Postpartum Depression: From "The Yellow Wallpaper" to Today

Introduction to Postpartum Depression

Postpartum depression (PPD), also referred to as postnatal depression, is defined as a form of clinical depression that may affect women — and, to a lesser degree, men — following the birth of a child. Recent empirical studies report prevalence rates among women of approximately 5 to 25%; however, methodological differences across studies make the actual prevalence rate unclear (Kinnaman & Jacobs 2006). Common symptoms associated with postpartum depression include irritability, sadness, guilt, low self-esteem, inability to be comforted, emptiness, social withdrawal, feelings of inadequacy regarding caretaking of the baby, changes in eating and sleeping patterns, anxiety, fatigue, episodes of crying, and decreased libido. Although a number of risk factors have been associated with the onset of postpartum depression, the cause of PPD remains poorly understood (Cox, Holden, & Sagovsky 1987).

The Yellow Wallpaper by Charlotte Perkins Gilman (1892) is a first-person description of her own experiences, articulated in her journal and narrated by her. Gilman is reported to have suffered from some form of "nervous depression" (Knight 1997); however, literary scholars have determined her condition to be postpartum depression. Her husband and doctor, John, who is described as a highly qualified physician, is portrayed as minimizing Gilman's condition as well as her suspicions regarding the homestead he selected for her rest-cure prescription. The treatment prescribed by her husband — seconded by her brother, who was also a physician — was to avoid anything that might cause fatigue, which was the basis of the rest cure typical of the era; this included refraining from writing or work of any kind. Although Gilman feels that being active, working, and writing would help her feel better, such activity is strictly prohibited (Knight 1994).

The understanding of and treatment afforded to the narrator in The Yellow Wallpaper, and the level of understanding and treatment available to women suffering from postpartum depression today, are vastly different. A substantial body of scientific and empirical studies and peer-reviewed scholarly literature supports the notion that postpartum depression is a treatable condition addressable through a variety of methodologies.

Current Understanding and Treatment of Postpartum Depression

The caregiver-infant relationship has been described as one of the most significant relational units nested within a complex paradigm of interacting individual, ecological, and societal factors that assist in shaping developmental outcomes (Goodman 2007, p. 107). Quality maternal-infant emotional bonds and the attachment security they provide form the basis for the infant's mental representations of self and others, as well as socio-emotional, cognitive, moral, and self-regulatory development; they also promote optimal developmental trajectories from childhood through adolescence (Goodman 2007, p. 108).

The effects of postpartum depression on infant-maternal attachment, maternal attunement, and the development of maternal-infant synchrony are therefore significant (Goodman 2007, p. 110). Many past intervention approaches have targeted either maternal depression or the mother-infant attachment and interaction, with limited effectiveness. Given the increased understanding of the maternal-infant connection and the significant impact postpartum depression has on that relationship, calls for more comprehensive treatment and intervention have been put forward. Moreover, such interventions would necessarily account for ecological factors — such as socioeconomic status — that may exacerbate the effects of maternal or postpartum depression on infant development and restrict or impede access to effective psychosocial care (Thompson & Fox 2010, p. 250).

Mothers are at increased risk of developing depression when their infants are of low birth weight, when pregnancies are high-risk, or when there is prematurity, poor motor functioning, or neonatal irritability (Besser, Priel & Wiznitzer 2002, p. 394). In addition to the characteristics of depression that so significantly affect maternal interactions with a child, other factors are important to consider. If the mother has been diagnosed with depression prior to pregnancy, she is more significantly predisposed to relapse during pregnancy. Because much of the traditional treatment for depression involves medication, this risk increases substantially if antidepressant medication is discontinued due to pregnancy (Besser, Priel & Wiznitzer 2002, p. 395). Depression during pregnancy carries adverse consequences not only for the infant but for the mother as well. Ecological factors — including socioeconomic status, combined with increased risks associated with higher numbers of life events, low self-esteem, high stress, low family income, and low satisfaction with or absence of social support — play a significant role in the development of postpartum depression (Thompson & Fox 2010, p. 252).

Most current treatment for postpartum depression combines pharmacological intervention with psychological approaches. These approaches can include non-directive counseling and psychodynamic methods, as well as cognitive behavioral intervention (Thompson & Fox 2010, p. 253). However, experts in the field have determined that solely targeting the mother's symptomology is far less effective than a combined maternal-child relationship intervention. Interventions that include both the mother and the child directly involve the child in treatment and attempt to restore balance within the mother-infant dyad. These may include mother-child psychodynamic psychotherapy, Watch Wait and Wonder, and parent-toddler psychotherapy — all grounded in the psychodynamic principle that when the mother is "encouraged to understand the influence of prior relationships on her current relationship with her infant, the mother-child dyad will improve" (Thompson & Fox 2010, p. 254).

These therapies serve to link the mother's present parental concerns to her own childhood conflicts, with the expectation that increased insight will promote greater competency and maternal functioning within the current dyad. The Watch, Wait and Wonder and Toddler Psychotherapy approaches also incorporate attachment theory, in which the mother is provided support and guidance through specific instructions focused on increasing her sensitivity and responsiveness while reducing intrusiveness in her interactions with her child (Thompson & Fox 2010, p. 254). The mother thereby aids and empowers the infant to work through core relational struggles, providing a greater sense of efficacy and mastery within the mother-child interaction. According to researchers, these methodologies have resulted in marked improvement of maternal depressive symptomology, greater reciprocity, increased competence in the parental role, decreased maternal intrusiveness, and an enhanced parent-child dyad.

Conclusion

Postpartum depression is regarded by experts in the field as an environmental factor that significantly influences the mother, the child, and the mother-child dyad. When postpartum depression reaches a chronic state, less-than-ideal patterns of mother-infant interaction can develop. As a result, secure attachment is delayed or hindered entirely, which negatively affects social, emotional, cognitive, and neurological development. Empirical findings and the very nature of child development demand a comprehensive treatment approach — one that stands in stark contrast to the rest cure prescribed in The Yellow Wallpaper. Early assessment by skilled and attentive primary care practitioners is critical to providing the right intervention in a timely manner.

As primary caregivers continue to deepen their understanding of the implications of postpartum depression, greater recognition of the supports necessary for both mother and child will follow. The mother, the child, and their dyadic interaction are each important components that must be addressed comprehensively. Addressing these factors — along with the ecological circumstances that may affect a mother's postpartum depression — requires skillful and careful examination in order to institute the appropriate level of treatment. These ecological factors should, and most often do, include consideration of the family and other life circumstances that may be relevant to addressing the needs of both mother and child. Fortunately, the kind of care rendered in The Yellow Wallpaper is no longer the mode of treatment women must endure. Significant advances have been made, and with continued understanding of this phenomenon, even better interventional options will be developed to help the mother, the child, their relationship, and the family as a whole.