It was supposed to be the happiest time of her life.
A few weeks earlier, Kelly Modro had brought home her healthy, 8-pound, 7-ounce baby boy, complete with a full head of dark hair and a dimple in his chin. She recovered quickly from her long labor and unexpected cesarean-section surgery. Her husband went back to work soon after her homecoming, and the 25-year-old first-time mom was left alone each day to care for their infant son, Keegan.
“That’s when things quickly started to unravel,” Modro says.
Keegan refused to latch onto her breasts to nurse, so Modro had to formula-feed him instead, which made her feel like an immediate failure as a mother. He also cried. A lot. Days and nights blurred together as the sleep-deprived Modro held her colicky baby, trying in vain to soothe him. “I would just sit there and watch him cry and think, ‘What did I do?’” she recalls. “I felt trapped. I wanted to scream, but I couldn’t.”
There were scarier moments, too, when Modro would carry her son downstairs from his nursery and imagine, in chillingly gruesome detail, what would happen if she were to drop him on the steps. Each day, when Modro finally got Keegan to nap, she dreaded him waking up. “I would hear my son cry and not want to get out of bed,” she says. “There was a dark cloud over everything in my life.”
This isn’t the picture of motherhood that typically comes to mind; but, in fact, many women don’t experience cheery bliss with a newborn child. That idealized notion is, instead, a dangerous fallacy that has even crept into the medical arena.
When Pitt professor Katherine Wisner was training as a psychiatric resident at the University of Pittsburgh in the early 1980s, she regularly saw women during and after pregnancy who were suffering from debilitating depression. The medical literature at the time contained little about the cause and symptoms of pregnancy-linked mood disorders—and even less about how to treat them. When Wisner asked her supervisors for advice on how best to care for these patients, her concerns were dismissed.
“They said pregnant women are ‘fulfilled,’ so they don’t become psychiatrically ill,” recalls Wisner, who now directs the Women’s Behavioral HealthCARE program at Western Psychiatric Institute and Clinic of UPMC. “Or they told me there was no such thing as postpartum depression, because it wasn’t in the Diagnostic and Statistical Manual of Mental Disorders.”
Outraged and frustrated by these misconceptions, the young doctor resolved to dedicate her career to helping women with emotional difficulties during pregnancy and the year after childbirth—a time known as the perinatal period. Some colleagues told her that pursuing this line of research would be professional suicide, that she would never receive federal or institutional support for her work. But Wisner was undeterred, driven by a combination of her feminist principles and sense of responsibility to her sick patients.
During the past two decades, she has published nearly 150 peer-reviewed articles, presentation papers, and book chapters related to the psychiatric treatment of women of childbearing age. Today, she is a professor of psychiatry, obstetrics and gynecology, and reproductive sciences in Pitt’s School of Medicine and a professor of epidemiology in the Graduate School of Public Health. She oversees several research projects funded by the National Institute of Mental Health that examine the impact of antidepressants on maternal and infant well-being; the use of these drugs during pregnancy; and the efficacy of bright-light therapy as an alternative form of treatment. When she isn’t doing research or seeing patients, Wisner—who also is an associate investigator at Magee-Womens Research Institute—is working in the community and with government leaders to raise awareness about perinatal mood disorders and expand services to help women and their families cope.
“Because of (Wisner’s) efforts, there is a much greater acceptance of the need for research pertaining to mood disorders during pregnancy and postpartum,” says psychiatrist Marlene Freeman, director of the Women’s Mental Health Center at UT Southwestern Medical Center in Dallas.
In fact, nationally, the plight of women with postpartum depression is finally coming into the open. Celebrities such as Brooke Shields and Gwyneth Paltrow have shared their battles with the disease. Federally funded medical studies are now published regularly on all aspects of this major public health problem. Congress is even considering legislation to ensure that moms nationwide are educated about postpartum depression and screened for symptoms.
But the need for research and treatment cannot be understated. Any woman who has a baby is at risk. Women with their first infants are at the highest risk—however, once a woman has an episode of depression, her postpartum risk is about double that of women who have never had an episode.
Beyond that, about 85 percent of women experience transient feelings of sadness and irritability soon after giving birth—a condition known as the baby blues. Wisner remembers her own experience of baby blues after bringing home the older of her two daughters in 1984. “I had just completed six months of pediatrics training, and I still felt like I really didn’t know how to take care of this screaming baby who didn’t come with a how-to manual,” she says.
The baby blues usually resolve without treatment within a few days. But one in seven mothers experience more severe, prolonged symptoms of postpartum depression—the most common medical complication of childbearing.
Like Modro, more than 800,000 American new-birth moms each year suffer from overwhelming sadness, anxiety, and a sense of hopelessness about life. They may cry a lot or have no motivation to meet their newborns’ basic needs or give them love and affection. They may feel worthless and guilty or even consider hurting themselves or their babies.
“Postpartum depression is really a nasty disease that takes the capacity for positive feeling away right when you’ve added this beautiful little creature to your family,” Wisner says.
In rare cases—1 or 2 out of every 1,000 births—the woman may have irrational thoughts about the baby (such as the infant being possessed) or see and hear things that aren’t there. These are signs of postpartum psychosis, a devastating illness made infamous by Andrea Yates, the Texas mother who drowned her five children in the bathtub.
Scientists say these mood disorders are set off by the sudden and massive drop-off in reproductive hormones that occurs after giving birth. Changes in estrogen and progesterone levels alone do not cause postpartum depression, but they can trigger the disease in women who may be predisposed by their genes or brain chemistry. Other risk factors include poor nutrition, previous episodes of major depression, or a family history of psychiatric illness. Left untreated, the effects of perinatal mood disorders can be far-reaching and may even last for years or longer.
Studies have shown that depression can raise the risk of delivering an underweight or premature baby, perhaps because new-birth mothers can have reduced appetites as well as more difficulty caring properly for themselves during pregnancy. Children of mothers with postpartum depression are more likely to have behavioral problems, such as sleeping and eating difficulties, temper tantrums, and hyperactivity. Delays in language development also are common.
“Intervention is critical, because if mom is sick, then baby is sick, husband is sick, family is sick, and the community is sick,” says Don Svidergol, a psychiatric nurse and senior research principal who works with Wisner at Women’s Behavioral HealthCARE.
Fortunately, women with perinatal depression often respond well to psychotherapy, as well as drug treatment. But during Wisner’s early days at Pitt, women suffering from these illnesses weren’t usually given medication. Adequate drug safety data for antidepressant use in pregnant and breastfeeding women did not exist. That meant any possible risk to the baby, no matter how small, was viewed as unacceptable, even if denying treatment posed a potentially greater threat to the child by endangering the mother’s health.
“I saw pregnant women in seclusion throwing themselves against the wall because they couldn’t be medicated,” Wisner says. “We wouldn’t think about withholding treatment for high blood pressure or diabetes, but psychiatric illnesses were viewed differently.”
Uncertainties about drug toxicity left Wisner unsure about how to respond when women from a breastfeeding support group asked her advice in the early 1990s about whether they could take the antidepressant nortriptyline while nursing.Three case reports she found indicated that very little of the drug crossed into the breast milk. It seemed unwarranted to make these women choose between the known benefits of breastfeeding and antidepressant therapy when the risk of taking the medication appeared low. Yet she wanted more concrete answers.
So Wisner launched a first-of-its-kind study to monitor the drug’s serum levels in the women and their infants while they continued nursing. No adverse events were reported. The groundbreaking results, published in 1991 in the American Journal of Psychiatry, led to more studies by Wisner and others on the safety of breastfeeding by mothers treated with antidepressants.
Now, nursing women may reasonably choose to use many of these drugs—including a few of the widely prescribed selective serotonin reuptake inhibitors (SSRIs) such as Paxil and Zoloft— without harming their infants. “We have developed substantial data that provide a lot of comfort for women who want to breastfeed,” Wisner says.
For pregnant women who are trying to choose whether to continue antidepressant therapy, the decision can be more challenging. Physicians have discovered that some newborns whose mothers take certain SSRIs during the last trimester of pregnancy display symptoms of side effects after birth. Despite a flurry of recent studies by Wisner and others, data about the safety of taking SSRIs and other antidepressants during pregnancy remain controversial.
“There is no risk-free decision here,” says Wisner, who published a model to help psychiatrists guide their patients through the decision-making process about treatment for perinatal depression. “Either the mom is sick, which has its own risks, or you treat her, which also has its own risks. My philosophy is that you present the mom with the risks and benefits and let her choose based upon her needs and values.”
Ultimately, though, any treatment for perinatal depression can only be effective if women with the disease are identified in the first place. Because of the stigma attached to mental health disorders, many pregnant or postpartum women are reluctant to admit they are depressed. Also, Wisner says, too many doctors don’t ask these patients about their moods or administer routine screening tests. Some are too busy. Others just assume it isn’t a problem.
That’s why Wisner helped to develop an educational Web site, funded by the National Institute of Mental Health, about postpartum depression (www.MedEdPPD.org). She also recently launched a five-year, $2.5 million screening project at Magee-Womens Hospital of UPMC. Through the study, new-birth mothers are being offered free postpartum depression screenings by phone, four to six weeks after giving birth.
If they screen positive for depression, then they have the option of undergoing a full psychiatric assessment during a home visit from one of Wisner’s research staff, who also can provide ongoing care management. Since 2006, 13.8 percent of the nearly 5,000 new-birth mothers approached have tested positive for depression or another mood disorder, matching national rates.
Modro couldn’t have been more relieved when the phone rang six weeks after Keegan was born. It was Mary McShea, a counselor at Women’s Behavioral HealthCARE, who asked the despondent mother a series of 10 questions developed by psychologists to detect postpartum depression. Has she felt sad or miserable? Has she been so unhappy that she has been crying often? Has she thought of harming herself?
“I scored through the roof,” Modro says. She has long battled anxiety and has a family history of bipolar disorder, but she grew up being told that her emotional problems were part of normal life. “For the first time, I had an unbiased ear listening to me and telling me that my feelings weren’t all in my head, and that felt really good,” says Modro. She began seeing a psychologist once a week and taking Zoloft to help control her anxiety. She also joined a support group of other mothers with postpartum depression.Slowly, the dark cloud that descended over her mind and body began to lift.
She now takes daily outings to the park or the library with Keegan—who is pulling up in his crib and on the verge of crawling—and looks forward to each new day with her 9-month-old son. “It’s always a new set of adventures, and that’s in a good way now,” she says.
For Wisner, stories like Modro’s are a bright reminder of why she became a champion for women and families in the first place—and why she’s still going. “I know how hard and stressful it can be to be a new mother, even under the best of circumstances,” she says. “I think we all come away from this work with an incredible respect for the human spirit and an awareness of the strength that these women have to cope.”
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