Bob–
I saw a thirty-four year old woman today for a follow-up visit regarding post-partum depression. She delivered her second child two months ago, and she first came to see me two weeks ago for severe depression. Her primary symptoms were intense fatigue, crying all the time for no apparent reason, not wanting to take care of the baby, passive thoughts about wishing she could just die, but no suicidal ideations. She said she was still managing to care for baby adequately, but barely. She reported a strained relationship with her husband, who I have never met but who, according to the patient, is quite insensitive to her needs, non-communicative, demanding. They also have severe financial constraints right now. Her mother was staying with her, which was helping, but she went back home to Minnesota three weeks ago, and that’s when things started to seem overwhelming.
At our first visit two weeks ago, she was exhausted and despondent. After her first delivery, she had been diagnosed and treated for post-partum depression, and so her expectation was to start on medications again. At the first visit, without fully disclosing my bias against the over-prescribing of psychotropics, I discussed non-medical therapies with her. I then elected to start her on Zoloft, because she was so overwhelmed, and her expectation was that she needed medicine–the only thing that had been offered to her when she similar symptoms with baby number one. I cautioned her that this would be a short-term intervention until we could address the underlying issues contributing to her symptoms. I recommended a counselor to her, and strongly encouraged her to begin exercising again. We also checked some labs to evaluate her glucose, thyroid and blood count, all of which were normal. I asked her to follow up in two weeks, which was today.
I was curious to see how she would be feeling today. When I walked in the room, she struggled to smile, but said she felt she was doing better. I asked if she thought the medicine was working. She said no, because she only took it for a week and then stopped. She didn’t like how it made her “zone out.” I asked what she thought was helping her to feel better, and she said the baby had started sleeping through the night, and she had started to exercise again. If she exercised, her day went much better. If she missed it, then things seemed overwhelming.
At this point, she began crying again. She confided that things were getting worse with her husband, especially without her mother there. She denied that there was any physical violence, just a lack of support and appreciation. She denied any thoughts of suicide or harming the baby. She didn’t want to start any medicines again. She had not yet made the appointment with the counselor, but requested the information again, because she felt like that’s what she really needed now.
Here is a situation that is way too easily labeled as “post-partum depression.” She is depressed, yes, and indeed she is in a post-partum state. But this is so multi factorial. The biggest factors here seem to be physical fatigue from the recent pregnancy, followed by two months of sleepless nights, huge hormonal swings, a strained marriage, a lack of social support, a lack of physical activity. None of this suggests a discrete physiological disease state that could be fixed by a magic bullet medication. I fear that by simply handing patients a prescription–what usually happens when they seek mental health care–we providers inadvertently trivialize the other overarching social, relationship, personality, and environmental factors that are the true root causes of their mental distress. In other words, we give them permission to ignore the real problems when we offer them seemingly simple solutions in the form of pills, pills that don’t really work long-term anyway.
For this patient, daily exercise is going to be the number one part of her treatment plan, followed closely by behavioral counseling. Perhaps an SSRI could have played a stabilizing role for her when her things were too overwhelming, but she stopped it of her own accord, and I’m glad. It was never going to be her solution. By declining the med and seeking non-medical and behavioral interventions, she has started down a better path, one that can restore her mental and emotional balance, both short-term and long-term, by addressing the root causes of her distress, without causing undue collateral damage..
Mark
