June 30, 2001
Kevin Van Paassen, National Post
St. Clair subway station, where a woman jumped in front of a train with her baby in August, 2000.
ReutersAndrea Yates of Houston drowned her five children. She was depressed after the birth of her fifth child, not shown.
But Dr. Shaila Misri has seen many women struggle with the same demons.
She has listened to women talk about doing the unimaginable: What if I accidentally pushed the baby off the balcony? What if the baby went in to the microwave?
She has listened to them describe buzzing sensations in their heads. Some speak of delusions that their children are devils incarnate. Others describe "command hallucinations" telling them to kill their baby.
"And there is a high risk these women will do it," says Dr. Misri, director of the Reproductive Mental Health program at St. Paul's and B.C. Women's hospitals in Vancouver.
These are the horrific, secret thoughts of post-partum psychosis, the syndrome believed to have allegedly driven Andrea Yates to hold her children's heads under the bath water until they died, then lay their still-wet bodies under a sheet on a bed.
On Wednesday, as their grief-stricken father tucked blankets into each of his children's white caskets, a North Carolina man returned home to discover the lifeless bodies of his fiancée and her three children -- all still clad in their pyjamas -- on the garage floor, victims of carbon monoxide poisoning. Police have not determined whether the deaths were accidental or a murder-suicide, possibly inspired by the Houston case.
Three weeks ago, a 15-month-old Calgary toddler was discovered dead in his mother's apartment. His three-month-old baby sister is missing and presumed dead. Concern has been raised that public health and social workers may have missed signs of a woman in the grip of post-partum psychosis -- the same illness that apparently drove a Toronto woman to leap in front of a subway train last August, her six-month-old baby son asleep in her arms.
Dr. Misri estimates one in 800 of all new mothers suffers post-partum psychosis -- the extreme end of a spectrum of mood disorders that includes post-partum blues and post-partum depression. Together they make up the most common complication of pregnancy and childbirth, yet centuries after they were first described, they remain the least talked about, least diagnosed and least understood.
"Psychiatric hospital admissions are more likely to occur at childbirth than at any other time of life," Columbia University professor Dr. Margaret Spinelli said in a recent issue of the Journal of Gender-Specific Medicine, yet the problem has gone largely unrecognized "because there's a real resistance to admitting the thing even exists," Dr. Misri says.
Society's message to women is that this should be the most blissful, fulfilling time of their lives, not a time when they might be wracked by delusions or hallucinations or feelings of overwhelming hopelessness and despair.
"But the reality is that women, whether you're talking about the post-partum period or not, have a higher incidence of depression [than men], and we know that's linked with stressors," says Francine Roussy, a perinatal psychologist at the Ottawa Hospital. "And here we go with childbirth, which is one of the most stressful things that happens to a woman, particularly with a first pregnancy."
But most women who experience post-partum mood disorders suffer in silence. "You can imagine the stigma of saying to your spouse or to your doctor: 'I have these horrific obsessive feelings about wanting to harm my infant, I don't want to be left alone with the baby, I feel like crying all the time, I have no energy, no appetite," says Dr. Misri, a professor of psychiatry at the University of British Columbia.
And the line that separates post-partum depression from the normal crying jags and mood swings that afflict most women after giving birth can be so "fuzzy for a lot of physicians and patients themselves," Dr. Misri says, that "until something dramatic happens -- the woman is on Lion's Gate Bridge and her heart is pounding in her chest and she can't breathe and she feels like she's going crazy -- it doesn't get picked up."
No one can know for certain what might have driven Andrea Yates to kill her children or what force pushed Suzanne Killinger-Johnson, a family physician -- a psychotherapist -- in fact, off a Toronto subway platform and into the path of a rush-hour train last summer.
Physicians are slowly gaining new insights into the biological, psychological and social factors behind post-partum depression. They are experimenting with new treatments aimed at easing the massive upheaval of hormones that may trigger symptoms in vulnerable women. Fewer of them are rushing to take depressed women off their medications as soon as they become pregnant out of fear it may not not be safe for the baby. And more physicians are screening their patients for symptoms of the disorder.
Rarely does a post-partum mood disorder lead to the tragedy that made headlines last week, but depression can be a surprisingly "normal" part of childbirth.
As many as 85% of new mothers experience the baby blues, the tearfulness and irritability and sadness that hits within the first few days of giving birth. In most cases, the symptoms subside within two weeks.
In some women, the blues develop into a full-blown depression. Symptoms, such as feeling chronically anxious or tired, loss of concentration and low self-esteem can begin within the first month of birth, or they may not appear for six months or longer. A percentage of these women also have negative thoughts of harming their babies, but never act on it.
Post-partum psychosis, on the other hand, strikes suddenly, within two days to two weeks after birth, and symptoms escalate quickly. Women experience delusions, hallucinations and suicidal or homicidal ideation or thoughts. Basically, the woman's contact with reality becomes severely impaired.
Physicians do not know what causes post-partum depression and psychosis, but one of the leading theories blames the effect of hormones on the brain.
During pregnancy, a woman's estrogen and progesterone levels soar to several times their normal levels; after childbirth, they plunge rapidly. Some researchers suspect estrogen may affect the functioning of serotonin, a brain chemical that has been more clearly implicated in depression and acts like a conductor, controlling the brain's "emotional tone," says Dr. Paul Dagg, director of clinical services at the Royal Ottawa Hospital and associate professor in the department of psychiatry at the University of Ottawa.
Doctors have begun testing estrogen patches on women with post-partum depression, and last month, a study published in the Journal of Clinical Psychiatry suggested estrogen pills may ease the symptoms of severe post-partum depression.
Anti-depressants such as Prozac appear to be safe. Dr. Misri has just completed a study that involved giving women who had a history of post-partum depression Prozac, Zoloft or Paxil during pregnancy and after, while they nursed. "The babies were born completely without any abnormalities," she says. "Secondly, we were able to prevent relapse in 75% of the women treated. And their interaction with their babies was no different" than in healthy women, "which goes to show treatment is critical." A growing body of research suggests that if a depressed woman is not treated, her children are more likely to grow up "emotionally blunted," cognitively impaired and suffer conduct behavior disorders, Dr. Misri says.
But many women refuse medications. They want to be clean or are already feeling so guilty they do not want to risk exposing their babies, through their breast milk, to drugs that may harm them in the long term. (Dr. Misri's study has so far only followed babies up to eight months of age; she has just received a grant to study the children up to kindergarten age.) And even physicians are hesitant to keep women on their medications. "I had a woman who was acutely depressed after the birth of her second child and the Paxil was stopped by the psychiatrist because she didn't know enough about the safety of the drug," Dr. Misri says. "So the woman not only became depressed (after the birth of her second child), she had to be admitted to hospital because she had thoughts of killing herself and her baby one week after the baby was born."
In fact, women who have experienced post-partum depression with one birth are almost certain to experience it again, doctors say. Those with a personal or family history of depression are also more vulnerable.
But it is treatable, and therein lies the tragedy, Dr. Misri says. While doctors are getting better at screening women, too often it is left to the 20-minute, six-week post-delivery check-up, "where everything is focused on the baby: 'How's the baby feeding, how's the baby's weight,' blah, blah, blah. The woman doesn't get any attention. And so it's missed." She said it takes seven months, on average, from the onset of symptoms before a woman is finally seen by a specialist.
She and others say more money needs to be spent on outreach, on getting trained professionals into pre-natal classes, colleges and universities, community centres and exercise groups so that no woman goes unrecognized or untreated.
Andrea Yates remained in a jail cell yesterday, charged with capital murder and under a 24-hour suicide watch. She could face the death penalty for killing her children. Dr. Misri says she "hopes to God" she does not.
"These women are not Timothy McVeighs. They are sick, they are ill. They are not criminals.
"What women in her right mind would want to kill her babies?"
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