When Mimi Khúc, 33, had her first child four years ago, she had an easy pregnancy and home birth.
“Everything was super happy and glorious, for maybe a week and a half,” she says.
On top of recovering from childbirth, she was nursing around the clock and getting very little rest. She had difficulties with breastfeeding and pumping. Her daughter wouldn’t drink from a bottle and was losing weight; she was also colicky and needed to be bounced continuously.
Within three weeks, Khúc’s husband went back to work. Then, her mother, who had stayed in Maryland to help out for a month, returned to Vietnam. Khúc, an adjunct professor in the Asian American studies department at the University of Maryland who was finishing her doctorate before her daughter was born, found herself alone with the baby for hours.
Severely sleep deprived, exhausted and filled with despair and anger, Khúc struggled to feel bonded to her baby. As the months passed, she began thinking about running away — and suicide.
“I was crying all the time. My husband dreaded coming home from work. He didn’t know what he’d be coming home to. There were days that I lay in bed and cried,” she says. “I felt trapped.”
Nine months after the birth, Khúc began to suspect that she had postpartum depression (PPD).
“I remember feeling like my life had ended. I had lost all my freedom. I was trapped by the needs of this little baby — her constant, insatiable needs, 24 hours a day,” she says. “I never slept more than a couple hours at a time. It was overwhelming, all-consuming. I couldn’t even commit suicide to escape — that I resented and despaired the most. I couldn’t abandon my daughter. I thought I would never be happy again.”
Fifteen Percent of All Mothers
According to national estimates, PPD affects up to 15 percent of mothers after childbirth (actual rates are probably much higher because many sufferers never get professional help and their cases are never reported).
Unlike “baby blues,” a transient mood disturbance that affects up to 80 percent of new mothers and should disappear within 14 days after delivery, postpartum depression is considered a serious and debilitating mental health disorder that can last for months or years. Symptoms include crying, sadness, irritability and overall depressive symptoms.
They can also include insomnia, lack of appetite, intense anxiety, panic attacks, obsessive-compulsive behavior (OCD), intrusive thoughts, suicidal thoughts, anger and rage. PPD can happen anytime shortly after the birth of a baby or begin anytime during the child’s first year, with possible harmful long-term effects on the child and the family.
Each year, an estimated 1.3 million mothers experience PPD. That statistic nearly equals the combined number of women annually who get diabetes (about 800,000 women), suffer a stroke (300,000 women) and are diagnosed with breast cancer (approximately 230,000 women). Postpartum depression is far more common than gestational diabetes. Yet, all women receiving prenatal care are screened for diabetes and very few pregnant and postpartum women are screened for depression.
Scientists still don’t know what causes PPD, why some women experience it in more extreme ways than others or why some recover more quickly while others suffer for years. However, based on research studies, experts have identified factors that increase the risk of PPD.
They include: sensitivity to hormonal changes (which are often abrupt and severe after birth); emotional and physical stress before, during and after pregnancies; history of miscarriages; difficult births; infant temperament; lack of support after the birth; lack of sleep; isolation; prior histories of depression and anxiety and family history of depression and anxiety (including PPD). Women who have previously gone through PPD are also at a much higher risk of experiencing it again.
Khúc says she felt alienated because no one in her family ever talked about motherhood being hard.
“Motherhood is not supposed to be hard — not in the context of war and displacement and poverty and fighting for stability and upward mobility. In the United States, children of immigrants, especially refugees, have nothing to complain about,” she says. “My family has this bootstrap mentality. You survive the United States and poverty. You don’t cry about it, you don’t complain about it. You don’t complain about mothering. You have it good. You have it easy.” Stigma surrounding mental illness is also deeply ingrained in Vietnamese culture, she says, as it is in many Asian cultures.
“Vietnamese don’t have a word for mental illness; you’re either crazy or not crazy. There’s no word for PPD,” Khúc says. “We don’t talk about mental illness in Vietnamese families even though it’s in my family and is common. There is so much silence about the Vietnam War and trauma in general.”
On Saving Face and Fighting Stigmas
While strides have been made over the past decade in public awareness around postpartum depression, becausemore women are speaking out about their ordeals (including celebrities like Brooke Shields and Gwyneth Paltrow), few stories exist about survivors of color, especially Asian Americans.
Of the nine research studies conducted to date in the United States examining PPD among Asian American women, three of them are co-authored by Deepika Goyal, a leading national expert on postpartum depression among Asian Indian women, a family nurse practitioner and a professor of nursing at the Valley Foundation School of Nursing at San Jose State University.
Goyal, a PPD survivor herself, says many Asian Americans may feel pressured to conform to cultural norms such as those that discourage talking about feelings and personal problems, especially mental health struggles. These factors may prevent many PPD sufferers from speaking up and seeking support.
“I talk to Asian American women, and they talk about the stigma of postpartum depression and the importance of saving face,” Goyal says.
As a whole, compared to Western culture, Asian culture tends to be less individualistic, Goyal says. “Asian Americans tend to be less self-oriented and more family-oriented. Depression might be seen as trying to get attention.”
Further stifling awareness about PPD is the U.S. media’s skewed portrayal of the condition. For example, a common misconception about PPD is that the only symptoms are sadness and crying.
In fact, health experts more frequently use the term “perinatal mood and anxiety disorders” instead of “postpartum depression,” because sufferers can also experience intense anxiety, panic attacks and rage — not only the sadness usually associated with depression.
Interestingly, two 2013 studies found that one in 10 moms may experience postpartum OCD (which may include intrusive thoughts and compulsive actions like checking and rechecking on their babies or washing and rewashing bottles) and that postpartum anxiety may be more common than postpartum depression.
Media reports tend to focus on the most extreme cases of PPD in which women experience psychotic symptoms (which only affect about 0.1 to 0.2 percent of mothers). Examples of highly publicized cases include those of Andrea Yates and Cynthia Wachenheim, who both made attempts to kill their children.
“It’s hard to get women to talk when you have Tom Cruise jumping up and down (on Oprah blasting PPD survivor Brooke Shields) saying you don’t need pills to treat depression,” Goyal says. “Also, women fear having their kids taken away.”
The stigma against mental illness is further exacerbated in the case of PPD sufferers by society’s unrealistically romanticized expectations of mothers: Mothers are supposed to be happy, kind, patient, grateful, strong and in control. A PPD sufferer not only risks being labeled as “crazy,” but also “unnatural” and dangerous to her own child’s well-being.
When Overachievers “Fail”
MiRi Park, a 37-year-old Korean American, describes her relationship with her mother as extremely close. However, after her son’s birth two years ago, she never told her mother how much she was struggling because she “just wanted to be a good daughter.”
“My mom is amazing. She was cooking and cleaning to help me. I didn’t want to seem ungrateful by bringing up my feelings,” says Park, who recently moved to Los Angeles from New York City, where she was an adjunct dance history and hip-hop professor at Hunter College and adjunct professor at the New School University.
Park recalls that every time she heard her son cry, she experienced physical pain throughout her body.
“I would have this dread, this moment of panic,” she says. “It took so long for me to identify that shooting pain as anxiety.”
Looking back, she realizes that part of what set her up for feeling unprepared and anxious as a new mother were her frequent sense of isolation, lack of help from others and the general silence in her family over childbirth and raising children.
“With my aunts, we talk about values and school, but we don’t talk about being pregnant and giving birth. I didn’t know about how the process of labor worked, much less postpartum depression,” she says. “In Korean society, you don’t air your dirty laundry. Within the nuclear family, you keep your stuff very private. What’s discussed is, ‘What college did you get into,’ ‘What’s your job’ and ‘How much are you making?’ ”
Park says her son was a calm baby overall, which made her feel she had even fewer reasons to complain. Several mothers interviewed also say they kept quiet about their suffering because they felt their own situations seemed either better or comparable to those of other mothers with newborns. They didn’t want to appear weak or sound like complainers.
“I didn’t think I had the right to say, ‘I feel fucked up right now,’ ” Park says.
Park cites her driven personality and high self-expectations as contributing factors to her PPD.
"I used to wake up dreading how I would get through the day until my husband came home," she says, “For the first time in my life, I didn’t have a plan. The helplessness lent itself to this pervasive anxiety.”
Park double majored in dance and journalism in college and earned a master’s degree from Columbia University. She became a professional dancer and had been dubbed “one of the world’s premier b-girls.” In 2004, she became Air Guitar World Champion.
“I was used to speaking and performing in front of large crowds, but being alone at home with the baby terrified me,” she says.
Liz Lian, 42, had her first child seven years ago, but she can still recall her experience vividly.
“The first year after my baby’s birth was my personal hell. It shook the foundation of my world to its very core,” she says. “I remember wanting to escape in the first few weeks after the birth.”
Lian holds a management degree from the Massachusetts Institute of Technology, a master’s degree from INSEAD in France and has pursued careers in consulting and education reform. Like many of the other women interviewed for this article, she says her high-achieving nature and subsequent unmet expectations after birth may have contributed to her feelings of frustration and failure — and ultimately, her depression.
She says the key factors that contributed to her postpartum depression were exhaustion from sleep deprivation and isolation, particularly from a lack of social support.
Specifically, shortly after the birth, she fought intensely with her mother, something she had never done before and had not expected. Her mother, who had been visiting from Florida and staying with Lian and her husband in San Francisco, left after 10 days. Lian wasn’t sure she wanted to see her mother again.
She and her mother talked afterward, but as she says, “It was strained. The relationship was definitely broken … I felt utterly alone.”
A number of women interviewed say a sense of filial obligation to always respect and please elders and the drive for high achievement, two things that often go hand in hand, were likely among the top factors that led to their PPD.
For example, the conflict between Lian and her mother escalated as Lian argued for and defended her choices around newborn care, breastfeeding support and her own postpartum care. As a brand-new mother, Lian felt torn between striving to be the best mother she could be and trying to preserve a harmonious relationship with her mother.
“These Asian values framed my postpartum experience,” says Lian, who is Chinese American. “It set me up [to experience] an expectations gap for months after the birth.”
Many women point to today’s pressures to be “supermoms” as added stressors. Women still handle the vast majority of childcare and housework. Often, mothers of newborns and young children are expected to “do it all” with little support since many of them live far away from immediate and extended family. (Or in some cases, mothers with newborns live near relatives but don’t receive the support they need.)
In addition, most women today must juggle home life with their careers. An estimated 57 percent of U.S. mothers with newborns work outside the home. For many of them, postpartum stress includes not only worrying about how to care for a baby and keep a household running but also how to return to work and balance the demands of being a mother, partner and professional.
Stress on Families
Due to the high stress that can come with having and caring for a baby, the first year postpartum has the highest rate of divorce than at any other time during a marriage. Add a mother with postpartum depression and it’s easy to see how PPD can place extra strain on any relationship.
Lisa Juachon, a 38-year-old Filipina American mother of two from Berkeley, CA, says she had postpartum depression for more than six months and that the condition nearly ruined her relationship.
Shortly after the birth of her first child 10 years ago, Juachon started fighting with her then partner, who is now her husband.
“I would make things up to justify leaving. He was being as supportive as he could be. I was just not happy,” she says.
They went to therapy, but neither her husband nor the therapist realized that Juachon had PPD.
“I felt that having to care for myself while the baby cried nonstop was driving me out of my mind. I would say, ‘How is this life?’ ” says Juachon, who thought other moms seemed to be happier than she was and enjoying life with their babies. “I would see other moms, and they were on another plane.”
Although she knew she was spiraling down, Juachon didn’t tell anyone for a long time.
“I didn’t want to rock the boat, make it an issue,” she says. “I was ashamed. I was scared. I didn’t feel that I deserved the attention, to get help. It never crossed my mind to ask for help because this is what you are supposed to do, be a mom and just do it.”
In addition to contributing to higher divorce rates, PPD is a leading cause of maternal postpartum mortality and morbidity. It can affect the whole family, even the baby’s well-being.
If left untreated, PPD can lead to poor maternal-infant bonding, which can result in developmental challenges in the child including delayed language development. It can also increase risk of parental suicide and infanticide. Children of depressed parents in general have a heightened risk of developing emotional, intellectual and behavioral problems.
Christine Hyung-Oak Lee, 42, a Korean American writer from Berkeley, had PPD for nine months. In her darkest moments, she wished her daughter would die so she could get a reprieve from her exhaustion and pain.
“I started having horrible thoughts about my kid. It was around two months. I walked around thinking, wishing my baby would have SIDS,” she says.
Many of the women say they felt deep feelings of guilt as a result of these negative thoughts. On top of battling fears that society and their families might perceive them as bad or incompetent mothers, they had to face their own self-criticism for failing to feel and act loving and nurturing toward their babies all the time.
For Afshan Jilani, 61, a marriage counselor based in Spring, TX, PPD symptoms appeared after the birth of her first child in 1974 when she was 20. She and her husband, young immigrants from Pakistan, were living in England. It was winter. She was home alone while her husband worked.
“I remember thinking, ‘I don’t think the sadness is going to end. I will be taken with it.’ I remember thinking it didn’t matter if I lived or died, and crying. I cried a lot,” she says.
Jilani tried to seek help. She told her husband and hospital nurses about her feelings. In an age when society had no name for her condition, she found little effective support. “The consensus was that this happens,” she says. “Every woman gets over it. Deal with it; it’s not that big a deal.”
Jilani’s depression began affecting her treatment toward her baby.
“I not only resented the baby, I was pretty cruel. How do I forgive myself?” says Jilani, who feels guilty about her behavior to this day (in fact, she didn’t want to give specifics for fear of hurting her now grown daughter’s feelings). “When my in-laws saw this happen they said, ‘Why are you mad at the kid? It’s not the kid’s fault.’ I had to be nice to my child while I was going through such pain. I don’t think they understood that it was chemical.”
How They Got Better
Because the health care system in the United States is currently not properly set up to screen for, identify, refer or treat patients with PPD, and because there is no real prevention or cure, sufferers are often left having to diagnose themselves and become their own advocates in order to get help and recover.
Mimi Khúc says she probably had PPD on and off for 10 months. She says she doesn’t really feel “cured,” only that her depression has been managed.
“I resist narratives that want to say it’s just a ‘chemical imbalance’ or that it’s just a physical illness without any kind of social or cultural context,” she says. “Being Asian American, Vietnamese, a woman of color — these didn’t just make it hard to talk about how I was feeling and get help. They directly contributed to my PPD.”
She says she recalls being “screened” at six weeks postpartum when she was offered a survey that asked how she felt “in the last week.”
“I remember feeling pressure to pick happy answers because I didn’t want to seem crazy, didn’t want to make myself vulnerable to the medical establishment as a woman of color,” she says. “I remember rationalizing that I wasn’t lying because it only asked ‘in the last week’ and not ‘in the last few weeks.’ ”
Her road to recovery involved a mix of therapy (couples and personal therapy), health supplements (St. John’s wort, fish oil and vitamin D) and increased family support.
During her more intense bout of PPD at about nine months postpartum, Khúc’s husband took a month off from work to be at home with her and the baby, and after that worked from home for several months. Sessions with a baby sleep consultant, self-care and reading about PPD also helped her manage her symptoms, Khúc says.
“Postpartum Depression for Dummies basically saved my life,” she says. “It helped me diagnose myself, and it assured me that there is a way out, that recovery is possible. It demystified my experience and feelings, normalized them. It gave me hope. That’s when I sought out therapy and started crafting my support system.”
Afshan Jilani, who was told by nurses that it would take a few months until her feelings “lifted,” waited out nine difficult months until she started to feel better.
“It was spring. I noticed that I was not that sad or that I could deal with the baby when she was crying,” she says.
As a practicing Muslim, she says her faith helped her considerably.
“I think I would have faltered a lot more if I didn’t have a faith,” she says. “It’s these experiences that humble you, that give you a certain reality that you are not going to be able to conquer it on your own.”
Liz Lian says it took two-and-a-half years to feel like herself again. Her journey to getting better included therapy, medication (which didn’t work for her), acupuncture, journaling and meditation.
Lian says what helped her most was finding the right mothers community — in her case, a group run by Yeshi Neumann in San Francisco’s Mission neighborhood. Through the group, she learned that transitioning to motherhood was “about going deeper into your inner life and learning how to open up to other people. It was about coming to terms with a new identity.”
For Christine Hyung-Oak Lee, hiring a mother’s helper and medication were keys to her recovery. Her helper started assisting her when her daughter was about 5 months old.
“She pretty much saved my life because she was the only person who came by every day,” Lee says.
However, after nine months of suffering and worsening OCD symptoms (such as having to clean the baby’s bottles repeatedly), Lee finally reached out to doctors who diagnosed her and prescribed medication including Zoloft, an antidepressant. Soon, she began feeling much better.
“My old self was back,” Lee says. “Part of what took me so long to get treatment is because I was scared of the meds. I felt I had to be strong in one particular way, and I felt I had failed because I had PPD.”
In hindsight, she wishes she had started medication sooner. She encourages other PPD sufferers to keep an open mind when it comes to medication.
“It’s OK. It happens. It’s your biochemistry. Get on the meds just like you would if you broke your leg and get a cast. It’s a medical condition,” she says.
A number of women say going back to work played a major role in their recovery. Lisa Juachon says returning to work part-time around nine months after her son was born helped her connect to her former self.
“It was part of me trying to get myself back and get my own space,” she says.
Fortunately, these women all had access to quality health care and most could afford medication, therapy and child care when needed.
However, not all families can afford the kind of “total package” that studies and experts say can help alleviate PPD symptoms and help mothers feel better faster: sufficient sleep (which may require night doulas and other paid child care), help with daily chores like cooking and cleaning (which again might require paying people to help), therapy, support groups, medication, acupuncture, massage, meditation, time alone, exercise, nutritional supplements and fresh food (including quality protein, fruits and vegetables).
Women of low socioeconomic levels are more susceptible to experiencing PPD. According to a 2011 study co-authored by Deepika Goyal, an unmarried, unemployed woman with little monthly income and no college education is 11 times more likely than a woman with a higher income level and education to experience postpartum depression.
That being said, greater resources and higher levels of education cannot guarantee that women can avoid PPD or get better faster, which is why widespread public awareness and early screening are important for anyone considering parenthood.
Educating Health Practitioners
All the women interviewed for this article say they wished their health care professionals, as well as those who teach childbirth and newborn care classes, had spent time discussing PPD and preparing them and their partners before and after their births for the possibility of postpartum depression.
Goyal says one of the main problems is the current way the health professional industry deals with identifying PPD.
“Doctors have 10 minutes per patient. They don’t have time to ask about PPD, and if they did ask, they don’t have anywhere to refer you,” she says.
She also noted that Asian American women may be overlooked by health care professionals as being at risk for PPD because of the stereotype that Asians “have it all together.”
“It’s the model minority myth,” she says.
Most health professionals, including those in close contact with new mothers (e.g., obstetricians, pediatricians, primary care doctors, nurses, midwives) are often not trained in PPD screening and thus have no protocol or place to diagnose women who might be showing signs of PPD. As a result, many sufferers get overlooked and go untreated.
“The bigger issue is that there are not enough trained mental health providers specializing in PPD,” Goyal says.
Experts like Goyal say early detection, as with any medical condition, is crucial. The longer a sufferer waits, the more severe her symptoms may become, and it may take even longer to recover.
Goyal advocates co-located mental health services that currently exist in some hospitals as the best way to treat PPD.
“It’s a clinic environment, so you can walk across the hall from your doctor’s office and begin to get treated,” she says.
Education for mothers, their partners and families from the onset is also key. PPD education should start at prenatal screening and continue throughout the pregnancy until at least a year after the baby is born.
Goyal emphasizes, however: “We don’t want to cause panic among women. It just needs to be discussed more often in the doctor’s office so it becomes normalized.”
While there is no surefire prevention for PPD, studies have shown that a mother (along with her partner and family) who is better informed about postpartum depression can help mitigate symptoms and speed up recovery.
Lee agreed that getting partners informed and involved before the birth is crucial.
“It was a tall order for me to diagnose myself,” she says. “It’s so crazy that we are being asked to diagnose ourselves with PPD on top of everything.”
It would also help if society started to discuss PPD more openly, Lee says.
“People who have not had it, they are very kind and nice about it when I tell them my story,” she says. “But it’s like telling them you have a hemorrhoid. They think, ‘That must suck, and I don’t want to hear about it.’ ”
It’s OK to Ask for Help
All the women interviewed urge others who suspect themselves to be suffering from PPD symptoms to seek help, remain hopeful and fight against feelings of shame.
“It’s OK to ask for help,” Lee says. “The biggest lesson of motherhood is to learn to ask for help, most of all if you don’t feel well.”
They also want others to know that they all went on to have healthy, bonded relationships with their children. Most even had additional children without experiencing repeat symptoms of PPD.
Juachon encourages all mothers to find someone to talk to if they’re feeling down.
“If you have an inkling that this doesn’t feel right, talk to someone about it,” she says. “It doesn’t mean something is wrong with you or you’re a bad person. Talk to your health care provider or a good friend you trust.”
Khúc emphasizes the important role of survivors and their stories.
“It’s important for me to identify as a survivor, to name it,” Khúc says. “Because naming it makes people have to see it and see all the silence around it. To me, it was a political act to name and identify it and continue to identify as a survivor.”