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More Than Blue

When I was expecting my first son, everything was going well in my life and I was totally into being pregnant," says Jane Brown*, an artist in New York City. But during her third trimester, her mood suddenly started to plummet.

"It felt as if something inside me were snapping," Brown recalls. "It was like my life was spinning out of control and no one around me could see it."

The more her friends and family tried to reassure her, the more isolated she felt. And when she gave birth to a healthy son, Brown felt anything but relief. "Eli was small, and I became obsessed with getting him to gain weight. I wasn't eating, sleeping, or returning calls, and I was losing too much weight. My husband didn't get it, and we began to fight a lot. I adored Eli but felt no joy."

Motherhood and joy: Given the images we see in ads and movies and on TV, why should we believe that a "good mother" feels anything other than joyful and whole? Yet two-thirds of the 20 million Americans who each year experience a major depressive episode are women -- most of whom are of childbearing age.

*Name has been changed.

Click ahead for Defining Depression

Defining Depression

While depression is a chronic illness, diagnosing it can be tricky because its individual symptoms vary. Most psychiatrists agree that someone who's clinically depressed has experienced ó over a period of at least several months ó a gloomy outlook on life, a lack of pleasure in most activities, and a general feeling of worthlessness. Other symptoms range from inertia, indecisiveness, guilt, and fatigue to anxiety, irritability, and tearfulness.

A depressed person may sleep too much or too little, eat too much or too little, and gain weight or lose it. She may lose command of her vocabulary or her ability to concentrate. She may lie in bed all day or compulsively do housework. She may pick fights with a spouse or clam up entirely. Over time, if left untreated, depression not only warps a person's way of seeing herself but also alters neural functioning so that depressive behavior actually becomes biochemically ingrained.

There's little consensus on just what causes depression, although it can be precipitated by traumatic life events. It's clear, however, that for some people depression comes out of the blue, the way any serious illness can. Even those whose depression appears to have an underlying cause are probably predisposed to it either genetically or chemically. It can occur at any point during a person's life, even in childhood; for largely unknown reasons, women are particularly vulnerable soon after childbirth.

At its most virulent, depression progresses from sadness to despair to suicide. Even a mother's profound love for her child may be no match for her desire to end such relentless pain; she may believe that ending her life will spare others -- including her kids -- from the hardship of living with her.

Click ahead for How Children Feel the Pain

How Children Feel the Pain

How a woman's depression may influence her child -- even a newborn -- is unpleasant to consider. In fact, some researchers think that the degree of a depressed woman's stress may influence the hormone levels in utero.

The effects continue after birth. "Some women who are depressed are less apt to make eye contact with their children or engage in the typical excited cooing and baby talk that other mothers do," says Jeffrey Kelsey, M.D., director of the Mood and Anxiety Disorders Clinical Trials Program at Emory University School of Medicine. Depressed mothers are also less likely to be physically affectionate and more likely to be irritated by typical baby behavior.

For the mothers of toddlers and pre-schoolers, this irritability can pose a big problem. "When I became depressed about ten months after my first daughter, Brittany, was born, I became increasingly dissatisfied with both of us," says Susan Cappetta, a mother of two in Concord, Massachusetts. "Then, when she was a toddler, I expected her to behave like a little adult. I'd yell at her and then feel guilty. I thought I had a strong-willed child, but, looking back, I realize she was a totally normal two-year-old."

Lack of energy is another symptom that makes caring for a young child difficult. Elizabeth Novitz, of Canoga Park, California, had struggled for years with depression, trying both medication and therapy, but in 1996 she was truly happy after giving birth to the daughter of her dreams. For the first three months, Novitz immersed herself contentedly in Lianna's care, "but the happiness didn't last," she recalls. "Gradually, I began to think about death. I couldn't help it. It felt as if Lianna were the only reason I had not to kill myself." Though recent treatment has helped Novitz overcome the worst of her depression, some lethargy and sadness linger ó and Lianna is now old enough to notice. "Sometimes, she'll bring me a blanket and say, 'Mommy, what's the matter?' I'll tell her I'm tired or a little sad, and she'll give me a kiss and go back to playing. She's sweet, but I worry about the long-term effect on her."

Equally worrisome is what children may think but not vocalize. "By age three, kids are extremely perceptive," says Dr. Kelsey, "and they have active imaginations. If Mom isn't looking at them, playing with them, or hugging them as much as she used to, they may think that she doesn't love them anymore."

Mary Duffy, a mother of two in Middlebury, Vermont, had been clinically depressed on and off for much of her life. But when she saw that a recurrence of her illness was clearly apparent even to her youngest child, it alarmed her enough to seek new treatment.

"By that time, I'd explained to Mimi, who was seven, that I was sick and that there were certain things I didn't have the energy to do. She'd help out in practical ways, such as carrying things to the car, and was always trying to do funny things to make me smile. But one day Davey, who was only three, handed me a toy and said, 'Here, Mommy, take this to work; it'll make you happy.'"

Some toddlers may act out rather than express their worries in words, says Martha Eidmann-Hicks, a licensed marriage and family therapist in Colts Neck, New Jersey. "Fighting with other kids or misbehaving is a way of forcing a withdrawn mother to be more involved," she says.

For this reason, parents should talk simply and directly about what's going on to children who are old enough to understand (see "How to Talk About a Parent's Depression"). But most important for a child's long-term happiness is that his mother gets help.

Click ahead for Obstacles to Seeking Help

Obstacles to Seeking Help

Guilt can be overpowering for depressed mothers because they haven't attained the mythic ideal of the woman made instantly happy by giving birth. This guilt can exacerbate the depression, leading a mother to hide her true feelings not only from close friends but also from doctors.

In a perfect world, every doctor would recognize depression the minute it walked in the door. But physicians are usually so busy looking for tangible ills that they fail to address an intangible one that stares them in the face. This was Brown's experience when she visited the pediatrician right after her son Eli (now 11) was born: "The doctor and my husband were asking me all these questions, and I couldn't cope. I remember wishing that I could just 'return' the baby. I handed Eli to the doctor and said, 'Here, take him. I can't do it.' He looked at me like 'What's wrong with you?'" But even then he didn't suggest that Brown might require medical attention.

Another myth that may prevent some women from seeking help is that depression is simply a character weakness -- that with a little gumption, anyone who is feeling down should be able to "get her act together." Failing to see that a lack of will is an effect, not a cause, of the problem, a sufferer may berate herself: "If I weren't so lazy, I'd snap out of it."

And a depressed mother may be in no position to rationally assess her mental health. For instance, a mom whose depression makes her unable to meet the demands of an infant may see her unhappiness as a well-deserved consequence of joyless mothering, not the other way around.

Lacking objectivity, depressed people may see themselves as unworthy of the very support they need and feel that they'll fail in any course of treatment. Or they may not even know they're depressed to begin with: "Depression can be so isolating that a mother may be unable to see the destructive effects it has on her and on her loved ones," says Eidmann-Hicks.

Duffy experienced this for herself: "When I had my first baby, I was constantly terrified that I'd hurt her," she recalls. "If I took her out, would I leave her behind in a store? If I bathed her, would she freeze? I would look at Mimi and think, 'How could I have been so selfish as to bring you into the world? How can I make life worth living for you when it's hardly worth living for me?'"

Click ahead for Finding the Right Treatment

Finding the Right Treatment

"The sooner a woman gets help, the better her prognosis, whether her treatment is based upon psychotherapy, medication, or both," says Lee Cohen, M.D., director of the Perinatal and Reproductive Psychiatry Clinical Research Program at Massachusetts General Hospital, in Boston. "Too often, women come to us with severe depression because of a delay in seeking help."

Even among those who do make it to his office, Dr. Cohen sees resistance ó sometimes not from the patient but from her husband or another family member. "It's important in these cases that loved ones realize depression is a true illness, like anemia or hypertension. Would they refuse or delay treatment for one of those conditions?"

Thanks to a variety of antidepressant medications, doctors now speak confidently about the treatability of the illness. Though the picture is far from complete, it appears that many depressed people have either a deficiency or a surplus of certain neurotransmitters in the brain. Most modern antidepressants, such as Prozac and Zoloft, work by altering such imbalances in brain chemistry; they're not "happy pills" that impose a false sense of well-being. As for whether it's safe to take antidepressants while nursing, the issue can't be resolved with controlled studies; it isn't considered ethical to include pregnant or nursing mothers in such research. But accumulated data (based on doctors' observations in their own practices) suggest that modern antidepressant medications have no ill effects on a fetus or a breastfed infant. An increasing number of physicians, therefore, allow women to remain on or start medication if their depression is serious enough to pose a significant risk to them and their babies. Doctors have yet to determine whether these drugs affect a child's later years. Research has shown that for mild to moderate depression, psychotherapy is sometimes helpful, with or without medication.

The growing consensus is that depression is treatable and that treatment is successful 85 to 95 percent of the time. Because of insurance restrictions, however, diagnosis has fallen largely into the hands of primary care physicians, who now dispense most prescriptions for antidepressants; many patients are leery of mentioning mood problems to a doctor they assume treats only their body.

Women who see only an ob-gyn on a regular basis may be even more reluctant to bring up psychological problems. But Frank W. Ling, M.D., chairman of the department of obstetrics and gynecology at the University of Tennessee, in Memphis, says that ob-gyns are becoming better equipped to treat depression: "A generation back, mental health issues were rarely discussed in my field, but now we're teaching residents to focus on total health."

How can you tell if your own doctor knows enough about depression to help you? First, says Ann Dunnewold, a psychologist in Dallas, be sure the reaction to your concerns is balanced. "If you go to him with a serious problem and he says, 'Oh, you're just stressed out; what you need is a night out with your husband,' he's minimizing the problem. Nor do you want someone who's just going to hand you a prescription on the spot." A quick way to figure out if your doctor is listening to you and giving correct information is to ask what diagnosis he's exploring, suggests Dr. Kelsey. "You want to hear something specific, such as 'depression' or 'dysthymia,' not an ambiguous term like 'stress' or 'nerves.'" If he doesn't think you're suffering from depression, he should be able to give reasons for his conclusion.

Click ahead for The Search for a Way Out

The Search for a Way Out

Because depression robs its victims of objectivity more drastically than most other illnesses do, it's often up to family members or friends to take action ó though sometimes those people too lose objectivity and fail to recognize depression's gravity.

For Cappetta, who manages technical support for a private school, intervention came from her colleagues. "My husband was too busy taking care of our daughters to see how bad things had gotten," she explains. "My coworkers were the ones who saw I was sick, talked to my parents and friends, and got me into treatment."

A network beyond the family circle can also be a potent antidepressant. Cappetta, while expecting her second child, found a support group for pregnant women with depression (see "Help and Information"). And Novitz cherishes a group of acquaintances that she met online while pregnant.

Different people respond differently to psychotherapy and medication, and the ideal treatment plan would allow the patient to see which worked best, says Dr. Kelsey. (While it can take anywhere from a few days to two months ó four weeks is typical ó for someone to feel some effects of medication, psychotherapy takes longer. That's why medication is usually recommended up front for severe depression: It is currently the fastest form of intervention.) A patient's beliefs are also important. Brown thinks therapy was the key to her recovery ó though she was also on medication for a year. "The therapist listened and took my fears and guilt seriously."

Novitz tried several antidepressants, but none were a "magic bullet." She thinks that therapy is what pulled her out of the danger zone and helped her gain strength.

For Duffy and Cappetta, however, antidepressants had miraculous effects after only a few weeks. Duffy, who has had a long history of psychotherapy, marvels at how resistant her therapists were the few times she asked them about medication. (Her physician wrote her first prescription.) "The drug took a while to work, but gradually I felt myself rising through the layers of my depression," she says. "I'd never been able to really play with Mimi and Davey because I was too sad to do anything as spontaneous as impersonate a teddy bear. But now I can let go and be silly."

It was amazing, Duffy says, to find herself "in a place I'd never been before. It suddenly struck me as I was crossing the road one bright winter day: 'So this is what people enjoy about being alive.'"

Award-winning health writer Julia Glass won the 1999 Pirate's Alley Faulkner Society Medal for best novella.