July 27, 2011
By Lisa Osborn, PsyD and Ivy Margulies, PsyD
Contrary to the popular belief that pregnancy is a biologically protective and emotionally joyful time, women are actually quite vulnerable to a spectrum of mental health disorders throughout the perinatal period – the time around pregnancy and postpartum (Beck & Driscoll, 2006). This range of disorders, more commonly referred to under the umbrella term of “postpartum depression,” is more accurately reflected by the terms postpartum or perinatal mood and anxiety disorders (PMADs). In fact, one in seven women who become pregnant will experience a mental health disorder during the course of her pregnancy or in the postpartum period, making PMADs the most common complication of childbirth (Beck & Driscoll, 2006; Bennett & Indman, 2006; Stone & Menken, 2008). Additionally, 50 percent of women diagnosed with PMADs postpartum had an onset of their symptoms during pregnancy (Stone & Menken, 2008).
Approximately one-third of all pregnancies will end in some form of loss such as miscarriage, stillbirth or termination (Kohn & Moffitt, 2000). Even when a woman does not bring home a baby, falling hormone levels coupled with the emotional consequences of loss may trigger PMADs leaving a woman at risk for up to six months (Bennett, 2007). Moreover, when there are birth complications or when a child is born with a birth defect, prematurely, put in neonatal intensive care or given up for adoption, the added stress places women at an increased risk for PMADs (Stone & Menken, 2008). While the Diagnostic and Statistical Manual of Mental Disorders-IV presents a limited symptom list and states that postpartum depression begins within four weeks after childbirth, women are actually at risk for PMADs anytime during their pregnancy and through the first postpartum year (Beck & Driscoll, 2006; Stone & Menken, 2008).
It is important to mention that men are also vulnerable to depression and anxiety during the postpartum period with as many as 10 percent of fathers experiencing symptoms (Madsen & Juhl, 2007). Furthermore, PMADs are more likely to occur when a man’s partner is depressed.
Few studies have examined the effects of employment on PMADs. However, it is an important issue for employers given that women make up approximately 47 percent of the labor force, (Bureau of Labor Statistics [BLS], 2011) more than half of women with an infant under the age of a year old remain in the workforce (BLS, 2011) and the fact that men are also vulnerable to PMADs. PMADs in the workplace have repercussions not only for the health and well-being of employees who have just had a baby, but also on an organization’s health care costs and work performance. Depression in general costs U.S. employers $44 billion per year in lost productivity and another $12.4 billion in health care costs (Stewart, Ricci, Chee, Hahn, & Morganstein, 2003).
Few would argue against the fact that the birth of a baby brings with it one of the biggest life changes one will experience. Added to the stress of this significant life transition are the additional challenges working parents face with regard to the work-life interface. Demands arising from paid work must be managed along with those from unpaid tasks at home. Demands from home include adjusting to parenthood, infant sleep problems and infant fussy behavior (all of which can increase postpartum symptoms).
Barriers to Identification and Care
Many women suffer silently after the birth of a baby, due to the stigma, shame and fear often associated with mental health issues. Studies reveal that women avoid seeking mental health treatment because they feel like “a bad mother,” fear their babies might be taken away from them because they are “crazy” or feel defective because they cannot do what should come “instinctually” (Pinto-Foltz & Logson, 2008). In addition, it is easy to imagine the stigma-related fears one might have pertaining to the workplace, for example, getting passed over for a promotion or a raise, or even losing one’s job. For men, there has been little recognition of PMADs until recently.
Too often when women do seek help, their requests are met with well-intentioned but poorly informed responses from family, friends and health care providers. One of the primary reasons women’s symptoms are missed, even when they are reported, is that they are dismissed as a normal and natural consequence of childbirth. PMADs symptoms hide in plain sight. Everybody knows that new mothers (and fathers) are sleep deprived. However, it is critical to distinguish between interrupted sleep which is characteristic of this period, from an inability to sleep even when given the opportunity. Sleep disturbance alone can place a woman at risk for developing PMADs.
Another normal occurrence of postpartum adjustment is the “baby blues,” which are experienced by approximately 80 percent of women (Kleiman, 2009). Many women report fluctuating moods, tearfulness and mild sadness or anxiety, etc. The “blues” typically resolve on their own. However, if the symptoms persist for more than two weeks, or become severe, a woman should be evaluated for PMADs. Postpartum psychosis, a serious and rare condition, also reveals itself early in the postpartum period. It is characterized by symptoms such as hallucinations, delusions and extreme agitation. It is a true clinical emergency and requires immediate medical attention. Left untreated it can have tragic consequences (Stone & Menken, 2008).
Another factor contributing to the misdiagnosis of these disorders for both women and men is that the term “postpartum depression” does not necessarily reflect the primary symptom experienced. Research shows depression ranks 10th on the list of presenting symptoms. For women, more prominent are the symptoms of anxiety, insomnia, irritability and feeling a “loss of self.” Some women report feeling like they are “going crazy,” have serious regrets about having the baby, experience disturbing thoughts that feel foreign to them about harm coming to the baby or become suicidal believing that their families would be better off without them (Beck & Indman, 2005; Kleiman, 2009). It is imperative to evaluate postpartum women seeking treatment for suicidal ideation (Kleiman, 2009). Men’s symptoms tend to exhibit as irritability, anger, frustration and withdrawal.
What Employers Can Do
PMADs can have serious consequences for mothers, infants, children and families regardless of socioeconomic status, race or ethnicity (Bennett, 2007). Untreated PMADs increase the risk of preterm delivery, can interfere with the mother/infant attachment and can result in social, emotional and behavioral difficulties in children (Pawlby, Sharp, Hay, & O’Keane, 2008; Stone & Menken, 2008).
Although the causes of PMADs are not fully understood, they are generally considered to be due to a combination of biological, social and psychological stressors (Beck & Driscoll, 2006). PMADs are not always preventable, but they are highly responsive to treatment. And while some episodes of PMADs resolve on their own, others can become chronic affecting the quality of family life and significantly contributing to marital friction and divorce (Roberts, Bushnell, Collings, & Purdie, 2006).
Employers who are interested in addressing the impact of PMADs in the workplace can examine the Psychologically Healthy Workplace Program domains of work-life balance and health and safety within their organization. The facts about PMADs can be used to inform family leave policy, determine workplace practices and select health service providers including those offered within an EAP. For example, Dagher (2008) showed that every additional day of leave from work after childbirth until six months postpartum decreases PMADs symptoms. Additionally, the following psychosocial factors such as time control, perceived control, available social support and supervisor support were identified as helping to minimize symptoms of PMADs. Some research (Dagher, 2009) has shown that both schedule autonomy and coworker support has a positive effect over perceived control of work-life issues, which may also reduce symptoms of PMADs.
With an improved level of understanding, screening and integrated physical and mental health care women, men and their families can benefit not only from preventative efforts but also from early intervention, which can dramatically improve the course, severity and outcome of PMADs when they occur. Employers that are aware of the negative impact of PMADs can help prevent them by helping employees who are pregnant or recently had a baby feel supported in their efforts to be successful at work. Employees that feel more supported at the office have better work-life fit and are more productive, which is a win-win for employee health and well-being, as well as organizational performance.
About the Authors
Lisa Osborn, PsyD is a clinical psychologist who specializes in assessing and treating mood and anxiety disorders in pregnancy and the postpartum period. Currently, she serves on the Los Angeles County Perinatal Mental Health Task Force working to build awareness about the mental health issues arising in pregnancy and the postpartum period. She has special interests in working with couples adjusting to parenthood and the issues women and men face in the workplace following the birth of a baby. Dr. Osborn is the Co-Director of Ivy & Osborn, a pregnancy and postpartum mental health center in Santa Monica.
Ivy Margulies, PsyD is a clinical psychologist specializing in perinatal issues, infertility, postpartum diagnoses, parenting, trauma, pregnancy/newborn loss, young widows and grief. Dr. Margulies is the Co-Director of Ivy & Osborn, a pregnancy and postpartum mental health center in Santa Monica. She has over 20 years experience working with families and children and has been associated with UCLA’s Child Study Center, St. John’s Hospital Child Study Center, Children’s Hospital Los Angeles, The Pump Station in Santa Monica and the Akasha Center for Integrative Medicine. Dr. Margulies is a contributing expert on ModernMom.com.
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