Chapter 5
A Professional Assessment: What’s Huffing and Puffing at Your Mind’s Door?
In This Chapter
Unraveling the confusion about the PPD diagnosis
Preparing yourself for an evaluation
Being screened professionally for PPD
Handling the news of your diagnosis
If you have postpartum depression (PPD), or if you think that you may have it, you should most definitely not shy away from seeking professional evaluation and treatment, because the faster you get help, the faster you’ll begin to feel better. The ideal professionals to give you an initial assessment include an informed, experienced, and sympathetic psychiatrist (a medical doctor with special training in mental and emotional disorders) or a clinical therapist, such as a psychologist (PhD). Knowledgeable psychologists can assess and evaluate you plus give you information regarding medications (if necessary). A psychiatrist, on the other hand, can assess and evaluate you and can also actually prescribe the medication if necessary and appropriate.
Having sought an assessment, you may receive a diagnosis of PPD, and for some people this can be confusing, scary, and even overwhelming. In order to help set your mind at ease — and to prevent a diagnosis of PPD from, ironically, making you feel more depressed — this chapter briefly explains the history (and difficulties) of diagnosing PPD and then focuses on what a modern PPD diagnosis looks like, what it means, and how you can best deal with it.
The Difficulties of the Diagnosis
Besides the fact that it ignores the reality that PPD has been known as its own unique disorder since at least the 1830s (to save you a headache, I won’t digress into the details here), the present terminology used by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) is quite confusing. The DSM-IV, which is the thick manual that doctors and therapists use to diagnose mental health disorders, is confusing for the following reasons:
It contains no actual diagnosis called postpartum depression.
The same woman may be described and diagnosed differently on different occasions (because of the all-over-the-place, up-and-down nature of PPD).
The medical records of patients hospitalized for PPD or other psychiatric illness after childbirth often use different terms to describe and diagnose.
The present terminology confuses not only those responsible for medical care, but the criminal justice system and insurance systems as well.
As a result, a woman with PPD often has her rights sacrificed or compromised. For example, when members of the criminal justice system hear “postpartum something or other,” they tend to overreact.
Although my colleagues and I are taking steps in the right direction by educating medical and mental health practitioners as well as the sufferers themselves, it remains to be seen if substantial progress will actually occur by the time the next edition of the DSM arrives. Luckily, excellent professionals are also working on clarifying and standardizing the official medical terminology.
Taking a Pre-Assessment: The Edinburgh Postnatal Depression Scale
I have two favorite formal PPD assessments, both of which may be used by the diagnostician as part of the evaluation. One is the Postpartum Depression Screening Scale (PDSS), and the other is the Edinburgh (pronounced “edinburrow”) Postnatal Depression Scale (EPDS). The PDSS is excellent, but only available for professionals to purchase and administer. It can’t be printed here for copyright reasons.
The EPDS is available only for researchers and clinicians for their private use, but I obtained permission to reproduce it here for you (thank you to J.L. Cox, J.M. Holden, and R. Sagovsky, who published the EPDS in the British Journal of Psychiatry, Volume 150 in June 1987). Note that the EPDS shouldn’t be used by itself to diagnose, but you can take the quiz now to help you see where you stand. And if you’ll be consulting a doctor or therapist, bring the results with you to discuss your score as part of the entire assessment. The diagnostician should have an EPDS manual that thoroughly explains how to interpret the various scores.
Pediatricians paying attention
Pediatricians are in an excellent position to catch PPD in parents. In increasing numbers, pediatricians are doing a great job of tuning in to the mental health of their patients’ caregivers. Doctors speak so much about the impact of a baby’s environment on his or her health and growth — what could possibly be more important than the primary caregiver’s psychological wellbeing?
Many pediatricians are now routinely conducting brief screenings of the moms during well-baby visits, and moms with depression are being identified. Sometimes the Edinburgh Postnatal Depression Scale is administered, and other times the screening may be just a couple of simple questions. For instance, asking the mom whether she has lost interest and pleasure in doing things and whether she’s been feeling down or worried, can, by themselves, start identifying moms with PPD. In about five to ten minutes, the results of the screening are explained to the mom, as well as the impact of the depression on her child, and then a referral is made. Some pediatrician offices now have a staff person who’s designated to make a follow-up call to the mom. Even though pediatricians rarely see fathers, these docs are also beginning to pay attention to dads’ mental health.
Pediatricians are getting the message that children of depressed parents are about three times more likely than their peers to suffer from depression, anxiety, or addiction. Thankfully, when a mother’s PPD is treated, her kids show improvement in their own symptoms within three months.
Answering a handful of questions
For the following questions, please circle the answer that comes closest to how you’ve felt in the past seven days:
A. I have been able to laugh and see the funny side of things:
0 - As much as I always could
1 - Not quite so much now
2 - Definitely not quite so much now
3 - Not at all
B. I have looked forward with enjoyment to things:
0 - As much as I ever did
1 - Rather less than I used to
2 - Definitely less than I used to
3 - Hardly at all
C. I have blamed myself unnecessarily when things went wrong:
3 - Yes, most of the time
2 - Yes, some of the time
1 - Not very often
0 - No, never
D. I have been anxious or worried for no good reason:
0 – No, not at all
1 - Hardly ever
2 - Yes, sometimes
3 - Yes, very often
E. I have felt scared or panicky for no very good reason:
3 - Yes, quite a lot
2 - Yes, sometimes
1- No, not much
0 - No, not at all
F. Things have been getting on top of me (translated from British English to American English, this means, “I’ve been feeling overwhelmed.”):
3 - Yes, most of the time I haven’t been able to cope at all
2 - Yes, sometimes I haven’t been coping as well as usual
1 - No, most of the time I have coped quite well
0 - No, I have been coping as well as ever
G. I have been so unhappy that I have had difficulty sleeping:
3 - Yes, most of the time
2 - Yes, sometimes
1 - Not very often
0 - No, not at all
H. I have felt sad or miserable:
3 - Yes, most of the time
2 - Yes, quite often
1 - Not very often
0 - No, not at all
I. I have been so unhappy that I have been crying:
3 - Yes, most of the time
2 - Yes, quite often
1 - Only occasionally
0 - No, not at all
J. The thought of harming myself has occurred to me:
3 - Yes, quite often
2 - Sometimes
1 - Hardly ever
0 - Never
Total Score:
Add your circled scores for each question. If your score is 14 or greater you may have postpartum depression or anxiety. But no matter what your score is, if you’re not feeling like “you,” speak with your healthcare provider. The next section explains how you can go about discussing your results.
Assessing a mom after going the whole nine yards (months, rather, and ten of them)
From Thomas M. McNeilis, D.O., F.A.C.O.G., Professor at Dixie State College
The postpartum period in a mom’s life gets very little attention because most of the time and preparation during pregnancy are focused on the delivery. Moms are left to cope on their own as they return home from the hospital (which is usually in less than 48 hours). If they happen to have complications such as a C-section, medical problems, or a traumatic birth, attention is focused on the infant and not so much on mom’s well being. Compounded with those facts is the point that there’s an overlap of symptoms of depression with symptoms of pregnancy that tends to obscure a diagnosis of PPD, so it often gets overlooked. Add to that mix the ignorance everywhere, even in parts of the medical community, about PPD, and you can see that getting a diagnosis right away is sometimes a fat chance.
Some commonly held but false beliefs are still prevalent in society, and my colleagues are no exception in their belief of them. For example, consider these:
Pregnancy protects against mental illness.
Depression is very obvious in pregnant women.
Most women have symptoms of depression only after birth.
The symptoms I look for in a new mom after she delivers are feelings of sadness, guilt, hopelessness, and worthlessness; difficulty concentrating; sleeping too little or too much; loss of interest in activities that she usually enjoys; recurring thoughts of death or suicide; and a change in eating habits. I keep a close eye on the mom if she experiences complications in the birthing process, such as C-sections and traumatic births, and if her baby has physical challenges, such as cleft lip and palate, RDS, jaundice, and so on.
From my experience, it’s important to diagnose these symptoms during pregnancy and the postpartum period for the following reasons:
PPD interferes with infant bonding.
Women that have these symptoms are less likely to seek physician help and tend to have poor prenatal self-care.
PPD can lead to substance abuse and self-medication.
PPD can cause medical or obstetrical complications.
PPD can lead to suicidal thoughts.
If women exhibit symptoms of depression during pregnancy with the marked change of fluids, electrolytes, and hormones, they’re more prone to a relapse or worsening of symptoms postpartum.
Discussing your pre-assessment with a professional
Your EPDS score isn’t a diagnosis — it just gives you and your healthcare professional good information and a place to start. Sometimes pediatricians’ or OB/GYNs’ offices have a pile of EPDS forms on waiting room tables with instructions to complete the form and hand it to the doctor or nurse on your way in to the appointment. If the designated person in the office sees from your score that you need a complete assessment, he or she will (hopefully) refer you to a competent mental health professional.
Receiving a Competent Professional Assessment
When OB/GYNs and family practice doctors use the EPDS or another simple screening method, it’s usually part of a very quick screening (usually five minutes or less), and from the results of that screening he or she may recommend that you see a mental health professional for a more complete evaluation. Anyone — including a nurse, doctor, technician, or another staff person in the office — can give the initial screening as long as he or she is trained to ask the right questions and to interpret the results accurately.
Making sure your doctor has proper PPD training
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The mental health practitioner who gives you a complete evaluation, on the other hand, must have adequate training. You definitely need to speak to someone with specialized training in identifying and handling PPD. I outline exactly how to find a competent therapist in Chapter 6.
Going another round to establish a diagnosis
After you’ve been screened and are referred to a competent professional (or have found that person yourself), you’ll go for a more thorough evaluation. It’s usually at the end of this evaluation that you receive a diagnosis. Different therapists have their own methods of evaluation, but much of the appointment involves the therapist asking you general questions about your physical and emotional well-being, followed by more specific questions. The therapist may use your initial screening (the EPDS or another one) as a guide.
For example, I work in a very practical fashion. Sometimes one of my clients has already taken the EPDS or another screening test, but usually she hasn’t. In a nutshell, I ask the mom about the following:
Her hormonal history
Her family and personal history of mood disorders
The quantity and quality of her sleep
Whether she has an appetite
What she’s eating and drinking
The major stressors she’s facing
Whatever else she feels is important for me to know
After she and I feel that I have a good understanding of what she’s experiencing, I outline a solid plan for her so she knows exactly and simply what she needs to do to start recovering.
A pediatrician’s perspective
From Geoffrey R. Kotin, MD:
“As a pediatrician in a large HMO practice, I often meet new mothers for the first time at the two-week well-baby visit. This appointment provides an opportunity for me to assess not only the health, growth, and development of the newborn, but also the level of bonding between parents and infant and, to some degree, the emotional health of the mother. Most new mothers are very engaged with their babies. I see them cooing to the infant, cuddling him or her, and I sometimes need almost to pry the baby away to do my exam. So, mothers who distance themselves (physically or emotionally) from their baby or seem excessively tired, tearful, or anxious raise my level of concern about the possibility of postpartum depression.
Pediatricians are concerned about depression in mothers because intuitively, they think that a mother who’s depressed would interact differently with her baby than a healthy mom, which can possibly lead to some adverse effects on the child. Current research does suggest that postpartum depression affects child development, behavior, and health. The following list shows these possible effects (though, remember that not all children of depressed mothers will suffer from these problems and if they do, many are able to overcome the effects and develop normally):
Children, especially boys, of PPD mothers didn’t perform as well as children of well mothers on cognitive tasks, such as language, at 18 months.
Several behavioral effects have been documented. Infants of withdrawn mothers have been found to spend more time fussing and crying than others. Infants of intrusive depressed mothers cry less but have been shown to avoid looking at their mothers and engaging with them. Insecure attachment to the mother in late infancy can be a consequence of PPD and can have repercussions later in childhood. Increased problems at school entry have been noted, such as anxiety and, in boys, higher rates of conduct problems and hyperactive symptoms.
There is concern that in some situations PPD may be a predisposing factor for child abuse.
PPD can impact appropriate use of healthcare resources and consequently child health. Infants of mothers who reported having depressive symptoms were found to receive less consistent preventive healthcare, including immunizations, and to have more visits to emergency departments than infants of mothers who didn’t report depressive symptoms.
In our clinic, mothers are asked to complete the Edinburgh Postnatal Depression Scale at each well-baby check in the first year. Women who score 12 or higher are encouraged to contact their primary care clinician or the mental health department for further evaluation (and we help with contact if necessary). They’re also given a list of other resources, including literature recommendations and Web sites of organizations that provide help to mothers with PPD.”
Reacting to Your Diagnosis
Not surprisingly, if the DSM-IV diagnosis of PPD is both misleading and confusing to professionals, it can be even more misleading and confusing for you, the layperson. To top it off, if you happen to have PPD, you’re already subject to feeling overwhelmed, anxious, and confused by new information when it comes in.
The good news is that many competent psychiatrists, doctors, and clinical psychologists skip the confusing language after they’ve evaluated you and simply tell you that you have PPD.
When your doctor reveals your diagnosis, you may experience a number of emotions, including relief. This relief comes from the fact that you now at least know that what you’ve been experiencing actually has a name. Plus, your healthcare provider will probably sit down and talk with you, explaining to you the variety of treatments for PPD and the fact that the depression will go away over time.
In addition to the relief of having a diagnosis, you may also react in several other different ways, the most common of which include the following:
Denial: If you experience denial, you may say any number of the following things (or something like them) to yourself:
“No, depression of any kind, including postpartum depression, is something that happens to other people, but not to me.”
“Because I’m not having scary thoughts about hurting myself or my baby, I don’t really have whatever this “postpartum thing” is, and therefore, the professional who evaluated me must have made a mistake.” (Unfortunately, there actually is a misconception that, in order to have PPD, you need to have feelings about hurting your baby or not caring about him or her.)
“I’m not that bad off. Everybody feels this way after they have a baby. This is just the blues.”
Thankfully, you have this book and other resources available to you, which means that you’ll be able to verify for yourself, based on your symptoms, whether the professional evaluation is correct (in the vast majority of cases, it will be).
Shame: Usually when a woman feels shame, she has a preconceived, negative notion of what this illness is all about.
For example, if you think that having PPD means that you’re “crazy,” not ready to be a mother, inadequate, or weak, you may find yourself wanting to fight your diagnosis. After all, who wants to be a member of that club? If you believe that PPD means something negative about you as a person and a mother, which it certainly does not, then you’d feel unnecessarily ashamed.
Inadequacy or weakness: Often, the disempowering question that goes along with this reaction is “Why can other mothers handle this and I can’t?”
The incorrect assumption is that PPD is happening only to you. Almost one in five mothers experience PPD, so chances are you’re meeting others with PPD every day (presuming you’re outside and around other people). The very woman who you’re convinced feels gloriously happy may have the therapy appointment right after you, so never assume. Just remember: PPD isn’t a character weakness — it’s an illness. Many strong, intelligent, good mothers are going through this right now with you — whether you’ve met them yet or not.
Guilt: If you experience this emotion, you may say to yourself “Maybe I caused this. Maybe I did this to myself.”
Often I’ll hear what sound like confessions from new clients who have just received the news that they have PPD. They imply that the PPD is their doing. They say “I’ve always had low self-esteem. Now it’s worse than ever. I should’ve been done with this problem before I became a mother.”
You didn’t bring the PPD on. This isn’t your fault. You wouldn’t wish this on yourself or anyone else. Even if you think that your personality or an unhealthy way of thinking may have fed into your depression, the PPD still isn’t your fault.
Self-pity: This is the “why me?” reaction. After all, it isn’t fair that you have PPD and others don’t. Your reaction is normal, so go easy on yourself. There’s a time and a place to feel bad for yourself. That way you can move through this part of recovery and keep moving forward.
At this point, I suggest to women that they throw themselves a pity party (see Chapter 13 where I give you tips on doing this), which allows them to move on to accepting their diagnosis and receiving treatment.
Although it may not seem like it when you first hear it, your diagnosis is a step in the positive direction. This is because after you accept the frustrating reality, you suddenly have the capacity to take action, to mitigate the biochemical, psychological, and environmental effects it’s having on you, and to get back on track with life the way you want it to be (which may be even better than before you had your baby). So if and when you hear the diagnosis, sit back, take a few deep breaths, open your heart and mind, and assume that on some level this is a very good thing you’re being told.