BEHAVIORAL MEDICINE

Sorrow When Joy Turns To By Arthur Middleton, M.D., FAPA

tion to irritability and the experience of tension prior to menstruation. Of those so affected, estimated as between 3% and 8% of women (during the times they have menstrual cycles), the symptoms occur approximately 5 – 11 days before a typical menstrual cycle. The following fictional clinical vignette is presented to highlight the issue of depression in women. JT is a 32-year-old married mother of a newborn son, age 3 months. Her husband is a construction worker, and she is an office manager for an office supply store. JT and her husband had carefully planned for this pregnancy, making certain that they were prepared for their child and could set aside time to enjoy what they believed would be the best time of their lives. While there was planning for things they could control, other life events presented a challenge. Her husband, 15 years older than JT, had a 10- year-old son from a previous marriage who was living with them. And shortly after JT learned she was pregnant, her husband was laid off. JT had concerns about her husband’s emotional state owing to his past history of substance abuse, but he had been treated in a comprehensive rehabilitation program and had maintained his sobriety (from both alcohol and cocaine) for three years. JT had worked with her employer to make certain that her job was secure as she planned to take extended maternity leave to be with her child and felt confident this would be the case. She enjoyed a good working relationship with her office staff who were supportive and encouraging during her pregnancy.

Despite the obstacles that surfaced, JT and her husband felt they were dealing with these issues and continued to look forward to the birth of Why aren’t you dancing with joy at this very moment is the only relevant spiritual question. – Vilayat Khan W e are all familiar with feelings of sadness. It is a common experience that often results from loss or unexpected negative life events. Failing an important test, financial events such as a home foreclosure or loss of a job are examples that are familiar to many. The individual who is depressed will often have difficulty in concentrating, anxiety, and for some, thoughts of death or suicide.

The Centers for Disease Control and Prevention (CDC) has reported on a World Health Organization report that unipolar depression was the third most important cause of disease burden worldwide in 2004. According to the CDC, 6.7% of U.S. adults experienced a major depressive disorder in the past twelve months. It was also reported that lifetime major depression was reported in 11.7% of women versus 5.6% in men.

Noting that depression affects men and women, albeit greater numbers in women, the experience is the same for both sexes. However, the context is quite different for women. In investigating the statistical gap in male versus female depression, it has been observed that girls are affected at an earlier age than boys. This has been hypothesized as due to an onset of earlier puberty in girls followed by hormonal changes. Young women may also experience depression as a result of premenstrual syndrome or PMS. In close association to PMS is Premenstrual Dysphoric Disorder or PMDD. This is a condition associated with symptoms of depression in addi

their child. JT and her husband also enjoyed the support of her mother and her husband’s mother, who were often at their home and planned to share responsibility for child care when JT returned to work. The net result was a warm and nurturing supportive environment that JT felt lucky to have. At the same time, during the later months of her pregnancy, JT could not shake the occasional feeling of sadness and concern about the future. Her mother, who had been treated for depression, reassured her daughter that the birth of her child would be the happiest experience of her life, but JT worried her husband would return to drug use as he expressed frustration and worry about not finding work.

JT delivered a healthy boy who was born without complications. She was proud of herself for dealing with all of the external issues that developed and began to focus on dealing with her extended family. Her 10-year-old stepson had previously been the center of the family. When she arrived home, her parents and in-laws were there for her. As promised, her mother and mother-in law provided in-house support for JT and her husband. But JT began to experience feelings that she had not anticipated; feeling sad, tired, and at times overwhelmed with the responsibilities of motherhood. She decided she would breastfeed, and initially felt that there was a bond that she had with her child that was beyond anything that she had ever experienced. However, breastfeeding began to feel like a chore, and she was reluctant to express this to her mother fearing that her mother would regard her as less than a perfect mother.

Gradually, JT began to sleep more, slowly withdrawing from her family, which did not go unnoticed. Her husband had a noticeable change in his mood as well. He became irritable and increasingly critical of his son. On one occasion, he became so angry at his son for not completing his homework, he abruptly left the house to walk down the street to calm himself. JT’s mother and mother-in-law both recognized this situation was becoming serious and spoke to JT and her husband. JT was encouraged to see her doctor, in this case her OB/GYN doctor (Obstetrics/Gynecology). JT’s doctor immediately identified the symptoms that JT presented as meeting criteria for Postpartum Depression and referred her to a psychiatrist she often referred patients to. The psychiatrist agreed with the diagnosis, and in addition to recommending “talk therapy,” also discussed consideration of an antidepressant. JT wanted to continue to breastfeed

and worried about taking a medication that would cross into breast milk. Her psychiatrist provided

information to JT on antidepressants that could be prescribed. However, it was recognized

that it was necessary to consider the possible risk and benefits of such a decision. JT’s husband was also part of the dialogue. After reviewing the literature and further discussion with her OB/GYN doctor, JT began an antidepressant and had a good response to the treatment, which included psychotherapy. Over the course of the year, the treatment included family therapy. JT was able to modify her work schedule, and with the help of her mother and mother-inlaw, who both help to watch her child, has returned to work on a part-time basis.

JT’s husband has seen a therapist as well and was able to find a new job. He has maintained his sobriety.

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The following references are provided for the informed consumer: • Organization of Tetralogy Information Specialists: Depression and Pregnancy http://www.mothertobaby.org/files/depression.pdf • National Institute of Mental Health: Women and Mental Health http://www.nimh.nih.gov/health/topics/women-and-mental-health/index.shtml • National Institute of Mental Health: Postpartum Depression Research (Video) http://www.nimh.nih.gov/media/video/postpartumdepression.shtml

Dr. Middleton is a diplomate of the American Board of Psychiatry & Neurology, and a Life Fellow of the American Psychiatric Association. He received his undergraduate training at New York University and an MD degree from Rutgers Medical School. Dr. Middleton completed his psychiatric residency at St. Vincent’s Hospital & Medical Center, in NYC. He is on the honorary medical staff (retired) of Hackensack University Medical Center in NJ, where he is also Chairman Emeritus of the Department of Psychiatry & Behavioral Medicine. Dr. Middleton has been on the voluntary teaching faculty of Mount Sinai School of Medicine and Brown Medical School. He is currently a Clinical Associate Professor in the Department of Psychiatry at Rutgers New Jersey Medical School. Dr. Middleton is retired as an Associate in the Department of Psychiatry in the Geisinger Health System formerly practicing at Geisinger Wyoming Valley Medical Center in Wilkes-Barre, Pennsylvania. Dr. Middleton lives in Dingmans Ferry, PA, and Manhattan, NY.