‘It’s not just hormones’: Current management of postpartum depression falls short, more intervention needed

Whenever she reads news reports of mums who died by suicide with their infants, Kin becomes distraught. She remembers her own experience from a few years ago when she was a first-time mother grappling with postpartum depression (PPD). She might have met a similar fate – if not for the intervention she received just in time. 

“I still remember how tempting it felt to throw my baby out the window and follow after her – I just couldn’t take it,” Kin said. “If my husband, mum, and mum-in-law weren’t there for me, I honestly don’t think I’d still be here.”

According to the Women’s Mental Wellness Service at KK Women’s and Children’s Hospital (KKH), during the postpartum period, about 80 per cent of women experience some type of mood disturbance or postnatal blues. The symptoms are typically mild and short-lived.

However, about 10 to 15 per cent of postpartum women experience something more severe: Postnatal or postpartum depression (PPD), with significant symptoms of depression or anxiety.  

Postnatal depression can affect any mum. Dr Theresa Lee, a senior consultant at KKH’s Department of Psychological Medicine, added that while first-time mums struggling to adapt to motherhood are more vulnerable to PPD, some women also experience it after subsequent births. 

Its effects can be brutal. Dr Lee said that not only does postpartum depression affect the mum’s overall well-being, it can also have a severe impact on the mother-child bond. This risks the child’s development, potentially leading to cognitive, behavioural and emotional problems.

How did the number get so worryingly high? What are the issues surrounding under-diagnosis and lack of, or delay in, treatment when it comes to PPD? What factors cause this delay? CNA Women investigates.

HER GYNAECOLOGIST TOLD HER IT WAS JUST HORMONES

Postnatal depression has a range of symptoms and women experience it differently, said Dr Lee. For example, one mother might feel extremely hopeless but be physically fine; another might struggle with sleep and appetite but feel down only occasionally. 

One issue surrounding PPD is women’s limited awareness of what its symptoms are, leading them to dismiss what they’re feeling and as a result, delay in seeking help.

A KKH survey done in 2023, involving around 600 pregnant women and women who had just given birth, found that only one in six women would seek professional help if they experienced symptoms of postpartum depression. 

Kin, who wanted to be known by her first name, can relate.  

The full-time doula, who became a mum at 28, described herself as “cheerful and easygoing” before motherhood. Her first pregnancy in 2019 was generally smooth, and she had been looking forward to becoming a mother.

Things changed after Kin gave birth – she started feeling down and teary almost immediately, which she said was “strange” and “very unlike” her. 

“The morning after giving birth, I was crying so much. I was so surprised because I don’t cry without reason,” Kin said. “When my gynae saw me, she told me it’s ‘normal’ as I was going through a lot of hormonal changes – and that word just stuck: I was just being ‘hormonal’.”

Another mother, who wanted to be known as Pia, told CNA Women that it never occurred to her that she was experiencing PPD. 

“I’d heard of PPD but read about it briefly, so I didn’t know what it was,” said Pia, who became a mum at 24. “When I began to experience symptoms, I just told myself that it was typical to have raging hormones after giving birth.”

Like Kin, Pia didn’t have “any major mental health issues” before motherhood. 

But after the baby came, Pia couldn’t shake her feelings of “dread and impending doom, as if something bad was going to happen to me and my baby”.

Both women ignored their symptoms – Pia for six months and Kin for two and a half years – until they reached a breaking point that led them to seek medical help. 

“I couldn’t stop worrying about my baby, and I started overthinking every single comment people made about my weight and other physical changes in my body post-birth,” Pia said. “Nothing my husband or close friends did to assure me made me feel better – that’s when I knew something was wrong.”

In Kin’s case, she had a “meltdown” where she “lost herself and couldn’t stop screaming” at her child and her husband. She told CNA Women that when she eventually calmed down, her husband insisted she get help. 

“For more than two years, I had been pushing aside what I was feeling. I thought it was normal to feel the way I did and that it would go away naturally,” Kin said. “But PPD was so hard – now I know it’s not just hormones. I just didn’t know what it looked like and I didn’t think it would happen to me.”

IT’S CRUCIAL TO CATCH SYMPTOMS EARLY  

Another important issue: Healthcare professionals need to catch the symptoms early, said Dr Lee. 

The process starts even before the baby is born, as antenatal depression – depression during pregnancy – is closely linked to postnatal depression. 

According to an article on the KKH website in September 2023, one in five pregnant women in Singapore experience antenatal depression. If the condition is not addressed early, it is likely to worsen and evolve into postnatal depression after the mother gives birth. 

This escalation may lead to the woman experiencing more severe symptoms, including the emergence of suicidal thoughts.

Cheryl (not her real name), who is in her 30s, had antenatal depression which developed into PPD. “I thought it was just typical pregnancy stress and hormones,” the administrator said. 

She added that if she had recognised the symptoms earlier, she would have sought help sooner and her depression would not have worsened after she gave birth. 

To address the need to catch antenatal – and subsequently, postnatal – depression early, KKH introduced routine antenatal depression screening in December 2022. 

The programme, called Psychological Resilience in Antenatal Management (PRAM), consists of a screening questionnaire to detect depression in the second trimester and address the condition before it worsens postpartum.

Another mum, Koh, who only wanted to be known by her last name, said she had a “traumatic” pregnancy and birth for her second child, which contributed to her PPD in 2020. She did not experience postnatal depression when she had her firstborn.

Two months postpartum, when she realised how negative she was feeling, she called the hospital where she gave birth for help.  

“But based on the symptoms I reported then, the staff told me over the phone that it sounded like adjustment disorder and closed the case,” she said. Adjustment disorder is mild distress that occurs when a woman adjusts to becoming a new parent.

When it comes to catching PPD symptoms early, the lack of manpower and resources in hospitals can be a concern, said Dr Charis Au, a family physician and medical director at Assure Family Clinic, who sees mums for their postpartum appointments. 

"Obstetricians and gynaecologists are typically the first professionals that postnatal women encounter, and since they’re often busy with other matters, they may not always be able to assess the woman’s psychological well-being,” she said. “This can lead them to inadvertently overlook PPD symptoms.”

However, ob-gyns or GPs who meet mums post-birth don’t need a lot of resources to catch symptoms early, Dr Au said.

When doctors are aware of the signs and have built a rapport with their patients, they can simply ask specific questions about the mums’ well-being and gather information from there. 

Dr Au added that doctors aside, nurses, midwives, and other professionals who attend to a woman’s postnatal needs can play a part and check in on her. 

“Sometimes it only takes a few specific questions to save the mum,” she said. 

UNCERTAINTIES SURROUNDING MEDICATION FOR PPD

Another conundrum when it comes to postpartum depression is that even when women recognise the symptoms, they may be hesitant about seeking treatment because they are worried about medication.

Not every mum who has postnatal depression needs medication – it’s usually prescribed for women with moderate to severe PPD, said Dr Lee. 

“For mild adjustment issues, social interventions like speaking with a counsellor or a medical social worker are more recommended,” she added.

“When I found out I had PPD, I refused to take any medication or even any natural supplements because I was breastfeeding,” Pia said. Her doctor had told her the risks of taking antidepressants while breastfeeding included feeding problems and increased irritability in the baby. 

“After he shared about the risks, I felt too worried to take anything,” she added.

However, Dr Lee emphasised that the medication available to women with both postnatal and antenatal depression is relatively safe. For the latter, psychiatrists consider the gestational stage of the foetus and weigh the risks and benefits of prescribing the medication.

“Our priority is the safety of the mother and her foetus, or baby,” Dr Lee said. “If the severity of her depression poses significant risks, such as the potential for suicide, the benefits of the medication may outweigh the associated risks.”

Koh, the mum who had PPD when she had her second child, was prescribed the antidepressant sertraline. “I was told it was the safest available antidepressant for breastfeeding mums. I wanted to get better, so I took it.”

Although she still experienced anger and sadness, the medication reduced the severity of those emotions and helped her to manage them. 

Even so, while general antidepressants can be used to treat PPD, as of now, there is still no specific drug designed exclusively for postnatal depression available in Singapore. 

Doctors like Dr Au said they welcome more options for PPD medication that have further minimised risks and side effects for the breastfeeding mother and her baby. It would help to reassure these women, who often choose not to take any form of medication while breastfeeding.  

In the United States, a new oral drug specifically targeted at easing PPD was approved by the Food and Drug Administration (FDA) in August this year. 

According to the US National Library of Medicine, the drug zuranolone, marketed as Zurzuvae, has been shown to significantly improve PPD symptoms quickly (between three days and two weeks) and is not expected to cause adverse effects in breastfed infants.

In response to CNA Women about whether Zurzuvae would be available in Singapore, a spokesperson from the Health Sciences Authority said that to date, it had yet to receive any applications to register Zurzuvae locally.

GETTING PPD SUPPORT FROM THE COMMUNITY AT LARGE  

When it comes to caring for women with PPD, it’s all hands on deck, said Dr Lee. 

“Lots of coordination between healthcare institutions and community partners, such as linking women with mild symptoms to counsellors in family service centres, have been happening,” she said. “But while we have come a long way, more can be done.”

She explained that it includes engaging the general public more regarding PPD. 

“The community and family members need to understand that every woman experiences motherhood differently and should be aware of how PPD can manifest,” Dr Lee added. “This awareness helps them recognise symptoms in the mums around them so they can support however necessary.”

For Cheryl and Koh, an unsupportive work environment affected their antenatal and postnatal depression. 

“I had a supervisor who wasn’t understanding about my pregnancy and constantly micro-managed and berated me,” Cheryl said. “I thought things would get better after I gave birth but it only got worse, and it’s only after seeking help that I realised how much my old company culture worsened my condition.”

In Koh’s case, her workplace was generally not as open about mental health issues, which added to her loneliness and isolation when she experienced PPD. 

“Companies can do their part to combat PPD by enabling help-seeking behaviour,” Koh said, such as providing flexible working hours or time off for treatment, offering health screening that covers mental health, and including mental health treatment in company insurance coverage.  

In addition to therapy, having strong social support helps greatly. 

After she was diagnosed and received psychiatric help from KKH, Koh found comfort in her church, while Cheryl and Pia have a circle of mummy friends and mum support groups to turn to. 

“Though I still deal with a bit of PPD even today, it makes me feel less lonely knowing other mums are going through the same thing,” Pia said. “If more mum-centric support groups are available and accessible, it would help so many women by so much.”