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Book Review: "A Deeper Shade of Blue"

Depression is devastating not only to a woman but to her children, as well. In "A Deeper Shade of Blue: A Woman's Guide to Recognizing and Treating Depression in Her Childbearing Years" (Simon & Schuster 2006), Ruta Nonacs, M.D., Ph.D., explains the causes of female depress, its relationship with hormones, pregnancy and birth, and how to prevent depression or mitigate its effects. Nonacs is associate director of the Center for Women's Health at Massachusetts General Hospital and an instructor in psychiatry at Harvard Medical School.

Some depressing statistics: According to the National Institutes of Mental Health, in any given year, about 10 percent of the adult population suffers from depression, and women are nearly twice as likely to suffer. The highest-risk period for women is during pregnancy and shortly after delivery.

And yet, the expectant mother is expected to be ecstatic; the new mother is supposed to be blissed out with oxytocin as she surrenders to the joy of nursing her newborn. Nonacs says it's all too easy for a woman's depression to be unrecognized, sometimes because she doesn't want to admit to it, sometimes because her feelings are dismissed by others as a brief hormonal episode.

In the brain, estrogen increases the levels of serotonin and norepinephrine, two natural mood elevators, while progesterone has a calming effect. But the levels of these hormones rise and fall during the menstrual cycle; that's why women may be edgy, anxious or depressed as their period approaches. Experts think these hormonal shifts may trigger depression, Nonacs says.

But Nonacs doesn't blame everything on hormones; she points out that women are exposed to higher levels of stress than men: physical and sexual abuse; poverty; the pressure of working and taking care of home and family; and, perhaps, even parenting itself.

"If a woman's ability to fulfill her role as a mother is compromised in some manner or if she feels that she is not able to perform this role competently she is at risk for depression," Nonacs says.

Ideally, mother and baby engage in a duet of communication that includes gazing into each others' eyes, facial expressions, sounds and gestures. As the mother learns to respond to the baby, the baby learns to trust that she will respond to his needs. (Nonacs doesn't focus on the oxytocin pulses that the brain releases during these interactions, but these pulses reinforce the bond in both baby's and mother's brain, invoking the brain's rewards systems to create a strong attachment.)

But a mother's depression can interfere with her ability to be fully present and responsive to her baby. In studies, Nonacs says, "… depressed mothers were more withdrawn and less responsive to their infants' signals. Their facial expressions and displays of emotion were more muted or flat, and their voices more monotone."

There's evidence that a mother's depression can also negatively affect older children, whose self-esteem withers under her negativity. Children of depressed mothers may have diminished cognitive skills, difficulty maintaining attention, behavioral problems -- and they may themselves be more at risk of depression.

The most important thing a woman can do is get help for depression, Nonacs says. Psychotherapy and medication can minimize the effects on the child, along with getting help from other care givers. There are programs that coach mothers in improving their interactions with their babies, and baby massage can help the depressed mother focus on the baby (providing the extra benefit of promoting the release of oxytocin in response to loving touch).

"A Deeper Shade of Blue" covers the different stages of fertility, pregnancy, birth and postpartum, examining the biological and situational elements that could trigger a woman's depression: infertility, miscarriage, premature delivery, the normal hormonal changes of pregnancy and the "baby blues" that often follows delivery.

The book helps women distinguish between cyclical mood swings and true depression, with checklists and narratives. She offers strategies for coping with the inevitable stress of motherhood, resolving conflicts with your spouse, taking care of yourself physically and emotionally, and the different types of psychotherapy available.

Nonacs also details the many medicinal and alternative therapies available for depression, from selective serotonin reuptake inhibitors (SSRIs) to bright light therapy to evening primrose oil.

She believes that post-partum depression can be prevented, and that, when it happens, its effects on the family can be minimized.

"At its worst, depression may interfere with a mother's ability to attach to and care for her infant, and this early disruption in attachment may result in a broad spectrum of problems as the child grows older," Nonacs writes. "… If you are a mother who has suffered from depression, this is likely a very difficult message to hear. You care deeply for your child, and it is unbearable to think that your depression may have in some way harmed your child." But children are remarkably resilient, she adds, and it's never too late to begin to repair the bond. "Acknowledging your depression and the problems that may stem from a child's exposure to this illness opens up an opportunity to intervene."