Consider whether you got the nurturing you needed from your own parents. If not, it can be quite a stretch to emotionally give to your children what you did not get! Motherhood already requires some significant sacrifice. Childhood feelings of neglect or abandonment can add additional stress to your adjustment when triggered by your own baby's cries. Motherhood is instinctive and it is also learned. What you did not get, you can learn to give. But first you must become aware of the lack!

Unresolved feelings about the pregnancy and childbirth can also contribute to postpartum depression. Because childbirth is an experience of great magnitude, it is NOT a neutral event for any woman. The very physical ordeal that is childbirth can be empowering or it can be humiliating, depending on how women are treated throughout the process.

Hormonal changes in pregnancy and postpartum can magnify feelings and contribute to depression. However, the underlying emotional vulnerability stems from the meaning of this transition in women's lives. Many things besides low serotonin levels (for which antidepressants such as Paxil are prescribed) conspire to cause depression. Antidepressants are best used as a compliment to psychotherapy when the counseling alone has not been successful at reducing feeling and thinking patterns that lead to depression.

Consider ongoing counseling with a therapist who has prenatal and postpartum expertise as long as you are on the Paxil. When you have identified patterns of thought and behavior that contribute to your depression and you feel you have the "tools" and a supportive and empathic connection with your counselor to work through life events, talk with your psychiatrist about gradually decreasing the anti-depressant. (Do not take an anti-depressant prescribed by a physician without psychiatric training or consultation. Like any specialty, mental health should be treated for cause and symptom, not symptom alone. In addition, psycho-pharmacology is constantly changing and requires expert consultation.)

Certainly you should use the Paxil if it is necessary for functioning or if it helps you get a "step-up" on changing persistent self-defeating behaviors. But it is not wise to use an antidepressant in lieu of therapy. It is likely that you will discover that your dependence on the drug is, at least in part, your compensation for depending on a primary relationship. With guidance, you may discover ways your husband and others can give you the emotional support you may need, but have not as yet identified.

Gayle Peterson, MSSW, LCSW, PhD is a family therapist specializing in prenatal and family development. She trains professionals in her prenatal counseling model and is the author of An Easier Childbirth, Birthing Normally and her latest book, Making Healthy Families. Her articles on family relationships appear in professional journals and she is an oft-quoted expert in popular magazines such as Woman's Day, Mothering and Parenting. . She also serves on the advisory board for Fit Pregnancy Magazine.

Dr. Gayle Peterson has written family columns for ParentsPlace.com, igrandparents.com, the Bay Area's Parents Press newspaper and the Sierra Foothill's Family Post. She has also hosted a live radio show, "Ask Dr. Gayle" on www.ivillage.com, answering questions on family relationships and parenting. Dr. Peterson has appeared on numerous radio and television interviews including Canadian broadcast as a family and communications expert in the twelve part documentary "Baby's Best Chance". She is former clinical director of the Holistic Health Program at John F. Kennedy University in Northern California and adjunct faculty at the California Institute for Integral Studies in San Francisco. A national public speaker on women's issues and family development, Gayle Peterson practices psychotherapy in Oakland, California and Nevada City, California. She also offers an online certification training program in Prenatal Counseling and Birth Hypnosis. Gayle and is a wife, mother of two adult children and a proud grandmother of three lively boys and one sparkling granddaughter..

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