The data show that 1 in 5 women will have a mental disorder during pregnancy or after childbirth. What is perinatal mental health and what are the associated disorders?
The perinatal period is the stage that encompasses pregnancy and the first year postpartum. There is a wide range of pathologies: depressive disorders, anxiety disorders, psychological disorders, etc. However, in the perinatal period there are some more specific factors such as perinatal depression. In the past, people used to speak a lot about postpartum depression. However, now the concept has changed because it has been seen that many of these depressions start during pregnancy. There is also perinatal bereavement, which is the loss of the baby, an area that has become much more visible in recent times. However, sometimes childbirth is a traumatic experience and this gives rise to complications such as depression or difficulties in bonding with the baby.
Why is postpartum depression the most frequent disorder?
It is the one most talked about because luckily a great deal of progress has been made in its detection and diagnosis. However, we are far from where we should be in the knowledge and proper treatment of postpartum depression. It affects 10% of women and can affect any woman regardless of where she lives, her economic situation, age or ethnicity, etc. There are different degrees of postpartum depression, from mild depression to the most severe forms that may require hospitalisation.
What can be done to improve the diagnosis?
In 2018, a screening programme was set up by midwives in sexual and reproductive health programmes. You take a depression screening test adapted for women and the perinatal period, because the symptoms are not the same as depression in other periods, and that is why it is sometimes not diagnosed properly. Questions are usually asked about sleep issues, about being more inhibited, tired, etc. And these things are already disturbed in women during pregnancy or the postpartum period. In this case, you have to focus more on anxiety, feelings of guilt, lack of enthusiasm, etc. We are ahead in screenings compared with other places, but the follow-up ends at the postpartum visit.
And then what?
Depression can appear over the course of a whole year after the birth, and this is where we still have a lot to do. For example, working together with Paediatrics. Because if a woman is healthy, she does not visit the doctor too often and, on the other hand, she does take the baby to the paediatrician regularly. However, paediatrics traditionally focuses on the baby and not on the mother.
Only 1 in 10 women will receive adequate treatment for their disorder. What can be done to correct this?
The British, who are way ahead of us, have studies that indicate that 75% of mothers are not diagnosed. And of those who are diagnosed, only 10% receive suitable treatment. What is the problem? That sometimes those who are diagnosed are treated for depression like at any other stage, without considering whether they are pregnant or have just had a baby. They receive the same treatment as that given to a 60-year-old woman, an adolescent or a 40-year-old man. And in this case, we have to see which treatments work best because depression does not just affect them, it also has a direct impact on the baby’s health. This is why we need a treatment for both of them: the mother should come with her baby in order to work on the relationship and ensure a complete recovery.
Before you explained how many cases of postpartum depression start before the birth.
50% of women start to have symptoms during pregnancy. So, if you detect it at this point, you can already start to activate a series of support mechanisms. However, there is still a widespread belief that it will be something temporary, that when the baby is born and she sees its face, the mother will suddenly be happy. The bond is not automatic, and if you are depressed it is more likely that it will not be good, because the woman's emotions are disturbed and, even when the baby is born, it will not make the situation change suddenly. On the contrary, it may make it worse.
Postpartum depression should not be confused with a transitory state of sadness and mood swings that 70% of mothers experience in the days following the birth of the baby. How can we tell where the limit is?
As in all mental illnesses, the limit is in the person’s functional limitations. Hormonal changes during the postpartum period can lead to mood swings, and that does not mean you are depressed. However, if these symptoms continue over a period of time, and I don’t bond with the baby, start to be unable to sleep, to have negative thoughts on a sustained basis, etc. and moreover this is limiting my ability to function: I am not performing well at work, I don’t want to go out or do anything... For a time, postpartum depression was ignored, with the idea that it was the mother who was not adapting well to her new role.
Sometimes, we find women who visit the specialized clinic very late, because they asked for help but people underestimated what was happening to them. They come when they have already been suffering for seven or eight months, and what they need is treatment for depression. And when they get better from the depression, their functionality improves too. It’s not that they stop having worries, doubts or anxiety, they just start to have those that all mothers have when they have a baby.
Does society understand mental disorders during pregnancy and the postpartum period?
Our patients experience a triple stigma: that of mental health, that of mental health in a woman, and that of mental health in a mother. In the first case, because it exists on a societal level. In the second, because as women they are expected to be good carers, and at the same time there is a series of stigmas about illnesses that are only related to women, which remain hidden, such as endometriosis or fibromyalgia. And with mental health, much more. And about mental health in a woman who is a mother. There is a widespread belief that motherhood brings happiness and excitement and that everything is easy or not very difficult. So, speaking about mental health problems in this period is much harder because the judgement is always much harsher. The subject of mental health in this period is silenced to a great extent, but we cannot act as if these illnesses did not exist.
How does the Perinatal Mental Health Unit work?
The programme has been running for 20 years, since Dr. Lluïsa Garcia-Esteve started an outpatient clinic to provide care for mothers with mental illnesses. In 2018, the unit was created with two facilities: the outpatient clinic and the mother-baby day hospital. The outpatient clinical treats pregnant and postpartum women, both those who are already ill and those with previous history. We also have the perinatal bereavement programme for mothers who have lost a baby and develop some kind of illness. As for the day hospital, since we opened it we have cared for around 160 mothers and their babies. It is intended for all mothers from the moment they give birth until the end of the first year postpartum, who require a little more intensive intervention because they have a mental disorder or moderate-severe bonding issues and need more than just the usual outpatient treatment.