Karen Kleiman, M.S.W., Licensed Clinical Social Worker and co-author of This Isn't What I Expected: Overcoming Postpartum Depression has been working with women and their families for over 20 years. A native of Saint Louis, MO., Karen has lived in the Philadelphia area since 1982 with her two children and her husband. After graduating in 1980 from the University of Illinois at Chicago with her Masters in Social Work, she began her practice as a psychotherapist, specializing in women's issues. In 1988 she founded The Postpartum Stress Center where she provides treatment for prenatal and postpartum depression and anxiety.

In addition to her clinical practice, Karen provides training and in-services for healthcare professionals as well as consultation and supervision to therapists. She frequently lectures and continues to write on the topic of postpartum adjustment. Her work has been featured in local and national magazines, radio shows, "Inside Edition" and in 1996 she appeared on the Oprah Winfrey Show.

Karen explains, "The most common illness following childbirth is postpartum depression (PPD), characterized by frequent crying, mood swings, irritability, extreme fatigue, difficulty concentrating, sleep problems, loss of sexual interest, anxiety, appetite changes, negative scary thoughts, feelings of inadequacy, hopelessness and despair. In addition, thoughts of suicide and feelings of anger, shame and guilt are often present. If you are experiencing any of these symptoms after the birth of your baby, or if you are concerned about the way you feel, please seek the advice of your healthcare provider."

A StorkNet member asked Karen this very important diet question:

Can a healthy diet help you overcome PPD? If so what foods should you try to eat or stay away from?

Karen Kleiman, M.S.W.: Diet alone may not alter the course of the depression, but it will certainly help keep you on the right track. Here are a couple of nutritional tips:

1) Avoid ALL caffeine (yes, small amounts can make a difference, particularly if anxiety is the predominant symptom) This includes colas, chocolate, coffee, tea.

2) Avoid alcohol. Alcohol is a brain depressant and will interfere with sleep which is so crucial right now.

3) Avoid concentrated carbohydrates (candy, cakes, ice cream and sugary beverages). These can cause rapid swings in your blood sugar that can mimic or trigger panic attacks.

4) Increase complex carbohydrates (whole-grain bread, rice, pasta). Complex carbs help keep your blood-sugar level steady without the swings that come from sugary foods.

5) Try to eat smaller, more frequent meals. Sometimes, mood swings can occur when our system is deprived of the proper nutrients and you might notice that you feel better if you provide your body with fuel throughout the day.

It's never a good idea to go too long without eating during this time.

Prologue from the book:

We became psychotherapists before we became mothers. Even as student therapists, we always had a special concern for our women patients. We saw ourselves as dedicated to working to help women who were struggling with low self-esteem, who felt powerless to solve relationship problems, or who were exhausted from giving to others but were unable to nurture themselves.

In addition to being committed to women, we also believed that we were knowledgeable about the special problems that our women patients brought to us. After all, we thought to ourselves, we were graduates of well-respected training programs, had what we thought were the right attitudes, and saw ourselves as free of the stereotypes about women that permeate the history of psychotherapy. We had heard about postpartum depression, but, like those who taught us, believed that it was rare and probably not much different from the other types of clinical depression.

We had difficulty believing that such a devastating illness as clinical depression could be related to childbirth. After all, we were confident that becoming a mother would be the happiest time in our lives--or almost any woman's life. We were competent professionals, givers of advice, and solvers of problems, who had looked forward to becoming mothers for as long as we could remember.

You can imagine how this story ends--we became mothers. We learned that motherhood is great--when it's great. But we also learned that when it's terrible, it's very, very terrible. We learned that you can love your baby more than you ever imagined possible, and at the same time be scared by how angry and frustrated you feel. We learned that the sound of a helpless, crying infant who is not hungry, wet, or stuck by a pin can destroy self-esteem in a matter of minutes. We learned that night after night of interrupted sleep can make you think you might really go crazy. We learned that it is possible to experience even a hug from your husband as an intrusion into your five minutes of peace and quiet. We learned that breastfeeding is not innate and that a screaming infant who is refusing your breast can make you feel the pain of rejection as you have never known it before. We learned that even though we loved being home with our new babies, we missed adult company and missed feeling the sense of accomplishment that we all get from our work or outside interests. In sum, we learned that all the rough parts had been glossed over and left out of our culture's idealization of new motherhood.

We haven't been the same as therapists ever since. After becoming mothers, our ability to identify and understand some of the issues related to motherhood became essential to our practices. We realized that when we asked the right questions, we discovered that many women suffered from postpartum depression. We recognized that we had often failed to see the patterns in women with postpartum depression ("PPD"), believing instead that they were coincidental, not necessarily due to having a baby. We regretfully admitted that we had never understood how stressful the postpartum period usually is. Our new-found awareness of the problem taught us that, as professionals, we have a long way to go in understanding postpartum disorders, and we set out to correct our own ignorance.

We both gradually came to specialize in postpartum depression, Karen in Philadelphia, Valerie in Chicago. Karen is a clinical social worker, family and couples therapist, and former lactation consultant, who founded and directs the Postpartum Stress Center in Philadelphia area. Valerie is a psychiatrist on the faculty of the University of Illinois College of Medicine at Chicago, where she directs the Department of Psychiatry Pregnancy and Postpartum Treatment Program. Karen has two children; Valerie has three.

The syndrome of depression and anxiety after childbirth is a common disorder that can strike any mother. In our practices, we discovered that some women who suffer from depression after childbirth recognize it right away; others suffer alone, knowing that they feel miserable but not aware that postpartum depression is a real illness, with a real name and a cure. We have yet to see a woman suffering from postpartum depression who expected it--we all have grown up expecting that this would be one of the best times of our lives.

Although postpartum illness affects each individual woman in a unique way, many of the issues precipitated by this crisis are very similar among its sufferers. By addressing these common themes, this book is designed to help you understand postpartum depression and to engage you in an active effort to recover. Each chapter begins with a statement or question commonly made by someone suffering from postpartum depression, followed by information and suggestions based on our experience treating women for depression and anxiety after childbirth.

We will first describe the syndrome of postpartum depression. We will cover the difficulties in accepting having this terrible illness at a time when the expectations of happiness were so great, and will help you understand the painful feelings that are symptoms of this illness. We will help you overcome self-defeating thoughts and encourage healthy ways of coping and nurturing yourself. We will describe how to mobilize support from your husband or partner, family, and friends, and devote a chapter to helping those people understand your illness. We explain the varieties of treatment options, including medication, psychotherapy, and self-help groups.

We also address common unresolved issues with your own parents that can affect your identity and self-esteem as a new mother with PPD. And we will help you to grieve the painful losses that come with motherhood complicated by postpartum depression. Finally, we describe stages of recovery and common concerns about the future after an episode of PPD.

At the end of the book, we have included the Raskin-Kleiman Postpartum Depression and Anxiety Assessment, which can be used by mental-health professionals to perform a comprehensive assessment of a woman who is entering treatment for the entire spectrum of anxiety and depression after childbirth. We use this clinical instrument in our practices and find that it helps us quickly identify important issues, coping styles, and availability of support. If you are in therapy now, you may find it helpful to bring your answers to your therapist's attention.

We hope that this book will help you if you or someone you care about is experiencing PPD. We also hope that this will help increase public awareness of PPD, and lessen the shame and isolation that makes this disorder so devastating.

~

Below are just a few suggestions for stress reducers, taken from This Isn't What I Expected. There is an entire chapter dedicated to coping techniques.

1.) Leave the beds unmade. Close the bedroom door if you don't want any unexpected visitors to see.

2.) Take a nap while the baby naps. If everyone keeps repeating this advice, isn't it time to try it?

3.) Take a bath using scented bath oil, or wear perfume. Don't wait for a special occasion -- do it for yourself. A wonderful fragrance sends a subconscious message that you are special and attractive.

4.) Wear wrinkled clothes.

5.) Simplify dinner: Replace a salad with sliced cucumbers. Replace a casserole with broiled chicken that you simply rub with oil and a sprinkle of garlic.

6.) Simplify your housework! Do the same chores less often or do fewer chores until you feel better. For example, it is okay to change your sheets less often!

7.) Have pizza delivered; ask your husband to bring home take-out food; treat yourself to an occasional grocery delivery service. Many grocery stores offer this for a small fee.

Please visit Karen's website and learn more about PPD.

We are very happy to announce the two winners of copies of Karen's book. Gena and Janet, we will be contacting you through email.

StorkNet Member: I've been suffering from PPD since my baby was about two months old. For the most part it is better now, but there is still the occasional bad day. I did have some depression before I was pregnant so it's hard to tell if it is that depression resurfacing or if it is the PPD still.

I guess my question is when is it no longer considered PPD? My baby is about to turn one. I feel that it is still more PPD related because unlike my depression in the past, I do have good days and it's very sporadic and doesn't seem to be related to anything in my life when it's a bad day.

Karen Kleiman M.S.W.: This is a question I am asked all the time, what is the difference between PPD and "regular" clinical depression, that is, depression that is not related to childbirth? Actually, postpartum depression *is* a clinical depression. So, in terms of symptoms it can present exactly like any other depression. What makes PPD unique is that it occurs within the context of having a baby. This means in addition to experiencing the symptoms of clinical depression (feelings of sadness, hopelessness, irritability, weepiness, anxiety, sleep disturbance, appetite changes, difficulty concentrating, constant worry, negative intrusive thoughts) -- the transition to motherhood assaults her with additional pressures and expectations, such as sleep deprivation, loss of independence and free time, the drive to be the perfect mother, lack of sexual interest, and the general stress of having a new baby in the house, just to name a few. So, if you think about it, it's no wonder a new mother feels so overwhelmed!

PPD is often characterized by good days alternating with not-so-good days and this is quite common. This is also, precisely what makes some women doubt that this is really PPD because there are days they feel really good. One of the things that I always say is, if you think something is wrong, it probably is. Women need to trust their instincts regarding the way they are feeling. It doesn't really matter what we call it, whether we call it PPD, or depression or something else. What's important is that you take it seriously and you take steps toward recovery. If you continue to worry about the way you are feeling, make sure to let your healthcare practitioner know this.

StorkNet Member: Any quick tips for dealing with the irritability aspect of PPD? I tend to just go off on my husband when I'm having a bad day. The things I get upset about are not things that he or I or our baby can control so in my calmer moments I realize my response to these situations is completely irrational.

Karen Kleiman M.S.W.: Irritability is a common symptom that is often disregarded because it doesn't "look" like depression. It is often the body's way of protecting itself from what it perceives as an overload which is why many women overwhelmed with irritability often feel like they are in the middle of a meltdown.

First of all, find a time when you are not feeling anxious or overwhelmed or irritable and sit down and talk with your husband. Try to explain to him what you think is happening here and help support his difficult position of being in the line of fire. Secondly, consider if there are other things going on or other ways you are feeling and make sure you are taking care of this, in the event that depressive symptoms are getting the better of you. Are you sleeping okay? Are you feeling tired, angry and unimportant? Are you overwhelmed with guilt? Are you feeling like you are missing out on the good things that other people are feeling? Talking about these feelings may actually help manage the irritability, because sometimes we feel irritable when we feel overwhelmed and misunderstood. You need support right now. This can be from your doctor, your therapist, your husband, your family, etc. Irritability is our way of saying, "Excuse me!!! I need something here!!! Could someone pay attention and take care of ME????!!!" So listen to your body and take care of yourself. Bring your husband into this process by explaining to him what's going on and tell him specifically what he can do to help. Then thank him for his support and remind him you will make it up to him when you are feeling better! :)

StorkNet Member: Two years before becoming pregnant, I was diagnosed with clinical depression and took Effexor up until I discovered I was pregnant. I am "cold turkey" now and have found it very difficult. Is it likely that I'm a strong candidate for PPD and if so, am I better off beginning Effexor again immediately after birth -- and maybe staving it off?

Karen Kleiman M.S.W.: Women who experience depression during pregnancy are at an increased risk for PPD. The use of antidepressants during pregnancy is controversial and depends on 1) the severity of symptoms 2) the medication used 3) the opinion held by your doctor and 4) the risk-benefit analysis of not treating the illness vs exposing the fetus to minimal amounts of medication.

Current research supports the use of antidepressants immediately after delivery to reduce the likelihood of PPD. Many women and their doctors choose this option, to start their medication right after the baby is born, and I mean right in the delivery room! This has been proven to make a difference in protecting the woman from the onslaught of PPD symptoms. Other women prefer to "wait and see" and if symptoms emerge, start treatment then. This is understandable, but remember that the symptoms are harder to treat the longer they are present.

Discuss your options with your husband and your doctor. If you are planning to breastfeed, include your baby's doctor in this discussion. Make sure to get as much information as you can so you are armed with the resources that will help support you during this time.

StorkNet Member: What can I do to stop the way I am feeling? Is there medicine or do you just have to wait it out?

Karen Kleiman M.S.W.: I'm sorry you're feeling so bad. What you do next really depends on what you're feeling, how bad you're feeling and how long you've been feeling that way. Some of the symptoms of PPD are actually quite "normal" during the first few months after childbirth; lots of new mothers feel inadequate or overwhelmed. Lots of new mothers feel like crying and are more irritable than usual. But if you're feeling this way most of the time and it's not getting any better, and you just don't feel like yourself, it's probably time to get help.

This means you should talk to your doctor about the way you are feeling. Many women feel closest to their OB and choose to talk to them. You can also talk to your family doctor. In either case, they should know you're not feeling well and can discuss treatment options with you. Options include: a referral to a good therapist who specializes in the treatment of women and depression. You can also discuss the use of antidepressant medication if your symptoms warrant it. Antidepressants such as Prozac, Zoloft, Paxil, Celexa, Luvox, Effexor, or Serzone are very effective in the treatment of symptoms that are biologic in nature. Some of these symptoms include: insomnia, change in appetite, suicidal thoughts, panic or anxiety attacks, difficulty concentrating, intrusive thoughts, loss of pleasure.

I know it can be scary to think about the possibility of taking medication, but the option of continuing to feel this bad can be pretty scary, too. The medications are safe, non-addictive and highly effective in treating the symptoms of PPD. So discuss this with your doctor because "waiting it out" is never a good idea.

StorkNet Member: I'm 21 now, but when I was 11 I had to deal with clinical depression for about 3 years--this was after my oldest sister committed suicide. I spent those three years in and out of the hospitals. I have a 4 month old beautiful baby boy now, but I sometimes worry the depression will creep back up on me. Am I more prone to PPD having already had to deal with one major depression? Help!

Karen Kleiman M.S.W.: You've certainly had to deal with an enormous loss, I'm sorry. And yes, both your sister's history and your own history of previous depressions will increase your risk of a recurrence of depression, particularly at this time when you're so vulnerable. That doesn't mean it WILL happen, it just means you're at risk.

There are a couple of things you can do. I would recommend finding a good therapist if you don't already have one. This is an important relationship that can serve to reinforce your emotional health and keep you on track. Secondly, I'm assuming you have previously taken medication to treat the depression and I would recommend you talk to your doctor and/or therapist about the possibility of taking an antidepressant prophylactically, to reduce the likelihood of PPD emerging. If neither of these options appeal to you, then I would recommend you get some self-help books on PPD, get as much information as you can, talk to your husband about the way you are feeling, fortify your support system, make sure you are taking good care of your physical self, eat well, rest as much as you can, and make sure you are in touch with how you are feeling so you can intervene immediately if you should experience any early symptoms of depression. Good luck to you and I wish you the best with your sweet baby.

StorkNet Member: After the birth of my son (1st born, planned c-section) I didn't even want to hold him in recovery. Breastfeeding was frustrating and I began to resent my son. Besides a painful recovery and guilt over my decision not to continue breastfeeding (because of the resentfulness toward my baby), I was also dealing with my baby's scary diagnosis of a brain disorder. On top of THAT, my son was also high needs requiring me to hold him 24 hours a day and he cried for half of that time with me unable to comfort him. Not a day went by where I didn't cry. My husband didn't know what to do because every time he came home from work I was an emotional wreck. I wouldn't eat and rarely slept. I just held my baby and cried. After 2 months I began to finally develop an attachment for my baby and realized that I would love him no matter what was wrong with him. That attachment has only gotten stronger, and now that he is almost 6 months old my appetite is fine and I feel back to normal . . . most of the time.

My question is: how do you distinguish between PPD and just normal feelings of being overwhelmed. Everyone told me that with all of the stuff I was dealing with, it was normal for me to be upset. But I don't think they knew how out of control and depressed I felt. Even now, about once or twice a month, I think a little too much about my son's condition and everything else in my life and go back to that "awful" place of despair. I can pull myself out and resume my life and enjoy my son for the miracle he is, but I am scared of losing control. Is it possible that I am still experiencing PPD or am I just overwhelmed by the "hardships" in life?

Karen Kleiman M.S.W.: Well, it really doesn't matter what we call it, either way, you've had a great deal on your plate and it's no wonder you feel bad every once in a while, don't you think? What a tremendous ordeal for you to go through. I'm glad to hear you've worked much of this through and for the most part, are feeling better. But remember, you've experienced an enormous loss (loss of the perfect baby) and this can take a constant toll on our effort to be the best mother we can be. Talking to a therapist can really help in this kind of situation. It's hard to maintain perspective when you are understandably so self-absorbed and overwhelmed. I imagine you haven't had time to do much else besides taking care and worrying about your baby.

It's time to take care of YOU, now. Part of that means understanding that you've experienced a trauma here and that you're just going to feel bad every once in a while. It also means making sure you take time for you to rebuild your strength and to provide time away from the stressful situation at home. It sounds like you've worked very hard. Now, take a deep breath and put yourself on the top of your list of things to take care of.

StorkNet Member: Is it possible to have postpartum 10.5 months after the baby is born? I have had problems with depression since my son was born last August '99. I am now 23 weeks pregnant and it has gotten even worse. I feel despair, resentment, and heavy hearted all the time. I cry all the time and put a lot on my wonderful husband's shoulders. I plan to talk to my OB next week but I don't know how to climb out of this dark hole that seems to be swallowing me up.

Karen Kleiman M.S.W.: Yes, it's possible to have PPD anytime during the first postpartum year and beyond. Particularly since you're pregnant and hormonally challenged, it's quite likely that things feel out of whack, causing you to experience feelings of sadness and resentment. It sounds like you might feel better if you could talk about some of this and regroup, since there's a lot going on for you. Do you have a therapist you can talk to? I'm glad you're going to your doctor. Ask for a referral to a good therapist. If your symptoms worsen, there are medications that are compatible with pregnancy, so talk to your doctor about this. You will be glad you did and you will start feeling better.

StorkNet Member: My mother suffered from depression as far back as I can remember. After my younger brother was born, I remember her being sad so much of the first few months. I'm 6 months pregnant and I have never suffered from depression like my mother but the thought of PPD terrifies me. Is this hereditary? Thank you.

Karen Kleiman M.S.W.: Well, the bad news is that depression *does* run in families so your mother's depression does put you at greater risk. The good news is that this information can be helpful diagnostically and can give us important information to use on your behalf. Your mother's history will help a healthcare practitioner provide optimal treatment for YOU, so make sure you know as much about her experience as possible.

In the work that I do, I often see women who are pregnant and at risk and may not be experiencing symptoms now, but I see them as a preventative measure to do our best to make sure we protect her from a possible depression or to prepare for it, in the event that one emerges. I know that sounds scary, but the truth is, you'd rather be prepared "just in case" than be blindsided when you least expect it. Remember that your mother's history does NOT mean you will experience the same thing. But I can almost guarantee that you will worry about it in any case and this worry will continue to put you at risk, which is why it's so important to talk about it with a professional who can hopefully put your mind at ease and offer perspective that will reassure you and keep you feeling positive.

Good luck with your pregnancy and I wish you continued good health.

StorkNet Member: Our fourth child was born two weeks ago. The first week I thought I was going to have a stroke. I felt and still feel so inexplicably angry at everyone. The baby is an angel but my other kids are catching the brunt of my wrath. Is this just my hormones or the pressure of being mommy to 4 kids going to be too much for me? My husband has been very busy and not here. I try not to be angry at him, someone has to bring home the bacon. I'm afraid I might be transferring exasperation at being left alone so much to handle this new situation by myself onto the kids. He comes home basically to sleep right now. We farm and it's very hectic this time of year. I feel so tired and can't even keep up right now with the house, laundry, etc. The baby has been sleeping really well and I'm getting as much rest as I can but I really feel overwhelmed. How long will this last?

Karen Kleiman M.S.W.: As you know, I can't diagnose through cyberspace, so my best answer is that if you feel overwhelmed and not able to sort out what your next best step should be, it's probably a good idea to talk to your doctor or find a good therapist who specializes in the treatment of women and depression. Simply put, the overload of four young children and a husband who isn't there much can take its toll on anyone. Over a period of time, this stress can impact other areas of your life, such as sleep, appetite, feelings of low self-esteem, feelings of inadequacy, loss of control, etc. And if left unattended, these feelings are likely to contribute to an increase in guilt which, of course, will only exacerbate your negative feelings. So my best advice to you is, if you continue to feel this way, please seek the help of a professional who can help you sort this out, in order to determine if you are struggling with a depression or not.

StorkNet Member: I was wondering three different things - Can having a tubal ligation have a direct effect on my postpartum depression? and . . . I had triplets and I was wondering if my depression could be at a little higher level than maybe what is normal for a singleton pregnancy - I am very depressed. Also, what are the best drugs for a breastfeeding mom with postpartum depression?

Karen Kleiman M.S.W.: Well, first of all, although there isn't any documentation of the relationship between a tubal ligation and PPD, I can tell you that in my practice, I have seen that the effects of the procedure can exasperate symptoms of depression, if only for a short while. This is because, regardless of the "reasons" for the tubal, and frankly, regardless of how much you may "want it" (as in an elective procedure) it usually represents a loss of some kind and so there can be a temporary dip in your recovery. This is usually short-lived and responds well to the opportunity to talk about these feelings. If you're already in therapy for the PPD, it's a perfect place to discuss this.

Having triplets certainly puts you at more risk for depression merely considering the additional stress and apparent lack of time for yourself. I do not know of any association between the degree of hormonal shifts with multiple births compared to single births, but it certainly makes sense to me that you would require additional support during this difficult time.

Lastly, any discussion of medication and breastfeeding is a complicated and somewhat controversial one. Generally speaking, it is always a risk-benefit analysis: weighing the risk of exposing the baby to minimal amounts of the medication metabolites versus the risk of not treating the illness. Speaking for my own clinical practice, we believe that a woman's decision to continue nursing is an important one and we carefully consider the medications that are compatible with breastfeeding. Keep in mind that this information is based on MY practice and will vary considerably from doctor to doctor.

The SSRI antidepressants (Selective Serotonin Reuptake Inhibitors) we are most comfortable using based on the research we have are: Zoloft (Sertraline) and Paxil (Paroxetine). Other antidepressants (tricyclics) that are used are Pamelor (Nortriptyline) and Desipramine (Norpramin), although it seems that the SSRIs are preferable these days because they have fewer side effects and are easily tolerated. Most doctors are less comfortable using Prozac with breastfeeding moms because it is the only SSRI that has a very long half-life which means it is in your system longer and harder for the baby to clear the medication.

Here are a couple of tips to keeps in mind if considering the use of medication while breastfeeding:

1. the older your baby, the fewer the risks

2. some doctors like to split the dose in half AM and PM so there is less of a "peak" in your system and this reduces the exposure to the infant

3. also try to time "when" you take the medication so your baby is not exposed to the highest level. Talk to your doctor about this. This is especially true if you are taking an antianxiety medication (such as ativan for example) which should be taken right after you breastfeed so it's in and out of your system by the time you breastfeed again.

4. many mothers are reassured by having their baby's monitored by the pediatrician during this time.

If you go to my website The Postpartum Stress Center, I have several links that will lead you to good information on medications and breastfeeding so you can make an informed decision. Discuss your options with your doctor, your husband, your baby's doctor so you can all agree on the best course.

StorkNet Member: It has been almost 7 weeks since the birth of our daughter. I had an easy pregnancy and delivery. I have had only one crying jag, and other than having no appetite, have had no other symptoms of PPD. Is this all I can expect, or could some of the symptoms hit later on?

Karen Kleiman M.S.W.: I can't diagnose through the Internet and of course, I have no way of predicting what you will or won't be likely to experience. What I can say is that if you're feeling good now, you should continue to do whatever you are doing to take care of yourself and remember that the first postpartum year is a time of increased vulnerability. PPD can occur anytime during the first year, although it is most common within the first three months. Do your best to take care of yourself physically, rest as much as you can, try to eat well even if you have little appetite, get out of the house and into the sunshine if you can, walk whenever you get the opportunity, and most important, stay on top of how you are feeling and if, at any time, you are worried about the way you are feeling, let your doctor and your husband know. Good luck and I wish you continued good health.

StorkNet Member: Recently a friend of mine told me of the struggle she had with postpartum depression. She stated that it began before the baby was even born and then after he was born she just wished that someone would come and take him away. She claims she met his physical needs but had no desire to bond with him. Her story scared me, as I am looking forward to my first child. Is there any way to prevent this and is this type of reaction common?

Karen Kleiman M.S.W.: Yes, I can understand why this would scare you. But remember, we don't know the whole story here. For instance, you say that her depression started during pregnancy. Was this the first time she experienced depression? Did she have a strong history of depression? (This could account for the severity of her symptoms.) It's always scary to hear how bad things can be for others when we find ourselves in similar circumstances. Could this happen to ME? Well, everyone's risk factors are different, but if you are at risk for depression, I would suggest you discuss this with your doctor and before your baby is born, come up with a plan that you and your husband are most comfortable with. Remember you may not be able to prevent a depression after childbirth but you may be able to reduce the severity of its impact if you are prepared. Get as much information on PPD as you can, get informed. Talk to your husband. Then, enjoy your pregnancy and don't expect the worst to happen. It may not.

StorkNet Member: What is the link between postpartum depression and an enlarged thyroid?

Karen Kleiman M.S.W.: Postpartum thyroiditis is the most common thyroid disease to occur after delivery. (thyroiditis refers to an inflammation of the thyroid) 5-7% of women will develop thyroid problems after giving birth. This is why it's important for ALL postpartum women to have their blood tested for thyroid disease. The symptoms of hypothyroidism or hyperthyroidism can mimic symptoms of depression and anxiety and these states are easily treated with thyroid hormones. I can't speak directly to the condition of an enlarged thyroid (goiter). This is best discussed with your doctor.

StorkNet Member: How common is it for PPD to take the form solely as irritability and anxiety without the usual elements of depression?

Karen Kleiman M.S.W.: Postpartum depression is typically a very agitated depression which may account for the fact that it is often misdiagnosed. Most women will present with a high degree of anxiety and irritability which is why many healthcare professionals who are not experts in the treatment of PPD, may dismiss it as intermittent anxiety or a stress reaction to the demands of motherhood. This is why a careful evaluation is necessary to determine whether there is an underlying depression that is responsible for the symptoms of anxiety. In other words, the answer is yes, sometimes depression after childbirth can present as anxiety and irritability and not look like a "typical" depression.

StorkNet Member: I'm a 40 year-old prima parta, "just a little bit" pregnant. I've had 4 miscarriages, no successful pregnancies. I also have bipolar II disorder. A lot of the symptoms you describe for PPD are actually quite similar to BP. Do I face an increased risk or a more severe bout of PPD given my (under-control-by-meds) illness?

Karen Kleiman M.S.W.: Yes, your history of bipolar illness will put you at risk for depression after childbirth, but that certainly doesn't mean it will happen for sure. This does need to be taken very seriously. Did you experience any depression after your previous losses? Are you continuing your medication during your pregnancy? If not, are you planning to medicate at the end of your pregnancy or immediately upon delivery? Most doctors agree that mood stabilizers are not recommended during the first trimester if it's possible for you to "wait out" the first three months. If not, it's always a case-by-case analysis. But we always recommend starting the medication right after birth, I mean within hours, so we can treat it prophylactically (before symptoms present). I would recommend that you discuss these options with your doctor and come up with a plan that works best for you.

StorkNet Member: I know that postpartum depression is most common shortly after childbirth, but is it possible for symptoms to worsen months later? Also, is the likelihood of postpartum depression greater with each subsequent birth?

Karen Kleiman M.S.W.: Symptoms of PPD that "worsen later" can be the result of a late onset illness or symptoms that were misdiagnosed or undetected earlier. So, the answer to your first question is "yes."

In addition, women are indeed at an increased risk for PPD with each subsequent birth. In my practice, for instance, we like to see our patients during the next pregnancy for a "check up" and prepare for the next postpartum period if we have previously treated them for PPD. Even though research tells us that each subsequent episode is potentially more severe, it's been my experience that when women are informed and prepared, they find it easier to cope any subsequent depression.

StorkNet Member: I'm asking this for my sister. She just gave birth last week. I expected her to be happy but she complains that the baby is always crying and she complains that she has no time to clean the house or do anything. How can I help her? Thanks.

Karen Kleiman M.S.W.: During the first 2-3 weeks postpartum, it is very common for mothers to feel weepy and overwhelmed. This is partially due to the dramatic hormonal fluctuations that occur immediately after birth. "Baby Blues" are so common in fact (80% of all postpartum women experience the blues) that it is considered a normal developmental experience. The best way to intervene is with some extra TLC. Women need to be reassured and comforted. Ask what you can do to help. Most women during the first couple of weeks postpartum, need practical help, help around the house, help with other children, help with meals or laundry or cleaning. But most important, help her by giving her permission NOT to do anything right now. The house does not need to be cleaned. The thank you notes do not have to be answered right now. Let the answering machine pick up the calls. Remind her to rest as much as possible and not do too much. If she works too hard now, she will be paying for it later. Remember, ask her what you can do to help.