The prognosis of most of the mental illnesses before and after childbirth is very good. The recovery period is generally a very difficult time for most mentally ill mothers, however. In the absence of any support of supporting measures, the suffering can become so intense that some mothers consider suicide, and sometimes extended suicide (with the baby), because they cannot bear it any longer. Hopelessness determines their lives. In this situation, almost all affected women often cannot believe that the depression will disappear. The hopelessness is a symptom of the depression on the one hand; on the other hand it is fed by a lack of education and professional support by competent, qualified health professionals in this problem area.
The best way out of postpartum mental crisis depends on its intensity and development; in cases of lighter depression, resorting to self-help may suffice. Self-help can accompany other measures in moderate depressions but it is often insufficient so it is recommended to enlist the help of experts. Immediate professional help is indispensable in severe postpartum depressions or even psychoses. If the woman is experiencing suicidal thoughts, or if the family surroundings present an additional stress factor for the mother, a hospital stay in a specialised mother and baby unit is recommended. We distinguish between the following forms of professional treatment depending on the intensity of the depression, examination results and personal preferences: professional counselling, psychotherapy, psychop,harmacological therapy, in-patient treatment, care offers, hormone therapy, natural therapy, alternative medicine and complimentary therapy. These forms of treatment can be combined with one another.
Professional counselling is offered – preferably – by certified public or local counselling centres, or by certified independent organisations.
Mothers affected by postpartum/peripartum crises can find specialist, competent advisors in pregnancy counselling centres (Schwangerenberatungsstelle) or in psychological / social help / psychiatry centres (Psychosoziale Beratungsstelle / Sozialpsychiatrischer Dienst). Support is also available for the mother’s relatives who are indirectly affected by these crises. The great advantage of these counselling centres is that, in most cases, support is offered quickly (within a few days or weeks) and for free. No doctor’s referral is necessary. These centres also often have branch offices in rural areas that can be reached quickly and easily. In addition to providing initial information and activating local networks, these centres offer long-term counselling in the form of individual sessions, depending on the mother’s needs and the severity of the condition. It is also possible to take part in group sessions if there is the capacity and demand for them. Advisors are bound by a duty of confidentiality.
Fortunately, not all mothers affected by postpartum/peripartum depression need in-patient psychiatric treatment or long-tern psychotherapy. Many affected mothers receive appropriate, targeted support from out-patient counselling sessions, but unfortunately this form of professional help is still relatively unknown as far as postpartum/peripartum illnesses are concerned. For example, few prospective parents as well as specialists know that pregnancy counselling in specialist centres is available up to the child’s third birthday – which covers the period in which postpartum/peripartum illness occurs. If the focus is on strengthening the emotional ties between the mother/father and the baby, parents can get professional support from child guidance centres (Erziehungsberatungsstelle) and early years support centres (Frühförderstelle). The addresses of the relevant counselling centres are listed in your local phone book or on the Internet (under the German names given in brackets) or you can find some on the list of the practise-based experts on this website.
If mothers are not getting enough support from family and friends, they can turn to other care offers, some which are (partly) financed by the health insurance system:
The mother assistant "mothers" the mother. She offers relaxation techniques and reconstitution exercises, gives advice on all questions concerning health and other worries, is responsible for the mother eating healthily, offers baby care support and organises the housekeeping. (www.muetterpflege.de)
The family assistant organises the housekeeping and looks after the (elder) children (welfare organisations such as Caritas and Diakonie in Germany)
Doulas (ancient Greek: "doulalei" = woman's servant) accompany women during birth, ensure comfortable surroundings, offer relaxation exercises and strengthen the relationship between mother and baby (www.doulas-in-deutschland.de, www.doula-info.de).
Stressful episodes in the lives of the affected woman and/or stress in current life situations or during pregnancy and after the birth generally contribute significantly to the emergence of a peripartal mental disorder. It is often sensible to seek psychotherapeutic treatment in order to deal with these experiences and to transform them into new, positive thoughts, feelings and behaviour.
In Germany, such treatment may be carried out by psychological psychotherapists (with the title "Dipl.-Psych". or "Dr. phil."), medical psychotherapists (with the title "Dr. med.") as well as alternative practitioners specialising in psychotherapy (with the title "HPG"). These occupational groups should have completed a further education programme lasting several years in at least one method of psychotherapy and should be continuing to improve their knowledge via regular advanced training.
There are many different psychotherapeutic treatments, but there is no such thing as "the best method" for treating mental disorders in the peripartum period. The best help for those women affected depends on their basic problems and their individual needs and dispositions. But it is generally the case that the relationship between the patient and the therapist is the key to successful treatment, i.e., how well, safe and understood the patient feels with the therapist.
In Germany, psychotherapy for the treatment of mental illness is essentially a standard benefit of the statutory health insurance system (Kassenärztliche Vereinigung), with the condition that the treatment is carried out by a psychological or medical psychotherapist who is acknowledged by the statutory health insurance system and this only for three of the approximately 400 therapy methods currently offered worldwide. The therapy methods paid for by statutory health insurance companies are analytical psychotherapy, psychodynamic psychotherapy and behaviour therapy. These cases do not require a referral from a physician, but it is possible, if the quarterly surgery fee has already been paid here. There can be up to five "trial sessions" (eight for analytic therapies) at each of the relevant therapists in order to determine the need for psychotherapy and the diagnosis, and above all to check whether both sides can build up a trusting relationship on which to base the treatment. Once these trial sessions have taken place, the patient has to apply for the therapy at the respective health insurance company. It is difficult to change therapist during treatment and there has to be a compelling reason for the change. There is a limit on the number of hours of treatment that can be approved, depending on the type of therapy. Psychotherapies offered by naturopaths or by psychological psychotherapists who do not work within the statutory health insurance system are not covered, though if the latter offer one of the three approved methods there is the possibility of applying to the health fund for the reimbursement of costs, the key precondition being that an acknowledged therapist cannot provide treatment within a reasonable waiting time. And therapy is then only possible if self-financed, the costs of therapy range from about 60 to 100 euros and the frequency of sessions as well as the required number of sessions differs dramatically depending on the therapy method and the disorder being treated. This investment may be worthwhile for women whose condition did not improve with the traditional methods. "Freelance" psychotherapists can usually offer appointments without or with only short waiting times.
Private health insurance companies cover the costs of psychotherapy on a very individual basis. Those requiring treatment should consult their respective private health insurance company.
By way of initial guidance, you will find below some criteria outlining the differences between the various strategies. The information aims to simplify the search for a suitable form of treatment. Individual strategies are given that in reality are occurring less and less in their purest form. In recent years, the trend, even in Germany, has been to use multidisciplinary methods in psychotherapy, regardless of the fact that this is not covered by the statutory and private health insurance systems, So it is possible, for example, that a psychological psychotherapist with a background in behaviour therapy uses methods similar to those of a colleague trained in psychoanalysis and with a medical background in order to treat particular symptoms. Under certain circumstances, this joint experience may be helpful to those affected, firstly as a way of stabilising the current life situation by changing behavioural patterns and training the patient in coping strategies, and then by treating the causes in the person's life history. The best thing to do is to get your own impression of psychotherapeutic treatment provider, possibly on the recommendation of another person who is affected by the same disorder. It may also be worthwhile to inquire about other methods offered in addition to the main treatment. The Schatten & Licht website provides a helpful, Germany-wide list of experts based in doctors' surgeries (see).
Strategies based on life history vs. strategies based on current behaviour
The focus of treatment in the former is on dealing with life experiences, mainly in childhood, which can unconsciously affect current problems. They include mainly analytical methods (e.g. psychoanalysis and analytical psychology) and the psychodynamic methods developed from them (e.g. transactional analysis, hypnosis psychotherapy and guided affective imagery (GAI, also known as Katathym Imaginative Psychotherapy)). The latter focus on current behaviour and experience and try to change it through recognition and the targeted training of new behaviour. They mainly include behaviour therapy methods (e.g. cognitive-behavioural therapy (CBT) and Dialectical Behavioural Therapy (DBT)).
Strategies based on interaction vs. proactive patient strategies
In the former, the therapist intervenes to a greater extent with questions and comments; the patient and therapist work together to determine the patient's problem. They include, for example, behavioural and psychodynamic therapy methods. With proactive patient strategies, the therapist intervenes only rarely, while the patient speaks openly about her problems and the associated thoughts and feelings (e.g. traditional psychoanalysis).
Language-based strategies vs. body-based strategies
In the former, problems are handled by "speaking about them" (e.g. conversational therapy, behaviour therapy and analytical strategies). Body-based strategies assume that the body reflects mental conflicts that can be exposed and treated via targeted movements, massage and/or touch. They include, for example, biodynamic body psychotherapy, Hakomi, concentrative movement therapy, Casriel Bonding Psychotherapy and Somatic Experiencing). Body-based strategies are currently regaining significance as a result of new cerebro-biological knowledge. In the broadest sense, these can also include, in the broadest sense, music and creative therapy, in which the body expresses itself via a creative medium.
Disorder-based strategies vs. resource-based strategies
The former focus on the treatment of symptoms and the disturbed personal development, or the deficient way of behaving, thinking and feeling that has caused them. These include, for example, traditional analytical strategies, behavioural therapy methods and psychodynamic therapy methods. Resource-based strategies take as a basis the abilities the person has already developed to cope with stressful experiences and offer guidance as to how to strengthen them. The basic idea is that everybody has the necessary power and strategies to heal themselves and these can be activated, developed and modified. Symptoms are interpreted more as attempted solutions in a condition of illness. These include, for example, psychodynamic imaginative trauma therapy, EMDR and ego state therapy.
General strategies vs. issue-based strategies
While the former deal with problems independently of the type and cause of the disorder, issue-based strategies are based on specific clinical pictures and their causes, in particular including methods to treat traumatic experiences that can be relevant in PPD cases. This concerns women that have suffered extremely stressful and unresolved experiences in their own personal history, e.g. their own birth as premature baby, long hospital stays as child, early experiences of separation from or neglect by parents, sexual, physical or mental abuse and traumatic birth experiences as a mother. It is sensible in these cases to take up specialised trauma therapy, such as EMDR, psychodynamic imaginative trauma therapy and dialectical behaviour therapy (DBT). The addresses of certified specialists can be found at www.degpt.de.
Further guidance can be found in a flyer produced by the Arbeitskreis Frauengesundheit e.V. (AKF), a women's heath research group. Entitled "Qualitätskriterien für eine frauengerechte Psychotherapie" ("Quality criteria for appropriate psychotherapy for women"), the flyer can be downloaded as a .pdf document under the Publications rubric at www.akf-info.de.
But here is a brief summary of some of them:
This is not a complete analysis of the personality but takes into account some of the patient's life experiences in order to clarify the origin of the conflicts that have triggered the symptoms and to train new behaviour. The therapist plays a relatively passive role. The patient remembers, fantasises and recounts,
EFT – Emotional Freedom Techniques:Based on the principles of acupuncture, EFT uses a tapping technique to stimulate certain meridians while the patient repeats sentences of self-acceptance and acceptance of his/her troublesome feeling. EFT has a direct impact on this feeling. The aim is to remove it and develop new possibilities for modifying the patient’s emotions and thereby also their behaviour. Fear and withdrawal can become confidence and happiness. EFT can release a great deal from inside, for example buried memories from a person’s childhood. It is important to be alert and attentive when using EFT in order to recognise this release effect as early as possible and to integrate the emotions that are being produced. EFT is also used to stabilise patients, particularly after traumatic experiences.
Family therapy/ systemic therapy
The idea here is that disturbed family relationships rather than individual disorders make people ill. The result is subtle, combative methods. It is therefore important to observe the whole system of relationships. The family's traditional way of communicating is analysed and new forms of communication and relationship patterns are tested.
The person treated is not a patient but a client. Talks between the therapist and the client are characterised by openness, sympathy, non-judgemental understanding and authenticity. The talks focus on current experiences and feelings, which are accepted and handled positively. The client's self-respect, self-esteem and self-consciousness are boosted by the sensitivity and non-judgemental acknowledgement of the therapist.
The present is important, the past is gone. Current feelings count, you don't have to investigate the causes behind them. Experience is more important than explanation. It must be possible to recognise real needs and live them out freely. The targets are to experience feelings, to perceive surroundings and other people, to deal with issues consciously, to support oneself through an inner dialogue and to act independently. All people and feelings are given their own voice, all of them represented by the client. The therapist's role is to support and stimulate.
Body psychotherapy is a form of therapy that finds ways to access problems which are otherwise hard to treat, and that opens up healing opportunities when verbal dialogue and reflection are not working. This applies especially to, but is not limited to, psychosomatic complaints, symptoms and illnesses. As our attitudes, emotions, feelings and moods are only partially influenced by our comprehension and reason, and are mostly influenced by conscious experiences by the whole organism, body psychotherapy offers a path of growth and change. A neck that has been hunched due to fear of being hurt or humiliated and that has shortened over the years cannot be made permanently straight through reason or manual therapy. Only when the “fear” within the neck has been released, and been experienced instead of held, can the contraction cease. The old fear - expressed in a present clearly recognised as non-threatening - now discovers that the danger is no longer there. The resolution of stuck feelings and the strengthening of self-regulation are approached differently during therapy, as they are individual; the interaction between these two aspects leads to the resolution of “old burdens”, to intense experiences and clear actions, to an absorption of the pulse of life’s energy.(www.koerperpsychotherapie-dgk.de)
It is mostly offered as group work. Scenes from the past, the present or dream scenarios are acted out with the leading actor, called the protagonist, playing his or her own role and using each person in the group as actors in the scenes. Conflicts and problems are played out and different solutions are tested. Feedback is given at the end.
ROMPC – Relationship-oriented, meridian-based psychotherapy and counselling: ROMPC is a method of trauma therapy that links awareness of the beneficial relationship and cognitive reappraisal of a traumatic experience with the limbic system. The limbic system is the part of the brain responsible for quick, pre-conscious reactions to threats and consequently for ensuring our survival. ROMPC aims at the decoupling of the triggers that come into effect after a traumatic experience and thereby give rise to excess stress and panic in endless repetition. Accessing the brain as well as the patient’s awareness makes it possible to develop a complete solution and free patients from emotional stress and its triggers.
The key theme here is solving current conflicts and problems. Memories of childhood and youth are revived. The therapeutic relationship is stronger than in the analytical psychotherapy. The therapist takes part in the conversation, asks for details and informs the patient of his/her observations. New strategies and forms of behaviour are then developed and put into everyday practice.
An individual's personality consists of three ego states that have to be kept in balance in order to achieve a mentally healthy life: the child ego state is characterised by child-like experiences and should be spontaneous; the adult ego state should react neutrally, thoughtfully and sensitively to current situations; and the parent ego state, that is characterised by parents, authorities and social norms and should be constructive and preventive. If interactions between people always stem from the same ego states, because one ego state is dominant, "games" arise that fix people in seemingly unchangeable and harmful behaviour. The need for care and sympathy must be satisfied all life long so as not to become emotionally stunted and so as to develop and maintain self-esteem and self-responsibility. The relationship between the therapist and the client is therefore affectionate and full of care.
Behaviour is learnt but it can also be "unlearned" by practising healthier behaviour. Specific targets of the therapy are discussed and analysed on three levels: in cognition, in behaviour and in body symptoms. The therapist and patient then work together to develop a treatment plan and methods to practise new ways of thinking, behaving and communicating.
Alternative medicine, complimentary therapy
Below is a selection of other forms of therapies that are currently being used.
Traditional Chinese medicine to re-establish inner balance (yin + yang). Treatment can support to rebalance the mind. Acupuncture can be performed by non-medical practitioners, doctors or even by midwives in the postpartum period. Acupuncture can contribute to brightening the mood and re-establishing mental balance in cases of depressive in the post partum period.
The benefits of essential oils have been well known since ancient times. The fragrances activate and stimulate the body’s natural healing powers. Only pure essential oils (no perfume oils) should be used. Pure essential oils are extracted from plants and contain up to than 300 different chemical constituents with different active substances. Essential oils are very concentrated and 50 times more effective than herbs. The oils influence the limbic system via scent impulses, but they can also be absorbed through the skin and distributed in the blood stream, and thereby have an impact on the entire body. Citrus oils have a mood-lifting effect. Simply apply a few drops onto the wrists or feet, or diffuse around the room.
Patients learn how to breathe calmly and regularly again in order to improve the body's oxygen supply, regain natural composure, release repressive emotions and release internal tension.
A relaxation technique in which self-suggestion influences the vegetative nervous system and thereby reduces stress. It can be learned in groups and then practised alone.
An Indian healing system. Three doshas (Vata, Pitta and Kapha) determine a person's character and body type. The relationship between the proportions of each dosha explains the strong and weak points of people and their bodies. If the balance is lost, i.e., if one of the doshas becomes pathologically dominant or weak as a result of a person's lifestyle, then the body sends signals that turn into diseases if they are ignored. Choosing a healthy lifestyle attuned to the relationship between the doshas, supported by an appropriate diet and medicinal plants, massages, steam baths or yoga exercises (see below), influences the doshas and their weighting within the body and thereby has healing effects.
A form of osteopathy. The skeletal structure from the skull (cranium) to the sacral bone (sacrum) is relaxed with fine, almost imperceptible manipulations in order to normalise the rhythm of the cerebrospinal fluid which can be distorted by blockades caused by falls or tensions. Such blockades can also be caused by psychological events that can again result in mental illness.
EFT or MET
The tapping of acupressure points on the body tackles problems and removes emotional blockades. Continuous change/healing is obtained by speaking a "reconciliation statement".
The patient is put into a state of trance and thereby more inclined to deal with unpleasant issues and to adopt new ways of thinking. In contrast to the widespread preconception, the patient cannot be forced to do what he/she does not want to do. Hypnotherapy can help in cases of depression, sleep disorder and anxiety.
Imaginative relaxation techniques
The body and soul will be relaxed by fantasies and managed meditation in order to break through the flow of negative thoughts and replace them with positive thoughts.
negative experiences from the past restrict our behaviour in the present and repressed emotions throw the body off the balance. Via muscle test, the body remembers at what age the negative feelings were first experienced. Energy blockades will be removed from the age when they occurred and new alternatives become possible in the present. The main effect of this method is the reduction of stress and the recognition of new options. As soon as the emotional stress has been released, the body can stabilise its own energies and use them to activate the self-healing process.
Art, music and dance therapy
Creative design, music and dance have always been popular therapy methods. It simultaneously addresses body, soul and mind, and helps patients achieve greater self-awareness, to self-actualise, to understand something and to express something, and thereby strengthens self-consciousness and trust in one's own capabilities.
Muscle (‘myo’) treatment methods developed by Dr Kurt Mosetter for pain and trauma therapy combine many different perspectives e.g. orthopaedics, modern Western medicine, psychology and traditional Chinese medicine. Our bodies are complex networks that have to be in balance to function properly. Forced and relieving postures, too little or too much movement, or physical and mental trauma can lead to our bodies being out of balance during the course of our lives. When interactions between muscles no longer function properly, it can result in painful structures in various areas of the body. Myoreflex therapists try to restore the body’s geometry of movement. Therefore, the therapist generally focuses on the muscles, as these are the key to a balanced distribution of energy within the body. The therapist may also use the traditional Chinese meridian system (energy pathways). For instance, the bladder meridian runs along the back of the legs and the spine, over the head to the eyes. A whole range of problems can be triggered here. According to Chinese medicine, the bladder meridian is associated with fear. Disruptions could be caused by mental trauma, as stated above, or by ongoing fears in the present. The treatment indications of myoreflex therapy include all illnesses of the musculoskeletal system concerning muscles, tendons, ligaments, joints, discs etc, functional organ disorders e.g. tinnitus, headaches, migraines, jaw problems, functional breathing disorders etc, psycho-traumatic burdens such as depression, burn-out, chronic emotional burden, anxiety and ADD/ADHD. (www.myoreflextherapie.de)
An osteopath (look for 5 years' training) senses with her/his "thinking, seeing and knowing fingers" possible dysfunctions deep within the body and treats them with the hands by sensing, listening, accompanying and, if necessary, by using supporting techniques and targeted manipulation. The range of treatment covers all functional disorders up to problems with inner organs and the nervous system.
Jacobsen progressive muscular relaxation
Easy-to-learn relaxation method that stretches and then relaxes individual muscle groups on a targeted basis. This increases awareness of the body and the ability to relax in general. Can be applied in situations of acute stress. It is used therapeutically to treat anxiety.
Jin Shin Jyutsu
The art of Jin Shin Jyutsu, which dates back several thousands of years, harmonises life energy in the body. It works with the human energy system. Touching certain points on the body (“energy centres”) releases a stream of energy in the body that feeds certain organs and areas and thereby removes blockages and disharmonies, and stimulates self-healing powers. Jin Shin Jyutsu can also be practised alone. Therapists can provide instructions and advice that are tailor-made for patients.
Chinese meditation and therapy technique. Cosmic Qi is guided into the body via breathing and makes the body permeable. Slow movement supports the concentration on the body as well as the respiratory flow.
The vitality or divine energy (Reiki) that permeates the universe is passed on via the placing of hands on the patient's body, thereby releasing blockades in the energy flow.
SAFE® – Safe Education for Parents
The SAFE® project (safe education for parents) was developed to support (expectant) parents in building up a safe bond with their child from pregnancy. ‘Safe bond’ means a high-quality, specific emotional bond between the child and their parents. The way in which the child’s signals (crying, reading, smiling and other mimicry and physical behaviour) are perceived, interpreted and answered is referred to as ‘sensitivity’ and this is a deciding factor when it comes to the quality of a bond. It may be influenced by a lack of knowledge or debilitating experiences from the past or present, and can impair the relationship with the child, as well as the child’s development. The focus of the SAFE® programme is on giving parents the ability to react to their children’s needs with sensitivity. SAFE® is directed at all expectant parents up to around the 7th month of pregnancy, and is carried out in closed groups until the end of the child’s first year. (www.safe-programm.de)
Chinese massage technique based on the meridians. Massaging along the meridians and acupressure points releases congestion in the energy flow and stimulates the sympathetic nervous system.
Wingwave® - Performance and Emotion Coaching
Wingwave® is a method of performance and emotion coaching that quickly and palpably releases performance-related stress and increases creativity, mental fitness and conflict stability. In Wingwave®, individual stress triggers such as thoughts, experiences and feelings are regulated at the emotional level. Wingwave® is a certified method that combines effective elements of various coaching approaches. Wingwave® is not psychotherapy, and cannot replace any such form of therapy. Wingwave® coaching is especially suited to intense performance-related stress. This can relate to a person’s career or education, or sport. Wingwave® is also used as a stress-reduction method in situations of acute stress. Wingwave® can help to resolve blockages in times of acute stress, to avoid burnout and to improve performance. Using a combination of various coaching methods, huge success can be seen after just a few sessions, and performance potential can be increased. In times of extreme stress, both halves of the brain may become blocked. Conflicts can only be tackled when both halves of the brain work together perfectly. This happens during the REM sleep phase. The Wingwave® method simulates “waking” REM sleep, where emotional burdens are processed and blockages are released in a kind of “turbo mode”. Integrated NLP and kinesiology elements support the overall effect of Wingwave®.
Indian self-awareness system. Different Hatha yoga postures and breathing exercises are practised slowly in order to achieve physical attentiveness and internal centring. It is learned from an expert but can be practised alone.
An increasing number of women are discovering natural therapies as a way of dealing with light depressions or, in severe cases, to supplement other medical treatment and/or psychotherapy. There are different methods that can be used under the supervision of a GP or non-medical practitioner, such as:
Bach Flower Therapy
For Edward Bach, illness was the outcome of a conflict between the Higher Self and the Personality. Any character trait can be lived as an either strength or a weakness. Bach Flower Therapy is intended to support the strengths. The method cannot be proven in scientific terms.
Samuel Hahnemann discovered that, in order to be cured, we need to choose a medicinal product that creates a similar complaint to the one that needs to be healed. For example, a remedy causing mild fever can reduce a fever if given in a highly diluted form. Initial aggravation shows that the chosen remedy was the right one.
Medicinal plants are consumed by animals intuitively and belong to the oldest, undisputed and most natural remedies known to man.
Vitamin, mineral and trace element therapies
Vitamin B, calcium, magnesium, folic acid, potassium, zinc and omega-3 fatty acids in particular are being used increasingly to support recovery.
Checking the thyroid and the hormonal status should form part of the general testing routine for women with postpartum mental disorders, as many different thyroid and hormonal disorders can arise after childbirth. Those women affected should consult an endocrinologist with regard to this matter. Expert tests often last a whole day in order to discover variations in the hormone level during the course of a day. Hormone saliva tests are today more precise than the still widespread blood tests. The examination should also include an ultrasound, of course. Taking synthetic hormones such as the pill often intensifies the depression or is the trigger for it.
Alternatives to synthetic hormones are bio-identical progesterone obtained from yams and that can be procured as progesterone cream. As it comes from a natural source, it is essentially different from synthetic progestogens. Natural progesterone is an anti-depressant and can be used successfully after childbirth and in cases of progesterone deficiency and premenstrual syndrome (PMS).
Then there are phytohormones that are also derived from plants such as monk´s pepper (agnus castus) and black cohosh (cimicifuga racemosa).
The most natural form of hormonal support, according to midwifery know-how of old, is for the mother to consume her own dry-baked and pulverised placenta in doses. Homeopathic substances can also be produced from the placenta nosode.
Placenta prophylaxis (PDF)
Progesterone prophylaxis (PDF)
Hormon-Schilddrüsen-Eisenmangel-Tips (German, PDF)
Medicinal drugs are often necessary to re-balance body and soul, but psychopharmacological therapy does not necessarily result in the personal problems of a woman being suppressed. The administration of drugs cannot be avoided with severe depressions and psychoses, but this should only be carried out in close co-operation with a medical specialist (psychiatrist, neurologist). There are now many drugs on the market that can be taken during breastfeeding (for more information see: www.embryotox.de and www.motherisk.org). If a mother wishes to breastfeed her baby, it is recommended she take these drugs as enforced ablactation could, due to feelings of failure and the hormonal change after childbirth, make a depression even worse.
There are different types of psychopharmacological therapies that can be used to treat mental illnesses.
Antidepressants can be classified into three categories: i) tricyclic or tetracyclic antidepressants, ii) selective serotonin re-uptake inhibitor (SSRI), and iii) MAO inhibitors. Antidepressants re-balance neurotransmitters in the brain. Neurotransmitters are chemical messengers in the brain that play a role in in the transfer of information between nerve cells. The noradrenalin and serotonin neurotransmitters appear to be particularly responsible for depressions. The following hast to be observed when taking anti-depressants:
The crucial factor is for the patient to take the drug regularly and according to the doctor's prescription. The drug usually takes 10 or 20 days to take effect. Side effects can be a dry mouth, nausea, constipation, sweating or an increased pulse rate. Everybody reacts differently to a particular drug and the strength of the reactions varies. The unpleasant side effects often disappear after one week. The period of time during which the drug must be taken differs from person to person. Never decide to stop taking the drug yourself! In contrast to sedatives and sleeping agents, antidepressants are not addictive. As soon as the biochemical balance in the body has been re-established, the drugs are no longer necessary.
Anxiety-relieving drugs (tranquilisers)
Anxiety-relieving drugs are also known as tranquilisers (sedatives) or benzodiazepines. Benzodiazepines are the most common group of tranquilisers. They are used to treat anxiety and restlessness, tension in the motor system, irritability and hyperexcitability. In higher doses, benzodiazepines cause tiredness and reduce concentration, but they are usually considered as relatively well tolerated. Tranquilisers should generally be taken only for short periods of time as they can become addictive when taken for long periods.
Anti-manic medication (drugs for bipolar disorders)
If a mother suffers from a mania after the birth of her child, it usually expresses itself in the following ways: elevated mood, low sleep requirement, very rapid rate of speech, manic thinking, distractibility, hyperactivity and a lack of or disturbed judgement.
Manias are principally treated with lithium, neuroleptics, carbamazepin or valproic acid. During treatment with lithium, the lithium level in the blood must be checked carefully as there is the danger of toxicity (overdose). Lithium is a metallic element that in nature only occurs in the form of salt in minerals, mineral water, plant and animal tissue, and also, in a very low concentration, in human tissue. Taking lithium can give rise to considerable side effects that can be avoided by taking small doses spread over the day. The side effects often disappear after a certain amount of time. Lithium is not addictive and is considered a safe method of treatment if the therapy programme is precisely controlled.
As with lithium, the levels of carbamazepin or valproic acid in the blood should also be regularly checked. Originally, carbamazepin and valproic acid are anti-epileptic medications that are used to prevent relapses and stabilise moods in the treatment of bipolar disorders. They are generally used if lithium has not been successful or if it was not tolerated by the patient or if there were other reasons preventing treatment with lithium. Side effects are also likely to occur here, too.
Antipsychotic medication (neuroleptics)
The administration of antipsychotic medication, known as neuroleptics, is necessary if mothers are suffering from psychotic symptoms. Neuroleptics re-establish the biochemical balance in the brain and treat psychotic symptoms such as hallucinations, delirium or mental confusion. The occasionally considerable side effects extend from drowsiness, dry mouth, constipation and dizziness to muscle pains, severe trembling, muscle cramps and a deceleration in physical movement. Additional drugs are often used to reduce these side effects. The physician has to find a correct dosage that both heals the psychotic symptoms and at the same time controls the side effects.
Sleeping agents (hypnotics)
Sleep disorders are a problem for many women suffering from postpartum depression. Any drug with a sleep-inducing or sedative effect can be defined as a sleeping agent or hypnotic, which means that hypnotics (= sleeping agent) cannot be strictly defined as a drugs group. Anxiety-relieving drugs sometime break through the spiralling anxiety that is responsible for sleeplessness in many mothers. Anxiety-relieving drugs such as benzodiazepines can therefore be an effective method against the vicious circle of sleeplessness. Antidepressants can also induce sleep. It should be pointed out that almost all sleeping agents carry the risk of drug addiction.
A stay in hospital is almost imperative in cases of severe depression, should the mother be experiencing suicidal thoughts, psychoses, or if the home surroundings present additional stress. Mothers receiving in-patient treatment should not be separated from their babies, as the separation of a mother from her baby is often counterproductive to the mother's recovery. Even in very critical cases where the baby is not admitted at the start of the mother's treatment, it should be a hospital that can accommodate the baby later. Mother and baby units are unfortunately not yet available nationwide in Germany and the facilities of the units that do exist differ considerably in terms of therapeutic offers, staff resources, the qualifications and specialisations of experts, and the space available. You should therefore compare the information given about the different units (see Mother and baby units) or contact the Schatten & Licht office (see ). It makes sense to choose a good institution (e.g. offering interactive therapy for both mother and child) because your therapy will work quicker, even if it means you have to be farther away from your family.
Support from partners, family, and friends
What affected mothers need most of all is attention; people, who are there, who listen and who try to understand.
All negative remarks and feelings should be taken seriously, never played down or judged. The depressive mother is suffering heavily from it! Her lack of energy and her hopelessness are symptoms of her illness. Appealing to the woman's sense of responsibility or telling her to pull herself together will only increase her suffering because it increases her sense of guilt and further undermines her already heavily eroded self-esteem. She therefore needs praise and support instead.
Avoid quarrels as the affected mother's irritability and accusatory demeanour can also be symptoms of the illness.
Affected mothers should be relieved of as many everyday responsibilities as possible. Above all, they need rest, recovery and lots of sleep! But it is nonetheless important to encourage her to accept small tasks in a loving way. The point is to give the day a certain structure and to set "milestones" so that she can claw her way from one milestone to the next. Every day is painfully long for someone who is depressed and the patient should be pampered in every possible way: a warm bath, her favourite music, massages, a good book, walks, cinema, going swimming, going out for dinner. It should also be repeated over and again that she will get better and that there is a cure.
Supporting, caring for and supervising the depressive mother should be shared by as many people as possible: family, friends, and neighbours. Even small jobs, such as doing the laundry or taking the baby (and other children) out for a walk, can be very helpful. You can also seek the support of a home help, family or mother assistant, prescribed by a doctor if necessary, and every mother has the right to the support of a midwife up to the tenth day following the birth and then up to 16 further visits over the subsequent eight weeks. The doctor can prescribe more midwife visits if necessary.
Even if the patient is suffering from a loss of appetite, she still needs to eat a healthy, balanced diet and to be offered healthy snacks and drinks between meals.
Those caring for the woman may sometimes have to take important decisions on her behalf and to manage her affairs in a calm and assured manner, e.g. looking for doctors and therapists, organising visits to the doctor or self-help groups and accompanying her there, if she does not feel capable of going on her own.
If may be necessary to supervise the taking of medicine. Drugs must be taken regularly and in accordance with the prescription, even if the patient is already feeling better. The patient should certainly continue to take the medication at last until her recovery is complete, though it is better to continue taking the medicine for longer to avoid a relapse later.
Indications of suicide must be taken very seriously! Threatened suicide is always a cry for help. Most people who commit suicide have somehow given an indication of it beforehand. Even if suicidal thoughts are not expressed directly, there are normally small or large signs hinting to an intention to commit suicide. There is also the danger that the mother could "take the baby with her" because she feels responsible for her/him. Immediate medical and psychotherapeutic help is required in such cases.
In-patient treatment is sometimes imperative in order to save the lives of both mother and baby. It is necessary to speak openly with the depressive woman. This is unfortunately no longer possible in most cases of psychosis, as the women affected by this are rarely capable of reaching a decision themselves. She should nevertheless be informed in advance, as it is impossible to know how much she can still take in.
There will be ups and downs in the healing process and this is normal. Even if a patient reacts well to treatment, and her wellbeing has clearly improved, she will continue to experience downs. This is normal and no reason for feeling discouraged.
Members of a depressive mother's family should also try to speak about their experience with other people so that they can express their concerns, anxieties and stress. It is certainly helpful to talk to other family members of (formerly) affected women (see Contact list for affected mothers).
However, no guarantee can be offered for the completeness of the ideas listed above; the points listed here should be taken merely as suggestions.
An affected mother can do many things to lighten her load herself.
She should have conversations with people who understand and talk openly about her negative feelings and fears in a bid to relieve herself of some of the stress.
And she should seek professional help for herself. There are various possibilities that can be combined (see Professional help).
She should try to get as much sleep as possible to help her recover, or at least sleep when the baby sleeps.
A balanced diet is important. On no account should mothers attempt to go on a diet in order to regain the figure they had before the pregnancy. Fresh whole foods counteract the exhaustion that is a problem for many women after childbirth. Several snacks spread over the course of the day are important for stabilising the blood sugar level: fluctuations in the blood sugar level can generate irritability. It is recommended to take food that is rich in potassium, such as bananas, apricots or pulses.
Physical exercise is extremely important even if it is difficult to pull oneself together in this situation. Exercise not only helps to revive the exhausted body, it also helps to ease the internal block that often reflects the depression. Exercise also has a positive effect on hormonal balance, neurotransmitters become activated and biochemical conditions are brought back into balance more quickly. We recommend going for a walk or swimming, cycling, gymnastics or even having a sauna. Different forms of relaxation exercise are also very helpful (see ).
Adopt a realistic stance on breastfeeding that is not related to stress. Breastfeeding can be uplifting but only when free of stress. Lactation experts can help you here. Mothers should see and enjoy breastfeeding as a form of tenderness between mother and baby and should not pay too much attention to the amount of milk. The best thing for the baby is always whatever parents can give with love and conviction, regardless of whether the milk comes from the bottle or the breast. If depressive mothers want to stop breastfeeding, it is important, because of hormonal changes, that this takes place slowly and without taking of medication if possible!
Try not to be perfect or have expectations set too high. Aim for sensible and achievable goals reduce them to the most pressing, whether housekeeping, looking after the baby or your own body, or anything else.
Maintaining a certain distance from the baby is healthy. The mother should have some free time to do things either on her own, with her partner or with friends.
Women who are affected often suffer from heavy feelings of guilt and an intense fear of failure if they are not able to care for their baby lovingly themselves to the extent that they consider correct. They also suffer from fear that the baby could be mentally harmed by this situation. It is important to note here that this risk will be minimised precisely by the mother handing over care of her baby to a trustworthy person, even on an hourly basis, so that she can take care of her own weaknesses and needs and get back on her feet again. In this way they completely fulfil their responsibility as a mother. The more a mother can give her baby the feeling that it is all right if its father, grandmother or friend cares for her/him, the easier the baby will cope with the temporary separation. This has also been confirmed by neurophysiological research. And as an African saying so aptly puts it, "It takes a village to raise a child."
There should be a rough outline to the structure and plan for how each day will be spent. It is important to keep the plan open, realistic and flexible so that it can be fulfilled.
Major changes such as moving, renovation, construction, change of job and separation from a partner should be avoided within the first three months after childbirth. This is not the right moment for drastic changes. The body and soul need rest and recovery and first need to adapt to the new situation with a newborn baby.
It is important to learn to accept help of any kind. Most people interpret the search for help as sign of failure. The cry for help therefore often comes with the breakdown, i.e. too late. But in fact it is exactly the opposite: it is a sign of strength to reflect on one's own situation, to be honest to oneself and to look for help.
Self-help groups dealing with peripartal depression and psychosis (see Forum).) have been forming in recent years. These groups are highly beneficial because they allow women who are sharing the same experience to meet, thereby enabling open and trusting conversation. Self-help groups create solidarity and understanding among the women, which helps them strengthen their own self-esteem and find individual solutions to get out of the crisis. In addition to the exchange of experience, self-help groups mainly serve to share information about literature, experts and therapies. The unspoken understanding of a similarly difficult illness and life situation is key element in the healing process. The women's own initiative strengthens their self-confidence, contributing considerably to recovery. Self-help groups are often very far away and difficult for affected women to reach so there is also the possibility of a conversation (mostly by telephone) with other women or family members who are, or have been, affected. The contact details are available on two lists that can only be obtained from the association by post (see ). There is also an Internet forum for an open exchange of experiences (see