“I want to be a good mother but I’m afraid. I didn’t have a good childhood.”
The nurse held back tears as she told me what the patient had told her. Involuntarily, I felt the prick of tears too, at her horror and the patient’s, conveyed in the recollection. It wasn’t that the abuse was violent or at a very young age. The betrayal of a child’s trust is hard to hear. The patient’s mother, herself neglected and vulnerable in childhood, had been largely unavailable, sometimes frightening, and immersed in her own addictions; her stepfather, the gentler parent, was also a substance user and had abused her, even as she tried to support him, so he could provide care for her.
As mental health professionals, we regularly hear different versions of this story. Childhoods marred or dominated by consequences of parents caught in their own mental health issues, emotionally or physically absent, addicted, unable to nurture. In the absence of watchful protection, abusers taking advantage. Of course, not all abuse occurs in this setting but low parental oversight confers opportunity.
Despite a difficult childhood, Diana* had achieved an education, a good job and decided – with her loving partner, and the past in the past – to start a family. Then the depression descended.
Postnatal depression affects 15% to 20% of women and can actually commence any time during pregnancy. However, it’s not one illness. It can be as complex and varied as depression occurring in any stage of life. Postnatal depression can occur as a relapse of an existing recurring depressive illness, or bipolar disorder. Some, however, only experience depression for the first time with pregnancy. We’re often asked if it can come back with later pregnancies: it may but not necessarily, and may not occur with every pregnancy. We know it can be triggered by grief, the huge role changes parenting brings, existing or new relationship conflict, stressors from extended family relationships, differences in intergenerational and cultural expectations and all myriad factors seen in depression.
The postnatal period is one of the most vulnerable for women to experience depression. The added crucial aspect is there’s an infant in the picture. The infant brain is developing rapidly and this development is modulated by parent/caregiver interactions. Babies respond differently to depressed parents.
The importance of “attachment” in psychology is recognised because of its universality. Around the world infants show observable patterns of attachment with a caregiver. Attachment patterns are reasonably stable through childhood. Moreover, we see a relationship between attachment and mental health down the track. However, while it’s a significant influence, it is not deterministic, which means, importantly, it can change and improve along with the mental health and wellbeing of the caregiver. So, what is intuitive knowledge in many cultures is supported by science: helping the parent/caregiver helps the person the infant grows up to be. Although more evidence is needed around which interventions make the most impact, attachment remains a compelling argument to provide services to new parents.
There is a lot going on in Diana’s depression. A past history and family history, maybe genetic factors in mood and addiction. She’s overcome much to get here and this makes going backward the more terrifying. She couldn’t sleep, her mind swirled with fears. She wanted an ironclad guarantee to eliminate any possibility her daughter could be unsafe. Ever.
Treatment is also complex. Her question: “How can anyone help me?” is valid. She was afraid it would turn out for her child the way it had for her. But this is a different place and time. We can start with treating distressing symptoms, immediate measures to improve sleep, lessen the panic. We can listen, without judgment, to the questions, doubts, the rational and the disproportionate – though what is disproportionate when this is in your experience? Importantly, and unlike her childhood, support is there. Our teams are specialised to take into account all combinations of contributing factors. Depression tricks your mind into feeling as if you’re a failure. Diana comes to understand that caring for her own mental health benefits her baby.
We can try antidepressants – many are safe in pregnancy and breastfeeding. If they can reduce distress, that’s less to struggle against. They can allow more strength and confidence to rebuild. However, this decision is entirely hers and we discuss and give her and her partner the current evidence and long-term outcomes. Medications can be part of but not the whole answer.
We offer targeted services, we’ll be with her and her new family through this. The goal is that she’ll be soon well again and more prepared for the future.
The reward is the next generation will have less to carry from the last.
In Australia, support is available at Beyond Blue on 1300 22 4636, Lifeline on 13 11 14, and at MensLine on 1300 789 978. In the UK, the charity Mind is available on 0300 123 3393 and ChildLine on 0800 1111. In the US, Mental Health America is available on 800-273-8255.
Dr Saretta Lee is a Sydney psychiatrist
* Name has been changed