Article Bank # A-78
CHARACTERISTICS, RISK FACTORS,
SYMPTOMS, LEGAL IMPACTS
Postpartum Depression Characteristics
“affects 10-20%” (The Continum of Postpartum Emotional Reactions” (Figure 4.1), Hamilton and Harberger, [Footnote 1] Postpartum Psychiatric Illness: A Picture Puzzle, (Univ. of Penn. Press (1992) [hereinafter “PPI”]), Chapter 4, “Cries for Help,” by Harberger, Gleason, and Honikman, [Footnote 2] p. 44; see also Mothers Who Kill: Postpartum Disorders and Criminal Infanticide (1991) 38 UCLA L. Rev. 699, 706, 712; Sharon L. Roan, [Footnote 3] Postpartum Depression (Adams Media Corporation (1992) [hereinafter “Roan”]), p. 2.)
“insidious development” (PPI, p. 44)
“Deleterious effect on maternal-child relationship, marriage, and family life;”(PPI, p. 44; see also PPI, p. 45 [Postpartum emotional problems…destroy lives”].
“Hangs on interminably”(PPI, p. 44)
“Help-seeking behavior often discouraged and trivialized”(PPI, p. 44)
“Excellent prognosis with recognition and treatment”(PPI, p. 44)
May have delayed onset of 6 weeks to 3-4 months, and a course of 6 months to one year (PPI, Chapter 16 “Reproductive-Related Depressions In Women: Phenomena of Hormonal Kindling?” by Parry, [Footnote 4] p. 206; see also Roan, p. 12 [“…the most common pattern is for the syndrome (if left untreated) to languish for several months or a year])
Postpartum Illness–risk factors
Mother of several children (Roan, p. 7)
Very young mother (Roan, p. 7
Short interval between pregnancies (Roan, p. 7
Marriage strain and lack of support from spouse (PPI, Chapter 5 “Prediction, Recognition, and Prevention” by Herz, [Footnote 5] p. 69-70[“probably the most significant risk factor”]; Roan, p. 7-8, 98 [ “strongest predictive factors” (8) “most significant risk factor” (98])
Stressful life events (Herz, p. 70; Roan, p. 7)
Inadequate housing (Roan, 90)
Poverty (Roan, p. 99) [“Poverty is called ‘a pathway to depression'”]
Lack of preparation for motherhood (Roan, p. 7)
Conflicting or unrealistic feelings about motherhood (Roan, p. 56)
Social isolation (Roan, p. 7)
Sick or colicky baby (Roan, p. 7)
Poor match between temperaments of child and mother (Herz, p. 70) [mother misreads the infant’s cues resulting in flawed interaction which causes frustration, anger, guilt and depression]
Lack of support and help from others (Roan, p. 7)
Absence of extended family (Herz, p. 70)
Family history of mental illness or depression (Herz, p. 70; Roan, p. 82-3)
Previous psychiatric illness (Herz, p. 68-9; Roan, p. 82-3)
Past experience of physical, emotional or sexual abuse (Roan, p.100-106) “victimization is a major factor in depression” (Roan, p.105)
Past history of incest involving the patient (PPI, Chapter 6 “Recent Clinical
Management Experience” by Fernandez, [Footnote 6] p. 80)
Poor relationship with her own mother (Herz, p.70 [“significant association” with postpartum illness]; Roan, p. 7)
Recurrent maladaptation to change in developmental tasks (Herz, p. 69)
Prior abortion or miscarriage (Roan, p. 84)
Difficulty with breast-feeding (Roan, p. 13; 90-92)
PMS (Roan, p. 117; Herz, p. 67; Fernandez, p. 80)
Thyroid problems (Fernandez, p. 80, 83; Roan, p. 115-116)
Use of oral contraceptives after birth (Roan, p.29)
Physical complications or stress during pregnancy or at the time of delivery (Roan, p. 7)
Primiparas parent (Herz, p. 68)
Thoughts of suicide and infanticide (Herz, p. 66; Roan, pp. 12-13; see also 38 UCLA L. Rev. 699, 712 ; Dunnewold and Sanford, [Footnote 7] Postpartum Survival Guide (New Harbinger Publications (1994) [hereinafter “Dunnewold and Sanford”]), p. 92)
Inability to cope, inability to deal effectively with the child (Dunnewold and Sanford, pp. 89, 92)
Ambivalence, anger or overprotectiveness toward the baby (Dunnewold and Sanford, pp. 89- 93; Roan, p. 13)
Ambivalence or negative attitude toward maternal role, “maternal role conflict” — [Predictor of high significance of postpartum illness] (Herz, p. 69; Fernandez, pp. 80-81)
Anxiety and agitation (Fernandez, p. 83; Dunnewold and Sanford, p. 93)
Irritability or explosive temper; feeling out of control (Roan, p. 13)
Feeling hopeless or helpless, overwhelmed (Dunnewold and Sanford, pp. 24, 89)
Feelings of guilt or shame that she is not a good mother (Roan, p. 13)
Obsessive thoughts (Dunnewold and Sanford, p. 89; 38 UCLA L. Rev. 699, 712)
Severe, intrusive and obsessive ruminations of harming the infant
“Cries for help.” (PPI, 45, 48 [“What appears to be intentional neglect in the care of a baby may be an important behavioral clue”].) “One must anticipate that families may be experiencing difficulty and view their method of communication as a unique language. ¶ Cries for help are usually transmitted ‘in code.’ The new mother, who is supposed to be enjoying her baby, has no explanation for what is happening to her. She fears the worst and is ashamed. Confused and frightened, she may seek help through her baby.” [Citation. Emphasis in original.) (PPI, p. 41)
Impact of Postpartum Depression on Mental State
Can severely impact clear cogent thinking, cause impulsive behavior and reduce problem- solving skills (Michelle M Weil, Ph.D. [Footnote 8]; see also Roan, p. 94)[“Nothing can rattle a parent more than the incessant crying of a newborn. For mothers who are already … depressed, excessive crying can send them over the edge.”] [Emphasis added.]
Can cause a “serious inability to concentrate characterized by muddled thinking and fogginess; or ‘frenetic zooming,’the feeling of your mind racing, or memory loss.” [emphasis added] (Roan, p. 12; Fernandez, p. 79 [Confusion, difficulty in thinking coherently]; Dunnewold and Sanford, p. 89)
Can cause uncontrolled reactions (Dr. Galina Gorodetsky, M.D. [Footnote 9] Roan, p. 13 [“explosive temper”])
Left untreated can lead to suicide or infanticide (Herz, 66; Dr. Galina Gorodetsky, M.D.)
Recognition of Postpartum Illness by the Legislature
The California legislature has passed two resolution attempting to deal with the problems of social responsibility for and awareness of postpartum psychosis. (38 UCLA L. Rev. 699, 716; S. Con. Res. 23, 1989-90 Reg. Sess., ch. 83 (July 26, 1989); S. Con. Res. 39, 1989-90 Reg. Sess., ch. 87 (July 26, 1989); )
Implied malice requires knowledge that the defendant’s conduct endangers the life of another coupled with circumstances manifesting a conscious disregard for life. (People v. Whitfield (94) 7 Cal.4th 437, 450-51.) This is a subjective standard. (People v. Watson (81) 30 Cal.3d 290, 296-97.) Accordingly, the defendant must act with “actual knowledge” of life endangerment and conscious disregard for life. (See People v. Cameron (94) 30 Cal.App.4th 591, 600.)
For example, in State v. Householder [unpublished] 38 UCLA L Rev 699, 721 a postpartum-depressed mother threw a rock at her child in order to quiet her, causing the two-week-old infant’s death. “Householder could use evidence of her postpartum disorder to show that subjectively, the risk to her child never entered her mind. In her postpartum-disordered state, she simply wanted to silence the child. [Emphasis added.] (Ibid.) Similarly in Regina v. Szola (Ont. Ct. App. 1977) 33 C.C.C. 2d 572, 573-75 a woman who had recently given birth to twins and was suffering from postpartum depression intentionally dropped one of the infants on the floor. The infant died from injuries to the head. A doctor’s review of the case stated that the woman dropped the baby in the hope that she would quiet him, but was prevented by her disorder from realizing that serious injury or death would result. [Footnotes omitted; emphasis added.] (38 UCLA L. Rev. at 722.) “Objectively, no reasonable person would [do such things to a baby]. Yet, subjectively, evidence of a postpartum disorder can be used to negate the subjective awareness of the attendant risks.” [Footnote omitted.] (Ibid.)
James Alexander Hamilton, Ph.D., M.D., is Associate Clinical Professor of Psychiatry (Emeritus) at Stanford University and former Psychiatry Chief of Staff at Saint Francis Memorial Hospital, San Francisco, California. Dr. Hamilton is the author of Postpartum Psychiatric Problems (1962) and a founding member of the Marcé Society (International Association for the Study of Psychiatric Disorders of Childbearing).
Patricia Neel Harberger, M.S., C.F.N.P., A.C.C.E, is Director of Primary Prevention and Counseling Services, Family and Community Health Associates, York, Pennsylvania, and former coordinator of Behavioral Sciences and Family Dynamics for the Family Medicine Residency Program, York Hospital, York, Pennsylvania. She is a founding member of Postpartum Support, International.
Patricia Neel Harberger, see footnote 1, above.
Nancy Gleason Berchtold, B.S., is founder of the Depression After Delivery Support Network. She is a member of the founder’s group of Postpartum Support, International and a lecturer in the field of postpartum disorders.
Jane Israel Honikman, B.A., formerly directed the Santa Barbara Birth Resource Center. She is a founding member and chairperson of Postpartum Support, International, and co-founder of Postpartum Education for Parents (PEP), Santa Barbara, California.
Sharon L. Roan is the personal health columnist for the Los Angeles Times and the recipient of many awards for her research.
Barbara L. Parry, M.C., is Assistant Professor of Psychiatry at the University of California at San Diego.
Elizabeth K. Herz, M.D., is Associate Professor in the Department of Obstetrics and Gynecology and Psychiatry at the George Washington University School of Medicine. Dr. Herz also serves as director of the Program of Psychosomatic Obstetrics and Gynecology at George Washington University Hospital in Washington, D.C.
Ricardo J. Fernandez, M.D., is Clinical Assistant Professor in the Department of Psychiatry, Robert Wood Johnson/Rutgers Medical School. Based in Princeton, New Jersey, Dr. Fernandez acts as advisor to the Depression After Delivery Support Network, and his area of special interest centers on postpartum psychiatric problems.
Ann Dunnewold, Ph.D., is a psychologist specializing in women’s mental health issues related to reproductive function, including prenatal and postpartum adjustment, pregnancy loss, infertility, and PMS. In independent practice in Dallas, she serves on the boards of Postpartum Support International and Depression After Delivery, and speaks frequently on women’s and family issues to professional and lay audiences. Dr. Dunnewold is married and has two daughters, an experience that provides empathy and a practical perspective in her work.
Diane G. Sanford, Ph.D., is a psychologist, educator, and mother, whose expertise in the treatment of postpartum disorders is nationally recognized. She is on the advisory board of Depression After Delivery, on the board of Postpartum Support International, and she is a member of the St. Louis Barnes Hospital Postpartum Advisory Board. Currently practicing in St. Louis, her efforts to promote postpartum wellness include working with Parents As Teachers, Lamaze instructors, and other parenting and childbirth organizations.
Dr. Weil is a licensed clinical psychologist who’s expertise include child, adolescent and adult psychotherapy, parenting skills, postpartum recovery, child development, resolving children’s behavior problems, educational and psychological assessment, and consultation on a wide variety of problem areas. Her formal training covers cognitive-behavioral theory, psychodynamic theory and psychodiagnostic and educational assessment. In addition to her clinical practice, she has held lecturer positions at both the Fullerton and Dominguez Hills campuses of the California State University System, and has held an Adjunct Professor position at Chapman University for over ten years.
Dr. Gorodetsky is an assistant clinical professor, Department of Psychiatry, University of California, San Francisco.