The Blues Clues

How and why having children can cause depression

By Deedee S. Espina

Walking six years after an experience she did not know what to call then, Gigi, a mother of two, says she didn't know she had it. Recently giving birth to her second baby, she is sure she didn't have it this time. She says she didn't know then, after giving birth to her first bundle, if she was having depression, a postpartum one.

    All Gigi could remember was that she was irritable. "I am not usually unreasonable. But at the time, I just couldn't snap out of being upset all the time," she recounts. She says that the unsolicited advice given to her by an extended family member on how to take care of her firstborn made her feel more incompetent as a new mother. She felt life she wasn't doing the right thing all the time.

    "I was so unhappy," she remembers. She says she wasn't even successful at breastfeeding. "Nobody really encouraged me. And my baby was already on the bottle before we went home from the hospital."

    For Gigi, everything after the first delivery was just chaos, extending up to six months. She calls it "a whole mess-up event." Even the house they used to live in she calls "a house from hell." Looking back now at the entire half-a-year of confusion intelligently, she says she is able to pinpoint what caused it. For confidentiality reasons, she does want to talk about it. However, she says, "I think you are generally disappointed by the way things are, because you expect. You have a certain expectation and then it doesn't happen," she points out.

    Gigi never got professional help. She wasn't even able to thresh out what really befell her until only recently. "Nobody really understood where I was coming from," she says. She feels that were it not for her intelligent disposition, her condition could have progressed into something more serious. "It happens," she says of her case. But today she is certain that she didn't have it after her second baby.

    Gigi's story could have been a case of the "blues" or "depression." According to psychiatrist Dr. Elizabeth Espinosa-Rondain, the blues and depression are clinically not the same. The blues occurs two to four days after giving birth. "It is transient," she says. On the other hand, postpartum depression, a more serious condition, lasts for weeks. And the conditions have generally different manifestations.

Three Levels

    Dr. Rondain explains: "The blues is the normal form of depression and it occurs in almost 85 percent of those who have given birth. The blues usually occurs after the first birthing; in the second, the blues becomes of lesser degree." Manifestations of the blues include tearfulness, irritability, anxiety, and ambivalence toward the child. More importantly, Dr. Rondain says, there is separation anxiety from being a single person. She explains that the responsibility of taking care of another human being is overwhelming for the first-time mother.

    Postpartum depression, or PPD, on the other hand, occurs in only 10 percent of women who have given birth. Depressed mood, guilt, anxiety, fear of harm coming to the baby, and obsessional features are some of its manifestations.

    After the blues and PPD comes postpartum psychosis, the most serious postpartum illness. It occurs less often (only one per 1,000) and is manifested by disorientation, very rapid mood changes, and delusions.

    Dr. Crisanta Villanueva, obstetrician-gynecologist of 50 years, believes that all three illnesses cannot be entirely attributed to pathological causes. In fact, Dr. Rondain relates that pointing to depletion of estrogen and progesterone after giving birth as the culprit has already been "ruled out since, despite introduction of the hormones, they saw that nothing happened." It appears now that the causes are more psychosocial than pathologic, the two doctors agreed.

    Mothers giving birth, especially for the first time, are at risk of these illnesses depending on the risk factors they are exposed to. History of depression, stressful life events such as an unwanted pregnancy or lack of support from the husband or the family, socioeconomic factors, and even complications during pregnancy or delivery all contribute to the possibility of getting a postpartum illness.

    Gigi, for one, had a complicated postpartum recovery. When she was ready to see the baby, she suddenly had postpartum hemorrhage, preventing her from bonding with her baby early on. Even the hospital crew irritated her to the point that everything was just really messed up.

    Dr. Villanueva stresses that psychosocial risk factors are actually evident during a pregnant woman's prenatal consultations. Side stories are often told in the course of the consultation. She explains that when a pregnant woman says something like "Sana huwag na muna" referring to the lack of preparedness in having a child, then the expectant mother is at risk.

    Dr. Rondain recounts the case of a Filipina who had postpartum psychosis, showing psychosocial factors in play. The woman went to the US through the backdoor. She got pregnant out of wedlock by her Filipino boyfriend. Though she had siblings in the US, they did not live together. The woman had psychosis; she killed her baby. She was not jailed but was committed to a psychiatric hospital. She later returned to the Philippines and continued her therapy. "She was under my care that time," Dr. Rondain recalls.

    The same woman now has two children in a marriage made here, and has shown no signs of depression or psychosis. "Though during the pregnancy, we knew that she was at risk because the psychosis can repeat," Dr. Rondain explains. The psychosocial factors were at play in the woman's life, both before and after the psychosis. The first pregnancy was chaotic, lacking in support for not having a husband and an extended family, aggravated by the situation that she was an illegal alien. On the other hand, the succeeding pregnancies were at a time when her life was a turnaround, with a supportive husband and family, and living in her own country.

    Dr. Villanueva once referred her patient to psychiatric treatment after observing her to be in a depressed mood. "She was always crying. She didn't want to eat or to take her medicines," Dr. Villanueva recounts. The warning sign of a postpartum illness became evident when the mother told her, "Ikaw na ang bahala sa anak ko." "We referred her to a psychiatrist, but while she was at therapy, we had to protect the child," she says, "because the baby was at risk."

    Dr. Rondain explains that postpartum psychiatric illnesses need psychiatric care. The route is the same for depression and psychosis-that of psychotherapy and medical intervention. Dr. Rondain explains though that a history of mental illness must be ruled out to make sure the case is postpartum-related.

    Postpartum illnesses have not received much attention in the Philippines as evidenced by the lack of statistics on cases and absence of clinics specifically catering to would-be mothers to raise their level of awareness on these illnesses. Dr. Villanueva says that in her 50 years of practice, she can point to only ten cases. On the other hand, Dr. Rondain says she has seen referrals, at the most ten cases, in her 10-year practice.

Cultural Strength

    Filipino culture has been resilient to the challenges facing mothers, they believe. "Our culture as Filipinos has perhaps contributed to the [low incidence] of postpartum illnesses in the country," Dr. Rondain shares. The readiness of having a family resides in the culture, adds Dr. Villanueva. "Even in the courting stage, the couple starts discussing having children." And that contributes to the mother's preparedness to accept that when she marries, the most important part of it is getting pregnant, having the baby, and losing much of her freedom as an individual.

    The responsibility of rearing a child is expected and accepted in this country, at least for most women, Dr. Villanueva says. Also, the Filipino family delights in the idea that the mother must be present in the household of her daughter or daughter-in-law when the latter gives birth to the first apo, thereby extending help and giving support to the new mother. This is something that makes the new mother emotionally strong, Dr. Rondain says.

    However, times are changing and the Filipino woman is facing risk factors of postpartum illnesses. The Filipino woman has become a major income-earner for the family and so having a child could prove a hindrance. The Filipino woman has started giving attention to her looks, and considers pregnancy a threat to her figure. All these, including socioeconomic factors put the Filipino woman, in her childbearing stage, at risk.

    There is a need to educate all women on these risks, both doctors say. The level of awareness of women on postpartum illnesses must be raised, as prevention is still the best cure. The prenatal care is the best venue for this educational component, says Dr. Rondain.

    Despite the help that mothers get from their husbands and families, they still need professional help. The absence of programs on prevention of postpartum illnesses could be overly taken for granted that mothers who may have the normal blues may not be helped out of the confusion, and thus are put to a graver risk of progressing into depression or psychosis.

    As one mother says, "We need all the help we can get after giving birth. Imagine the sleepless nights, the loss of freedom, the responsibility that rests upon your shoulders, and the physical changes that you yourself go through. It's an unimaginable combination of emotional and physical strength that a mother needs. In fact, I want to believe that the female is really the stronger sex after all."