hen Stefanie Norlin's daughter was born prematurely, she was immediately consumed  by a whirlwind of stress and anxiety. On top of the normal flurry of health issues associated with premature birth, Norlin's daughter also had to see specialists for gastrointestinal issues. 

Norlin expected motherhood to be hard, but not like this.

"I remember loving her so much and not wanting to do anything where she would get hurt," says Norlin. "But I would feel angry that this was not what I imagined motherhood would be like. I had wanted to be a mom for so long and it wasn't turning out the way I had expected it to. I felt I was a failure because I didn't feel as excited as I thought I would."

Norlin’s story feels familiar to me. I, too, fell deeply in love with my newborn but, at the same time, struggled with how damn hard it all felt. 

Still, I was afraid to give voice to these thoughts. 

There are stories we carry around inside of us about the magic of motherhood. These stories can heighten a sense of disconnect we feel around our own experiences.

My husband and I spent three and a half years trying to get pregnant. The stress and the difficulty of this process nearly destroyed our marriage. When I gave birth to my daughter and felt simultaneously “I would die for you,” but also, “I never want to do this again,” I felt guilty. After all, wasn’t this everything I had always wanted?

Yes, motherhood is supposed to be hard, yes. But it’s also supposed to be worth it. And so, we grin and bear it. And in so doing, we fail to construct the support system we need. We fail to ask for any help at all. This can be especially dire for those who are grappling with full-blown depression.

It took Norlin six months before she realized she had postpartum depression.

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In recent years, more women have been opening up about their experiences with postpartum depression. This emerging conversation is a vital and positive sign, as stigma and gender bias have left scores of women undiagnosed and untreated over the years. 

But there's still a lot of information this fledgling dialogue leaves out and, lately, the conversation has taken a back seat to more pressing conversations about the COVID-19 pandemic. As much sense as this might make, however, these two public health issues do have some overlap. As the country has locked down, seemingly non-essential or non-emergency medical visits have been postponed, visits that could have given clarity to mothers experiencing depression. And their support systems — psychologists specializing in perinatal depression, in-person postpartum support groups, and extended family and friends — have become inaccessible, too. 

According to a 2019 technical report from the American Academy of Pediatrics, 15-20% of women experience depression when they become mothers. And, in fact, 50% of those diagnosed with a major depressive disorder at this time begin to experience psychological issues before their child is even born. 

This growing data has implications for how we approach maternal depression, not least of which is when we should begin screening for it. But as with many aspects of women's health, there's still much we have to learn. And, well, learning it hasn’t really been our highest priority lately.

o first, some clarity on what we’re discussing here. While "postpartum depression" is the most widely recognized phrase for the depressive episodes women experience at the time of new motherhood, it's often used interchangeably with other phrases that may more accurately reflect the onset of a woman's depression. 

In reality, depression often kicks off during the pregnancy itself. Which is where the phrase perinatal depression comes in. Perinatal depression refers to a major depressive disorder experienced both during pregnancy and up to one year postpartum. If we began using this phrase more often, it could serve to demystify the experiences of mothers everywhere. 

But by leaning on the phrase “postpartum depression,” we erase the experiences of women who feel depressed before they give birth. And this silence around depression during the prenatal period can have a chilling effect. If women don't know that perinatal depression exists — and that it’s a common experience — they may not realize it's happening to them. If they don’t know that perinatal depression exists, they may never seek out the help they need.

As for the research on how perinatal depression differs from other forms of depression, information is still sparse and, in fact, guides such as the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) don't even list a separate diagnosis for the condition. 

Rather, one finds a listing for the more general Major Depressive Disorder (MDD), accompanied by a signifier that the onset of depression occurred during the perinatal period. But for many women, the condition is very real, and professionals working within the maternal health realm wonder if those who experience perinatal depression are actually more attuned to the hormonal fluctuations that occur during pregnancy and postpartum.

After all, some studies show that an increased prevalence of depression correlates with hormonal changes in women, not just during  the perinatal period, but also during puberty. This suggests that female hormonal fluctuations may indeed be a trigger for depression.

Still, as with any other form of depression, the causes of an episode can be multifaceted. 

"It's not all hormone-related or else everybody would be struggling, and that's not the case," says Christina L. Wichman, DO, who heads up The Periscope Project, and whose research focuses on perinatal psychiatric disorders. 

"There are a multitude of factors,” she says. “Personal and family history. Well-being. Psychosocial factors. Was it a wanted pregnancy? Is there good partner support? What were her expectations for motherhood?"

But for those who are in the thick of perinatal depression, the larger problem is in naming what they have in the first place.

When Lisa Romeo gave birth to her first son at the age of 34, she knew right away that something was wrong. "I had no sense of joy," she says. "I had no desire to be loving to my child. It hit me like a truck."

She told the pediatrician at one of her child's early checkups that she thought there was something wrong. In turn, he told her she was just sleep-deprived, and that it would pass. 

"And so I believed him," says Romeo. 

Friends and family weren't any more helpful, merely urging her to snap out of it. Until she got pregnant, Romeo and her husband had been trying to conceive for three and a half years. You finally have a healthy, beautiful baby, they told her, which carried the implication that she was being ungrateful. 

Romeo already felt guilty. "My husband was so happy and so joyful," she says, "and that made me feel even worse."

It took Romeo a year and a half before she went to a therapist who happened to specialize in postpartum depression. Being able to put a name to what she'd been feeling was an immediate relief. It took only a few months of psychotherapy and medication before she began to emerge from her protracted depression.

There are a variety of screening tools that enable doctors to screen their patients for perinatal depression. Patient Health Questionnaire-9 (PHQ-9), for one, is used by general practitioners to determine the severity of a depressive episode at any point in a patient's life. The Edinburgh Postnatal Depression Scale, meanwhile, is specific to perinatal depression, and Wichman explains that it teases out some of the symptoms of depression that are common during and immediately following pregnancy, including lack of joy, lack of motivation, issues with sleep, increased anxiety, and more. Some of these questions bear out the fact that perinatal depression doesn't always look like what you might expect.

This was the case for Stefanie Norlin, who had experienced some situational depression in the past, but who still didn't realize she was going through postpartum depression. "I did not realize [I had PPD] until six months after my daughter was born," she says. "I was panicky. Anxious. But I thought it was normal."

Norlin thought she was simply riding a wave of postpartum hormones. But then her mother and her husband pulled her aside. "The things you're worried about, that you're fixated on," they told her, "you should talk to your doctor about it." 

While Norlin was drowning in anxiety, Romeo was consumed by guilt. "I couldn’t be the mother I thought I should be," she says. "I felt helpless, ashamed, sad all the time." Even after she emerged from the fog of her postpartum depression, Romeo remained overprotective of her children.

"There was this constant feeling that I had to prove myself as a mother, that I had to watch myself and make sure I was doing it right, doing enough. I never could relax into motherhood. Ever."

And me? I felt both of these emotions. Guilt over how much my experience of motherhood seemed to be adversely impacting my mental health. Guilt that I was not stronger. Guilt that the joy and gratitude I felt lived alongside a persistent depression.

And then there was the fear. The constant fear that I would fail my daughter in some way, fail to keep her safe from all the dangers of the world. In the face of this fear, I couldn’t relax, couldn’t release control, couldn’t ask for help, even when things were hard. 

This was my job. 

This was motherhood.

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Beyond women's own experience of motherhood, research has shown that if perinatal depression is left untreated, there can be lasting consequences for their children.

"Infants are very attuned to their impact on their environment," says Michael O'Hara, a psychology professor at the University of Iowa and the co-director of the Iowa Depression and Clinical Research Center. "If trying to engage mom is unsuccessful or brings negative feedback, that can be harmful in that developing relationship." 

Amritha Bhat, an assistant professor of psychiatry at the University of Washington School of Medicine and one of the leaders of their Maternal-Child Mental Health Program, echoes the impact postpartum depression can have on the relationship between a mother and her child. 

"Some research shows that when mothers are depressed, there are subtle changes in their expressions and differences in the ways they respond to their baby," says Bhat, "which can interfere with attachment and bonding." 

The repercussions of this can echo out into a child's future, leading to a lag in cognitive, social, and emotional development.

But it's not only the postpartum period that can have an adverse effect on a child. "The consequences of not treating [perinatal depression] are really significant," says Samantha Meltzer-Brody, director of the UNC Center for Women’s Mood Disorders. 

"People used to think, 'Just white-knuckle it through and we'll treat you later.' But fetal exposure to a mother suffering from depression and anxiety is detrimental to the developing fetus as well," she says, referring to the negative effect it can have on fetal growth and development. "We have to take it seriously and we have to treat it appropriately." 

How can women heal themselves, and also mitigate the effects their depression and anxiety might have on their baby? "To acknowledge that they're experiencing it is the first step," says Bhat. "Mothers will think, 'I'm tired, but of course I'm tired. I have a baby.' Being able to recognize that there's something else going on that they need help with is crucial."

After that? Bhat recommends a number of lifestyle changes for those experiencing more mild forms of perinatal depression. She suggests seeking out more social support, perhaps joining an online or in-person peer support group for pregnant women or new moms. She recommends becoming active, as physical exercise is known to improve mood. And then, of course, there is psychotherapy and, for moderate to severe depression, medication. 

After only three or four months of medication and therapy, Romeo couldn't believe how different she felt. "I thought, 'Oh, this is what it's like to feel okay being a mother,'" she says. "I feel sad looking back on everything I missed out on." Still, she feels grateful that she found her way to a therapist who was familiar with postpartum depression. "In the first 10 minutes sitting on her couch, it was just comforting that this idea exists. That it's not my fault. That I can handle this. They can help me and we can get past it."

And that's the crux of the issue: recognizing that perinatal depression does exist. Unfortunately, research on perinatal depression is still scant and, as a result, both mental health professionals and primary care doctors are ill-prepared to diagnose and treat those who present with it, and both stigma and misperceptions around the diagnosis still exist.

"The biggest myth is that pregnancy and postpartum is supposed to be this really happy, joyful time," says Wichman. "But 15-20% of women will struggle with a psychiatric disorder during the perinatal period." 

Bhat points out that many still mistake their experiences with depression for the baby blues. "They think that they're a bad mom because they're not filled with complete and unalloyed joy that they're pregnant or that they have a baby," she says. "They think that they need to be joyful and present with their baby 100% of the time." She mentions the concept, developed by pediatrician and psychoanalyst Donald Winnicott, of the good enough mother. "No one has ever defined what a good mother is," says Bhat. "You just have to be a good enough mother. Good enough for your baby."

Meltzer-Brody, who oversees the UNC Center for Women’s Mood Disorders, echoes this:

"The struggle is in overcoming the stigma that somehow people can yoga themselves out of it. That it's just a matter of good nutrition or doing yoga or having a doula and that will ward off any sort of psychiatric illness during that period. If only that were the case. There are people who do all of those things and continue to be incredibly anxious or depressed."

"The more we talk about it as women," says Norlin, the once-anxious mother. "The more we develop a language we can use and it builds an acceptance and it makes it normal."

But above all else?

"Get help faster," says Romeo. "Don't let it fester. The longer it goes on, the harder it is to get rid of it."