Beyond Stigma
Beyond Stigma
Have you ever purchased a bunch of daffodils to support cancer research? Or pinned a pink ribbon on your shirt as a fundraiser for breast cancer? Or participated in a walk-a-thon for multiple sclerosis? Throughout the year, we are exposed to, and participate in, many campaigns which profile and raise funds for diseases of all types. However, there are noteworthy gaps in regards to illness which do not receive the public spotlight, and which, given their prevalence, don’t get the support they deserve.
Can you think of awareness raising activities which support mental illnesses such as depression, anxiety or substance abuse? Can you identify a symbol, a ribbon, a bracelet or a flower that you associate with a mental illness or an emotional disorder?
Mental health researchers and epidemiologists estimate that between one fifth and one quarter of us will experience a mental health illness in the course of our adult lives. That’s between 20-25% of all of us! That’s you and me, our friends, our families and our colleagues who are experiencing these problems. We are many in number, but collectively we still maintain a deafening silence about our experiences of mental illness.
Historically, Western civilizations have identified diseases by classifying them by their symptom patterns, and then developing appropriate treatment processes. And when the symptoms go away, we collectively identify the restoration of health. Mental illnesses have not been as amenable to diagnosis. There isn’t a standard blood test that can identify depression or addiction in the way that we can easily tell whether or not our cholesterol level is elevated. It’s also harder to see when a mental or emotional illness has healed – a cast isn’t removed, and there aren’t any stitches to be taken out to let it be known that healing has taken place.
The “invisible” and “unseen” aspects of mental illness extend beyond the level of diagnostics and treatment. Although it’s not uncommon for us to discuss our experiences with heart disease, diabetes and even prostrate cancer, typically, we don’t talk openly or publicly about mental and emotional concerns. A cloud of shame and embarrassment is still associated with these illnesses. We often believe that they must be the result of a character flaw or some other personal vulnerability. We tend to internalize the causes of mental illness (and ascribe them to personal or familial causes) but externalize the causes of physical illness (and attribute them to a virus, a germ or a genetic cause).
Our silence speaks more to our limited understanding of mind/body processes than it does to the nature of disease. Surely being genetically predisposed to diabetes is no different than being genetically predisposed to anxiety? Both conditions interfere with daily life, and both are treatable. Both can be managed in ways that allow for full and satisfying life experiences. We don’t hold individuals personally accountable for their genetic makeup. So why is it more acceptable to acknowledge diabetes than anxiety? Why do we openly acknowledge one condition, whereas we tend to hide the other?
With the advent of MRI technologies and other sophisticated and sensitive diagnostic tests which map the biochemistry and electrical circuitry of the brain, our ability to link mood and behavioural activity to brain function has grown beyond recognition. It’s quite possible that one day we will be able to concretely and objectively identify mental health symptoms. But given the cost and limited availability of these types of testing, we’re not there yet!
To reduce stigma, we need to become aware of how effective current treatment practices can be in addressing depression and anxiety. We need to change how we view mental illnesses and recognize that, in most cases and when treated appropriately, these conditions can be readily managed and healed. Mental health concerns fall along a continuum of severity, and most of these illnesses are amendable to treatment.
So where does stigma come from and what can we do about it? Most importantly, how can we reduce the myths and misconceptions that are associated with mental illness? How can we create acceptance so that when we experience a mental health crisis, we can step forward and receive the help we need, rather than trying to hide the illness from both ourselves and others?
The historical and cultural roots of stigma lie in our culture’s split between mind and body, and the fear we associate with conditions that are not concrete and tangible. We don’t have to look back very far to find asylums as the “treatment of choice” for those suffering from mental illness. The images associated with these institutions are dark, frightening and painful. It’s only in the last 100 years that effective therapeutic interventions, both pharmacological and psychotherapeutic, have been available. We still have much to learn about how to “heal” and “recover” from mental illness, although the progress we have made in recent years is astounding.
To reduce stigma, we need to become aware of how effective current treatment practices can be in addressing depression and anxiety. We need to change how we view mental illnesses and recognize that, in most cases and when treated appropriately, these conditions can be readily managed and healed. Mental health concerns fall along a continuum of severity, and most of these illnesses are amendable to treatment.
We need to educate ourselves about mental illness. When we become aware of our stereotypes, judgments and prejudices, we can examine them and change them. Mental illness is not a life sentence – it’s a common and treatable health condition. In just the same way that someone one who has a knee replacement may need to modify certain aspects of their lifestyle, so may someone who is prone to anxiety or someone who is bipolar. In either case, the condition itself, whatever it is, does not define who someone is, or what they are capable of doing.
We need to normalize illnesses that have historically been hidden and ignored. When we speak about our experiences of mental illness, we help to remove the internalized shame that is associated with mental illness. This is not an “us” and “them” situation. We are all “us”. We are all potentially vulnerable to suffering from mental health problems, and all of us have the potential to heal, or at least to manage, these issues and lead a full life.
It has been said that suffering can be defined as pain multiplied by resistance. In the case of mental illness, pain results from the inner turmoil and relationship distress that are part and parcel of the course of these illnesses. However, if we can remove the resistance we have to mental illness by addressing the stigma, shame and judgment that we traditionally associate with it, then we can reduce the suffering. It’s time to speak openly and normalize our experiences of mental illness and for mental health issues to receive the public recognition they are due.
Postpartum Depression
Postpartum Depression
In a review of forty-eight papers from eight longitudinal studies focusing on women’s social and emotional health in the first year after birth, postpartum depression (PPD) was found to be a severe condition that potentially affects ten to twenty percent of women worldwide. (1)
The same review found that the two strongest predictors for postpartum depression and anxiety were the previous history of depression and poor partner relationships. Additionally, while becoming a mother at a young age is by itself not a risk factor, it could be when coupled with social disadvantages. We can’t ignore that research has shown single mothers to be at higher risk for both physical and mental health disorders, as compared to mothers that are in established relationships. (2)
Rates of PPD can be as high as 1 in 3 among the subpopulations of adolescent, veteran, or socioeconomically disadvantaged women.
It is important to remember that depression during and after pregnancy (also called perinatal depression) is treatable, and women with the proper treatment do recover. There are several treatment options to explore depending on the severity of the indicating symptoms and socio-economic factors. In this article, we identify indicators, long-term risks and courses of action for the treatment of postpartum depression, including talk therapy. There’s a growing awareness among obstetricians and pediatricians about the need to address perinatal depression. Still, like all other mental health disorders, it is something the family must work on together.
Symptoms and signs of postpartum depression
The common, mild postpartum mood changes known as “baby blues” can be caused by the effects of sudden hormonal withdrawal. The postpartum mother may experience mood swings, crying spells, anxiety and difficulty sleeping.
The baby blues can be expected to last for a few weeks unless the mother has a pre-existing mood disorder that allows this period to linger slightly longer.
On the other hand, postpartum depression and its myriad of mood disorders is an amplification of these symptoms that can come on stronger and last longer than postpartum mood changes. Symptoms can include a persistent low mood, accompanied by trouble performing daily tasks, and the mother feeling detached from her newborn baby. Left untreated, postpartum depression can become chronic and, in some cases lead to thoughts of harming one’s self, spouse, or child, and suicidal ideations. Think you’re experiencing postpartum depression? You are not alone. About one in seven women experiences depression during or after pregnancy. The sudden hormonal withdrawal after a woman gives birth is just one factor in this universal and unpredictable condition. Individual experiences with postpartum mood disorders will vary between mothers, sometimes even between pregnancies.
Poor maternal-infant bonding and the long term implications
National Public Radio recently produced
a segment for their podcast, Life Kit, which talks about five things families need to know about perinatal depression, its symptoms and treatment options. In this podcast, Jennifer Payne, a psychiatrist and the director of the Women’s Mood Disorders Center at Johns Hopkins University is quoted as saying, “I always say if mom’s not happy, no one’s happy.”
Perinatal depression has been associated with certain conditions like
premature delivery and low birthweight babies, and studies have shown that PPD is associated with cognitive delays in the child. However, one of the more fundamental processes affected by perinatal depression is breastfeeding, where the condition results in a mother experiencing less satisfaction from their infant feeding method, and are more likely to stop breastfeeding. (3)
Like many mood disorders, the impact is felt throughout all relationships. In regards to PPD specifically, we focus on the effect it has on the maternal-infant bonding, but the spouse sometimes gets forgotten because it is accepted that this relationship is already established.
What gets buried are the hurt feelings, distorted thoughts, misinterpreted intentions and lack of clarity and joy that depression can bring into the home.
Trusted literature highlights some
approaches to keeping the partner bond intact and strong during times when either parent is experiencing depression. These approaches include open communication, compassion, and taking steps to keep the depressed partner healthy when depression makes it difficult for them to engage in self-care.
Causes, outcomes and how PPD differs from other depressions
Mental health problems are never considered the mother’s fault or failure. They are complications of pregnancy and childbirth, like preeclampsia and gestational diabetes, with PPD being even more prevalent. Researchers don’t fully understand what causes PPD, but like all mental illnesses, biology and environment are contributing factors to how a mother experiences its symptoms.
Hormones play a significant role in PPD cases. Levels of certain hormones, mainly progesterone and estrogen increase throughout pregnancy. Once the baby is born, the levels of progesterone and estrogen fall dramatically. That drop in hormone levels is likely responsible for the mental health symptoms many women experience during this time.
Exacerbating factors that affect PPD specifically are the constant needs of the newborn baby that tend to disrupt the regular routines of life that keep our mental health stable. Childbearing is challenging and in some instances expecting mothers may face complications. Add in sleepless nights and various lifestyle and personal sacrifices to take care of a new baby. If they lack the family support and financial means to distribute duties of care, these exacerbating factors can create pressures from the complex emotions facing new mothers.
Young, single mothers in precarious economic circumstances are more likely to experience mental health conditions. Other risk factors include marital stress, birth trauma and a history of abuse.
It is very easy in some cases for postpartum depression to go undiagnosed, unacknowledged, and untreated. Psychotherapeutic modalities, pharmacologic and psychosocial interventions cost money and are less accessible to vulnerable populations like young, single mothers. Another reason is that the mother may already have a mood disorder that masks, dovetails with, or confuses the symptoms of PPD she might otherwise be able to identify. Her depression may also set in during pregnancy, upsetting what we think we know about PPD, that it only occurs after a mother gives birth.
Postpartum depression isn’t a weakness of character. It’s merely a complication of pregnancy and giving birth. The anxiety and excitement over baby wanes and the hard work begins. Low-energy, lack of rest, lack of motivation, no time for self-care, and resources may be rationed in order to put baby first. If you have or suspect you have postpartum depression, getting treatment early can help you manage your symptoms and help you bond with your baby.
One major hurdle that many women face in seeking treatment is convincing their families that they have an illness and that they need help. The stigma alone, along with feelings of helplessness, guilt, and anxiety, can create an overwhelming barrier between the mother and the dedicated treatment she requires and deserves.
How to move forward & manage treatments
It has been concluded that women in low and middle-income situations are more susceptible to experience medically unexplainable physical symptoms known as somatoform disorders with anxiety and depression. (4) Physician recommendations suggest you look for these risk factors: a history of depression, current depressive symptoms and socioeconomic risk factors like being low income, very young or a single parent.
In Canada, we have many professional resources at our disposal, most of which are covered by provincial health care programs.
OB-GYNs, pediatricians and general practitioners can screen for depression and help women get treatment at the earlier signs of perinatal depression, or in the case of prolonged postpartum depression that requires outside help.
Midwives also play a critical role in the identification, support and referral of women experiencing mental health problems. (5) Many women do not seek help from mental health services when needed, therefore the potential for a midwife to have an impact on women’s mental health warrants further examination, and a possible recommendation for treatment
In terms of psychotherapeutic modalities, two kinds of talk therapy — cognitive behaviour therapy (CBT) and
interpersonal therapy (IPT), may prevent PPD in at-risk women. (6) CBT works by changing a patient’s thought patterns and actions, and IPT helps a patient improve relationships by assisting them in improving their communication skills.
Pharmacologic and psychosocial interventions also exist. Antidepressants, for instance, maybe considered as effective and safe during pregnancy and breastfeeding.
Medication, in combination with talk therapy, is more effective than medication alone. We are all unique and may react differently to medications. Before taking medications, consult with your physician or primary care provider to ensure they are safe for both you and your child.
If consultation with a physician is not possible, what can you do?
You can turn to an organization like Postpartum Support International, a nonprofit that helps women and their families find support for postpartum depression, to learn more and connect with others in a similar circumstance.
On your own, making a routine of self-care has been shown to improve mental health symptoms like those experienced in PPD by improving overall health, so you can cope better with the stress of taking care of a newborn. Self-care means eating regularly and staying hydrated, getting adequate sleep, and taking breaks during the day when possible; exercising, which can be solo-time or used to bond with the baby; seeking out community and social support.
References
- Maternal mental health in Australia and New Zealand: a review of longitudinal studies. Schmied V et. al. https://www.ncbi.nlm.nih.gov/pubmed/23583667
- Single mothers have a higher risk of mood disorders. Subramaniam M et. al. https://www.ncbi.nlm.nih.gov/pubmed/24714708
- Does maternal postpartum depressive symptomatology influence infant feeding outcomes? Cindy‐Lee Dennis Karen McQueen. 22 March 2007. https://onlinelibrary.wiley.com/doi/abs/10.1111/j….
- Association of somatoform disorders with anxiety and depression in women in low and middle income countries: a systematic review.
- Shidhaye R et. al. https://www.ncbi.nlm.nih.gov/pubmed/23383668
- Maternal mental health in Australia and New Zealand: a review of longitudinal studies.
- Schmied V et. al. https://www.ncbi.nlm.nih.gov/pubmed/23583667