Postnatal depression: when you "should" be happy and you are not

“Everyone around me was happy. I felt like I was watching through glass.” I have been hearing versions of this sentence for years. It is almost always followed by the same addition: “I know I should be grateful.”

That word — “should” — is the heart of what I want to write about. Postnatal depression is hard enough in itself. What makes it harder is that it arrives in the one period of life everyone assigns happiness to in advance. So a woman carries not only the distress, but also the conviction that the distress proves she is a bad mother.

What resolves on its own and what does not

The first thing to separate is time. In the first week after birth there is a very common period known as the baby blues. Tearfulness, sensitivity, tears and relief alternating. It affects most women and passes by itself within a few days. It is not a disorder and needs no treatment; it needs rest and someone who does not wave it away.

Postnatal depression is something else. It does not pass in ten days, it does not depend on whether you slept, and it affects not only mood but capacity. Left unaddressed, it lasts weeks and months.

What it looks like from the inside

The most common description is not crying. It is detachment. A woman does everything she has to — feeds, changes, gets up at night, goes to the weigh-ins — and has no sense of being present while doing it. As if she were a caretaker rather than a mother. It is precisely that absence of feeling that frightens people most, because they read it as proof that they do not love their child.

Alongside it come constant anxiety that attaches itself to the baby and does not ease even when everything is fine; being unable to sleep even when the baby sleeps; the sense that everyone else is managing and only you are not; irritability that takes you by surprise and that you then hate yourself for. And guilt, which practically every woman carries — I have written about the difference between guilt that tells you something and guilt that only gnaws in my piece on healthy and toxic guilt.

Tiredness is the most cunning part here. Everyone attributes it to the baby, and rightly — nobody is getting enough sleep. But tiredness from too little sleep improves after a good night. This kind does not.

The thoughts nobody says out loud

This is the part I always emphasise, because it saves people from unnecessary terror. A great many mothers have sudden, unwanted, intrusive thoughts after birth about something happening to the baby — that she will drop him on the stairs, that he will fall from the changing table, sometimes even the thought that she herself could harm him.

In research by Canadian investigators, the large majority of new mothers reported such thoughts. They are not a sign that a woman will harm her child. They are practically the opposite: they appear precisely because the protective system is switched on to its fullest. What matters is that these thoughts repel the woman — they frighten her, they do not attract her. That revulsion is the distinguishing sign.

Something else is going on when a mother does not experience the thoughts as intrusive and alien but as making sense, when beliefs are present that do not match reality, or when confusion appears. That is neither postnatal depression nor anxiety; it is a state that needs medical attention immediately, not next week.

When does it actually begin

The word “postnatal” is misleading, because it suggests the whole thing begins after birth. Often it does not. One of the largest screening studies, carried out with ten thousand women in Pittsburgh, looked at when the condition had started in those who screened positive. In only around four in ten had it begun after birth. In a third it had begun during pregnancy, and in a quarter the depression had already been there beforehand.

Why it happens

The honest answer is: not in everyone for the same reason. What we have are three sets of explanations that overlap.

Hormonal. After birth, oestrogen and progesterone levels drop steeply within days. An interesting experiment from 2000 artificially reproduced that drop in women who had already had postnatal depression — and in most of them it triggered symptoms, while in women without that history it did not. That suggests what matters is not the levels themselves but differing sensitivity to the change.

Biological and everyday. Chronically broken sleep is itself a risk factor for depression, not only a consequence of it. The postnatal period is the only stretch of adult life in which months of fragmented sleep are socially expected and therefore go unnoticed.

Relational and circumstantial. The factors that predict most consistently in research are not hormonal but these: previous depression or anxiety, lack of support, conflict in the couple, a difficult pregnancy or birth, financial pressure, social isolation, and motherhood without one’s own mother nearby — whether because she is not there, or because the relationship with her was not good.

Why so many women stay silent

Because the cost of speaking looks higher than the cost of silence. Women often tell me they were afraid someone would label them dangerous, that social services would come, that their child would be taken. That fear is almost always unfounded and almost always present.

The second reason is the language around them. “Enjoy it, it passes so fast.” “It was the loveliest time of my life.” “At least the baby is healthy.” Every one of those sentences is well meant and every one closes the conversation, because it says the distress is a mistake in how she is experiencing things.

The third reason is that in the first weeks everyone asks how the baby is. Almost nobody asks how the mother is — and when they do, the question is often rhetorical. If you are looking for where the path to help actually starts in Slovenia, I have described it in my piece on referrals and waiting lists.

What about the partner

Depression after the birth of a child is not exclusively a woman’s. Meta-analyses show that in the first year roughly one in ten fathers develops a depressive episode, most often between the third and sixth month. In men it more often shows as irritability, retreat into work or physical symptoms than as sadness.

This is not a competition for attention. It matters practically, because a partner’s depression is one of the strongest factors keeping the mother’s from improving. When both are in it, a quiet accounting sets in within the relationship: who is more tired, who has done more, who is allowed to feel bad. That conversation is often where I start with couples.

To the partner reading this and not knowing what to do, I would say one thing. The most useful thing is not to solve or suggest. The most useful thing is to take over a whole task rather than half of one — you get up one night a week, you know when the next paediatric appointment is, you answer the relatives. The question “what should I do” hands the load back to her. The sentence “tonight I’m taking over” moves it.

Where this text does not hold

Now some counterweight, because so far I have written rather one-sidedly.

First: not every distress after birth is postnatal depression. The transition into parenthood is a genuine loss — you lose sleep, your body, your independence, your professional identity for a while, your previous relationship with your partner. Grieving for that is healthy and is not a disorder. If the state fluctuates, if your child still moves you, if you have days that are lovely, then we are probably looking at adjustment rather than depression. I have described the difference in more detail in my piece on why depression is not sadness.

Second: questionnaires are not a diagnosis. The Edinburgh scale used in clinics is a good screening tool and a poor judge. A score above the cut-off means “let’s talk”, not “you have an illness”. A score below it excludes nothing, especially in a woman who answers questions about her feelings the way she thinks she ought to.

Third: the hormonal explanation is appealing because it removes blame, and for exactly that reason we tend to reach for it too quickly. If a drop in hormones were a sufficient cause, every woman would get postnatal depression, since hormones drop in everyone. In most women it does not happen.

And fourth: therapy is not always the first or the only step. With a severe picture, with an inability to look after yourself, with the thought that the child would be better off without you, a doctor is the first address, not a therapist. The question of medication is also worth opening without shame — I have written about how medication and therapy complement each other in my piece on antidepressants and therapy.

What actually helps

Systematic reviews show that psychotherapy is effective in perinatal depression, both for treatment and for prevention in women at higher risk. That is not surprising, but it is important to say, because many women fear the only option is a medication they do not want to take while breastfeeding.

Outside of treatment, three rather prosaic things help. The first is sleep in one piece, at least one night or part of a night per week, which requires someone else to take over. The second is getting out of the flat every day, even briefly. The third is one single person to whom you tell the truth without softening it, rather than a post adjusted to expectations.

And one more thing worth saying to every woman in this: being exhausted and empty does not mean you are not a good mother. It means you are ill and that the illness is speaking loudly. Drawing that line is often the first thing we do in therapy — I have gathered some thoughts on speaking to yourself differently in my piece on self-compassion.

What to remember

The baby blues in the first days passes by itself; postnatal depression does not. If the state lasts more than two weeks and takes your capacity away, it is not character and not a lack of gratitude. It affects roughly one in seven or eight mothers, which means that in any antenatal class you are in a room with several people who know this.

It often begins not after birth but during pregnancy or earlier, which is why the question belongs in antenatal care already. Intrusive thoughts about something happening to the baby are common and not in themselves dangerous, as long as you experience them as alien and repellent. When confusion or beliefs that do not match reality are present, that is an emergency.

Help exists and it works; talking therapy is a well supported option here, including when medication is not wanted. The first step is almost always the same: saying out loud the sentence you have been pushing aside in your head. Nobody is going to take your child. They are going to take part of the weight.