If expectant mothers are allowed to feel only joy, those who are depressed will not seek the treatment they need
"To be pregnant has been for me each time the supreme joy... I was doing the greatest thing in the world without having to do anything - all I had to do was be," said Ms Gloria Vanderbilt, heiress, socialite and mother of television personality Anderson Cooper of CNN.
One can be sure that there are countless unnamed women with child-bearing experience who would less than wholeheartedly endorse what she said. Still, pregnancy is often described in cliched terms as "a time of rapture and fulfilment", where the physical discomfort is trivial relative to the "thrill and miracle" of "a new life within".
In reality, though, pregnancy is a rather dislocating experience - especially to those becoming pregnant for the first time. In her essay in the Los Angeles Review of Books, Lily Gurton Wachter writes of the foreignness of pregnancy: "Your body becomes inhabited by a stranger, by a guest who is stranger than any other guest you've ever hosted, insofar as you have never even met; and yet also closer and more intimate than any other… you become strange to yourself, estranged from who you once were, from what your body used to be or mean or contain, so that your body turns into something that you no longer fully understand. In pregnancy, the distinction you once knew between self and other comes undone."
This blurring of boundaries and shift in identity with its attendant expectations bring in their wake an array of physical, psychological and emotional changes that can be unsettling and even frightening; in some women, it could lead to depression. There is now a growing body of evidence that depression during pregnancy and in the post-partum period is more prevalent than previously thought.
HARM TO BABIES
Dr Helen Chen is the head of the Psychological Medicine Department at KK Women's and Children's Hospital. More than a decade ago, she set up a fledgling service for women with mental health issues and it has since grown into a full-fledged department staffed by a multidisciplinary team which also has a focus in perinatal psychiatry.
A mother of two adolescent daughters, Dr Chen is lean and petite with luminous eyes and a lively way of talking - particularly when it's on the issue of women's mental health. Perhaps, part of this animating passion and drive come from her own experience of her pregnancies - the worries, anxieties and fears of those times may be why she has plunged determinedly into the sorrow of other women to do something about it.
In 2008, she started the Postnatal Depression Intervention Programme where mothers are screened for depression when they return for their postnatal check-ups four to six weeks after their delivery. Since then, many thousands of mothers have been screened.
Postnatal depression (encompassing the spectrum from mild to severe depression and perhaps affecting 10 to 15 per cent of mothers worldwide) has on occasion been in the news - usually because of some awful tragedy, as in the case last year of a mother who clutched her two-month-old baby in her arms and leaped out of her 12th-storey flat.
"Contrary to common belief, a mother with postnatal depression rarely kills herself," said Dr Chen. The more common consequences of untreated postnatal depression (other than the miseries it inflicts on the mother) are on the baby's health - largely stemming from the emotionally, psychologically and even physically fraught mother.
"Postnatal depression has been shown to have negative effects on the infant's intellectual and emotional development. Research has shown that mothers who are depressed tend to have negative parenting styles, such as being over-intrusive in their child's activities, being more irritable and impatient, or being withdrawn and unresponsive," she said.
Less recognised until recently, antenatal depression (which is depression during pregnancy) is probably about as common as postnatal depression - affecting up to 12 out of a 100 expectant mothers. Some of these women are already depressed before pregnancy and remain so; in some, the pregnancy triggers the depression; while others who have recovered from their depression choose to stop their medication, fearing that it would harm their babies, only to subsequently relapse.
Whatever the origins, an expectant mother in the throes of depression will find carrying out the myriad sundry activities of looking after herself and the pregnancy insufferably difficult. She is less likely to sleep and eat well, and keep to her obstetric appointments. Antenatal depression also has various baleful effects: studies have shown that there is an increased risk of miscarriages, premature births, and of babies born with low birth weight.
If antenatal depression remains undetected and untreated, it is likely to transit to post-partum depression - in more than half of the women with post-partum depression, the condition was a carry-over of pre-existing antenatal depression.
Pregnancy is a prerogative that God or Nature has conferred (or foisted, depending on how one feels about it) on females who consequently have to bear the risk of depression that may come with it, but it is also something that affects their male partners.
Hard as it is to live daily in the darkness of another person's mind, it is particularly painful if the one affected is the person we love. The most loving partners could get exhausted from trying to be understanding and supportive, and despair in their helplessness at not being able to make things better. And they can get depressed.
A review of 43 studies (published in the Journal Of The American Medical Association) with a total of more than 28,000 fathers found that an average of 10.4 per cent of these men suffered from depression some time between the first trimester of their partner's pregnancy and the child's first birthday. Although the relationship is not one-to-one, having a partner with depression seems to increase an individual's likelihood of having it.
Last year, an influential US government-appointed health panel called the United States Preventive Services Taskforce recommended for the first time that women should be screened for depression during pregnancy and in the post-partum period.
It is still unclear just how many doctors here would do so. It may be that some doctors who see women during and after pregnancy are somewhat hesitant to check for mental health problems because they feel ill-equipped to handle them (there is, too, that fear of legal liability should they mismanage a mental health issue). Further, there might be a perception that screening would do more harm than good should a woman screened positive for depression become more worried and fearful and feel stigmatised.
The evidence, however, shows that a relatively simple and quick screening accompanied by even minimal counselling helped women with depression. Screening not only causes no harm, but the process also gives the doctors and patients the occasion to talk about depression and lessen the stigma.
And we also need to temper that popular narration that has made pregnancy and motherhood into a simulacrum of unadulterated maternal bliss and joy.
Most pregnant women and new mothers would experience a gamut of emotions and thoughts: a vacillating swirl of love and frustration, tenderness and anger, exhilaration and anxiety, protectiveness and helplessness, and even fear. If we only romanticise and sentimentalise pregnancy, these ambivalent mothers would see themselves as weak and abnormal, and worried about being judged as bad mothers. They would bury whatever negative feelings they have, and play up for themselves and to others their positive feelings of their incipient motherhood. And so, they wouldn't want to talk about their bad feelings, and would be both ashamed and afraid to seek treatment.
"As a community, we need to face the issues of maternal mental wellness with courage, to talk openly about these issues and not judge vacillating affected mothers who are unable to cope," said Dr Chen. "For through this, mothers can embrace themselves as good enough mothers, and be able to hold well their children through life challenges to become resilient individuals."
And, she added, "we need an honest presentation of motherhood". By this, she means that becoming a mother is an experience that is profound and transformative; with a wide range of moods and attitudes that are bewildering and conflicting at times; and with that mixture of positives and negatives - but all of which are parts of the same whole.
The writer is vice-chairman of the medical board (research) at the Institute of Mental Health.
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