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On Nature and Nurture: Depression In Women

By: Hindie M. Klein  

The Feminine Factor 

Developmentally, girls are known to be verbally precocious and often learn to speak and "express themselves" far earlier than their male counterparts. If expressing oneself is often part of the remedy that can alleviate depression, why is it that women are twice as likely as men to experience clinical depression? Although all the reasons for this difference are not known, research suggests that biological differences in women such as hormonal changes and genetics may contribute to depression. Additionally, social factors, such as greater stressors from work and family responsibilities, and the roles and expectations of women, may lead to higher rates of clinical depression. 

Although depression may manifest itself in the early childhood years, the highest incidence of depression in women begins in adolescence, when there are dramatic changes in roles and expectations for teenage girls, along with significant physical and hormonal changes. Girls tend to suppress their anger and are more prone to turn it on the self by increased guilt, obsessive rumination, a sense of having little control over life events, and lowered self-esteem. Girls will be more prone to manifest the classic definition of clinical depression: "anger turned inward." Additionally, if there is a familial predisposition to depression, symptoms may begin during this time, a sad portend of what may lie ahead. 

Adulthood in women brings with it a variety of stressors, such as major responsibilities at home and at work, and caring for children and aging parents. The higher incidence of depression in adult women may not be due to greater vulnerability, but to the particular stresses many women face. When both husband and wife work, women are more likely to have a greater share of household and childcare responsibilities. Rates of depression are highest for women when they are unhappily married. (Interestingly, being unmarried, including being separated or divorced, increases depression in both women and men.) In later adult life, some factors that increase the risk of clinical depression in women include the death of a spouse, and such illnesses as heart disease, cancer, diabetes and arthritis. It is important to note, however, that depression is never a "normal" part of growing older. 

Postpartum Depression and Child Care 
During the reproductive years, mood fluctuations caused by hormonal shifts may cause an increase in depressed mood. For many young women in the child-bearing years, this is most dramatically visible in a clinical condition called postpartum depression (PPD). Although the days and weeks following the birth of a new baby are often joyous, exciting and surrounded by family and friends, it can also be a time when a woman may feel quite unhappy and overwhelmed. I have chosen to focus on this particular time in women’s life cycle because depression during this time affects more than just the woman; it affects her ability to mother and to care for her new infant and possibly her other children, as well. This in turn can cause attachment disruptions between the mother and her infant, and can affect the emotional development of the other children. 

DIAGNOSTIC CONSIDERATIONS 
Approximately one in ten women experience postpartum depression after childbirth. There are three forms of depression that can occur after giving birth: the "baby blues," postpartum depression (PPD), and postpartum psychosis. Experience demonstrates that the prevalence of postpartum depression in the Orthodox community is similar to that found in the general population. 

The "baby blues" usually peak three to five days after delivery, and can last a few hours or days. Usually, however, they are resolved within about 10 days after delivery. Although the baby blues are short-lived, some researchers believe that women who experience these symptoms have an increased risk for PPD. Symptoms of baby blues include mild sadness, tearfulness, anxiety, irritability and fluctuating moods. PPD refers to a major depressive episode that occurs about four weeks after delivery. PPD is not an unusual form of depression; it is noteworthy in that it occurs around the time of childbirth. The length of PPD is different for every woman; some women feel better in a few weeks, while others may feel depressed for months. Most women with PPD display symptoms for more than six months, and if untreated, 25% of patients are still depressed a year later. Women with a history of depression may have PPD even longer. 

Postpartum psychosis is the most severe form of postnatal depression. While this condition is rare, it is extremely serious, disabling, and often requires hospitalization. Symptoms include hallucinations and delusions that often focus on the mother’s desire to hurt herself or her baby. Immediate medical attention is required in these situations. The causes of postpartum depression (PPD) seem to be a complicated interplay of several factors. The mother’s psychological state may be influenced by changes in levels of brain chemicals, hormonal imbalances, and the environment. It is important to note that symptoms of PPD in women may vary considerably, and a competent clinical evaluation is required. Some symptoms of PPD, i.e. low energy, weight fluctuations or sleep problems, occur naturally after childbirth. To distinguish between "normal" postpartum feelings and what could be PPD, at least five of the symptoms should be present over a 2-week period and at least one of symptoms must be depressed mood, or diminished interest or pleasure in daily life activities. 

Symptoms of PPD include: persistent low mood, hopelessness, helplessness, anxiety, panic, fear of being alone, and fear of harming the baby. Mothers may also experience insomnia, agitation, decreased energy or motivation and an inability to cope with routine tasks. In addition, PPD risk factors increase if there is a family history of depression, if there is a prior history of PPD, if there are difficulties with the baby (health, temperament, feeding, or sleeping problems) or if there are marital problems. It is therefore recommended that expecting mothers with such history seek advice from their doctors with every pregnancy. 

TREATMENT 
As in other types of depression, early identification and treatment are the keys to successful therapy. Treatment involves three phases: acute treatment (typically 6-12 weeks), which involves alleviation of symptoms; continuation treatment (which can last between 4-9 months), aimed at stabilization and recovery; and maintenance treatment, aimed at preventing recurrence in women with a history of PPD. Treatment may involve medications (usually antidepressants), cognitive-behavioral therapy, or psychotherapy. If medication is required, the psychiatrist must monitor response and side effects to the medication. It is important to note that it usually takes several weeks before most people begin to notice the benefits of antidepressant medication. If the woman is nursing, the doctor must make sure that the medication prescribed will not affect the baby’s health. 

In general, when a woman has a new baby, be it her first or tenth, the role of the husband and other significant family members is crucial. Husbands’ support and involvement not only send a strong message of caring to their wives, but also allow them the invaluable experience of attaching and bonding with their new baby. 

CARE AND NURTURANCE FOR MY BABY AND ME 
Hopefully, for most women, the time preceding and following childbirth is filled with positive, warm and exciting feelings that enable the mother to focus on and bond with her newborn. This "primary maternal preoccupation" is a psychological reverie for the two. For a period of time, no one else exists; there is only the intense attachment between mother and child. Women with PPD may feel helpless and inadequate and may withdraw from their childcare responsibilities. So, for example, a mother with PPD may be unresponsive to her baby, which in turn will cause the baby to try harder to get mother’s attention or comfort when they are upset. 

PPD can have long-term effects on a child’s emotional growth, especially if the condition goes untreated or lasts for a long time. Children of depressed mothers often have a difficult time expressing their feelings and participating in social activities. Children who are raised by depressed mothers commonly show one or more of the following characteristics: negative mood, poor adaptation to change, poor academic performance or intellectual ability, or inability to achieve secure attachment. In some cases, children may develop a major depression or anxiety disorder. 

There are ways in which a mother with PPD can insure that the mother-baby bond is not disrupted. These include: nursing or bottle-feeding more frequently in a quiet place, while sustaining eye contact with the baby; napping when the baby naps; holding and talking softly to the baby; enlisting husband, children or other family members to help with the baby; going outside with the baby, for a change of scenery and fresh air. In addition to nurturing their babies, mothers must learn to nurture themselves. A mother who feels angry, depressed, frustrated or tired may enlist her spouse or someone else they trust to care for their baby while they take some time for themselves. 

Some Final Thoughts 
This piece has attempted to provide an overview of depression throughout the woman’s life cycle, with particular emphasis on postpartum depression and its effects on both mother and child. It is my sincere wish that this article will provide education and hope to those that need help, enabling all women to achieve the goals set by Mishlei in Eishes Chayil, the sweet ode to Jewish women that is sung each Shabbos eve: "Piha pas’cha be’chachma, v’Toras chessed al le’shona…" 

Dr. Klein serves as Director of Tikvah at Ohel in Brooklyn, NY.

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