"Meditation" by H.Koppdelaney on Flickr

“The Way of Peace” by James Allen.

The Way of Peace (free Kindle edition here) is a lovely and inspiring little book of musings on meditation, peace of mind and developing personal qualities of kindness, love and understanding. It has the typical James Allen self-help flair that inspires me to become a better version of myself (and that’s always welcome).

Here is a short excerpt from the book:

“Meditation is the intense dwelling, in thought, upon an idea or theme, with the object of thoroughly comprehending it, and whatsoever you constantly meditate upon you will not only come to understand, but will grow more and more into its likeness, for it will become incorporated into your very being, will become, in fact, your very self. If, therefore, you constantly dwell upon that which is selfish and debasing, you will ultimately become selfish and debased; if you ceaselessly think upon that which is pure and unselfish you will surely become pure and unselfish . . . There is an unavoidable tendency to become literally the embodiment of that quality upon which one most constantly thinks.”

This is a powerful thought – we eventually become the content of our thoughts, so we should make every effort to cultivate our thoughts and purify them. Think about the person you’d be honored to become, and the qualities you’d be proud to possess. Anything else should not be nurtured in your thoughts, only the good and positive should find home in your mind.

The fact that parents think of their child as a “part of, and the same as themselves” ^{7, p. 234} suggests that the loss of a child is very much the loss of a part of one’s self and represents a unique challenge.

The Shock of Sudden and Unexpected Death

The death of a child has become rare in the Western world, due to improved prenatal and perinatal care, it is considered exceptionally painful and traumatic, with parents not being prepared to face such loss.^{8, 9} Nowadays, pregnancies continuing after the 20th week are usually wanted and anticipated with joy and commitment. In the case where such joyous event ends up being a tragedy, parents face a major challenge. For many young parents, this may be their first experience with death and loss.⁸ When the death occurs unexpectedly and suddenly, as opposed to following a long disease or terminal condition, the shock, guilt and bewilderment experienced by the parents are much more severe and long lasting.^{1, 3} Although a long and debilitating disease is another source of trauma for parents, it provides an opportunity to psychologically prepare for the death and understand the cause of death.^{3, 10} In fact, sudden and unexpected loss is correlated with higher levels of distress and parents are at much higher risk of experiencing complicated grief.⁹

In one study¹ researchers interviewed and assessed bereaved parents about 20 months after the child’s death. Their results showed that mothers who experienced the sudden death of a child had more prolonged grief than those who anticipated the grief. Results from the same study did not support expectations that mothers experience more severe grief than fathers. A Swedish population-based study⁵ by demonstrated that fathers’ opportunity to know about the impending death of a child in advance is correlated with better prognoses of grief processing. These results indicate that medical practitioners need to be honest with parents, when the death of a child is concerned, to allow time for accepting and preparing for the imminent death. However, research finds that physicians are aware of a child’s terminal prognosis 3 months before parents are (Wolfe cited in ⁵).

Findings about the profound negative effects of sudden loss explain why parents who experience Sudden Infant Death Syndrome (SIDS) face especially troublesome complications and adjustment problems. These parents suddenly have to deal with the unexplained and, possibly unpreventable, death, the sudden severing of the the attachment and bonding and the involvement of other agencies in the investigation process.¹¹ Currently, SIDS is identified as “the sudden death of an infant younger than one year that remains unexplained after a thorough case investigation, including a complete autopsy, examination of the death scene, and review of the clinical history.” ^{12, p. 870} It is the leading cause of death among healthy infants and accounts for about 2,200 deaths each year.¹²

(For additional information about Sudden Infant Death Syndrome, including statistics and risk factors, see here)

References:

Pharmacological Treatment

A number of studies have pointed out that Postpartum Depression (PPD) is essentially the same as Major Depression (MDD) and, therefore, benefits from pharmacological treatment with antidepressant medication, but very few studies have conducted randomized controlled trails comparing different medication and placebos.¹ In general, pharmacological treatment of MDD has proven to be just as effective as psychological interventions.² However, the adverse effects on breastfeeding and infant well-being remain largely unknowns and medication has to be prescribed with caution.^{1, 2} An extensive review by Fitelson and associated¹ outlines several open studies that have established fluoxamine, sertraline, bupropion, nefazodone and venlafaxine as effective pharmacological treatment for PPD. Yet, the validity and generalizability of these studies is limited by small sample sizes (4 to 15 participants) and tainted by pharmacological companies’ sponsorship. In  cases where patients have responded well to a particular antidepressant in the past, experts advise practitioners to choose the same medication for the treatment of PPD.^1,3

Pharmacological Treatment as a Preventative Measure

There is some evidence that pharmacological treatment can have preventative properties as well. A randomized placebo-controlled pilot study by Wisner and colleagues (2004)⁴ has shown that sertraline treatment started shortly after delivery prevented women with history of PPD from experiencing another episode. Yet, these results remain inconclusive and more research is needed to establish the role of antidepressants in PPD prevention.

Pharmacological Treatment’s Effect on the Child

The major concerns surrounding pharmacological treatment of PPD revolve around its effect of lactation, breastfeeding and infant well-being.¹ Infants are particularly vulnerable to the effects of medication, due to their immature blood-brain barrier, hepatic and renal systems and still developing neurological systems and brain structures.⁵ Still, research on the effects of antidepressants on the baby through maternal breastfeeding is very limited and largely contains of small studies with questionable external validity, and isolated case studies.¹ Some researchers have deducted that sertraline and paroxetine, among the Selective Serotonin Reuptake Inhibitors, are least likely to be detected in the infant’s system and adverse effects have rarely been observed.⁵ In comparison, citalopram and fluoxetine, appear to be more readily transmitted through breast milk. Their effects range from sleep changes in the infant to more serious respiratory, gastrointestinal problems and even seizures.⁵ In addition, antidepressants in infants have been correlated with increased plasma levels.¹ Although the observed effects among infants have been of mild to moderate severity and have remitted after the mother discontinued medication use, there are no guarantees there will be no effects in the long run. In addition, research has not determined whether lack of clinically significant amounts of antidepressants in the baby’s system actually means the child is not affected in any way.¹ These concerns suggest the need for further research, including more longitudinal studies.

Why Medication May Not be The Best Option

The benefits of breastfeeding have been extensively studied and firmly established by prominent organizations, such as the World Health Organization, the American Academy of Family Practitioners and the American Academy of Pediatrics, all of which recommend breastfeeding for at least six months after birth.^6,7,8 Considering this, most clinicians recommend non-pharmacological treatment for cases of mild or moderate depression, especially since these can be just as effective, but without the risk of side effects.¹ Yet, if pharmacological treatment is initiated, experts suggest that the baby’s pediatrician is immediately informed and begins to routinely examine for possible exposure and monitor any changes of sleeping and feeding patterns, sedation, irritability and other signs of drug toxicity1.^1,9

Research has demonstrated the effectiveness of psychological and psychosocial treatments of PPT, which also bypass the risk of side effects and infant drug toxicity.^{1, 10}

Interpersonal Therapy

Interpersonal therapy (IPT) has been suggested as effective psychological treatment for PPD and women who received IPT had a significant decrease in PPD symptomatology.¹¹ The typical course of IPT lasts for 12 to 20 weeks and focuses on four main interpersonal problem areas: role transition, role dispute, interpersonal deficits and grief. Clients are encouraged to transform their problematic interpersonal approaches into more healthy and adaptive ones, which is expected to improve the mother-infant and  mother-partner relationships and help the new mother for the upcoming transition back to work.¹¹ It has been further established that a group format of IPT may have benefits compared to individual therapy, as it increases social support, helps new mothers improve their interpersonal skills, allows for realization of the normality of the symptoms and issues and reduces the stigma associated with PPD.¹

Cognitive behavioral Therapy

Cognitive Behavioral Therapy (CBT) is another therapeutic modality that has proven no be beneficial in the treatment of depression, including PPD.^1,12,13 The main focus in CBT is to help clients modify their distorted cognitive patterns and negative thinking and initiate behavioral changes that will enhance their coping and reduce distress.^13,14 Fitelson and associates¹ have reviewed a study where only six sessions of CBT correlated with significant decrease of depressive symptoms in postpartum women. A pilot study by Cho and colleagues (2008)¹³ has examined antenatal CBT as a way of primary prevention. The intervention incorporated classic CBT components for treatment of depression and components aiming at enhancing marital relationship and communication. Their CBT intervention proved effective in reducing automatic negative thoughts, marital dissatisfaction and communication dissatisfaction. This individual CBT intervention not only improved well-being during pregnancy, but also during the postpartum period. The authors’ conclusion is that individually-tailored CBT intervention is more effective than a group format. However, if group sessions are the only option, helping professionals should avoid issues around personal fatigue, the condition of the unborn baby and dissatisfaction from partner.¹³ One key hypothesis in these studies is that interventions  that improve the quality of the marital relationship have great preventative power for PDD, as they increase both actual and perceived support.

Person-Centered Therapy

Person-centered counseling, also referred to as non-directive counseling, has also shown to decrease depressive symptoms in postpartum women in a number of randomized controlled studies.¹

Social Support

Lack of adequate social support is among the first risk factors for PPD, therefore peer and partner support groups have received a lot of attention among researchers.¹ Dennis (2003)¹⁵ has studied the effects of mother-to-mother support over telephone communication and has observed the beneficial effects of this approach. In fact, the severity of depressive symptoms was significantly reduced in eight weeks. Additionally, women who have been identified as high risk for developing PPD were involved in telephone-based peer support over 12 weeks and were later recorded to have lower incidence of PPD when compared to a control group. This gives hope that these noninvasive and cost-effective therapeutic approaches can also serve as preventative measures.

Alternative Therapies

Interesting research by Field and colleagues (1996)¹⁶ has shown that teaching new mothers to massage their infant reduces irritability and sleep problems in the baby, while leading to reduced depression in the mother. This massage therapy is a relatively simplistic techniques with potential to greatly benefit both the mother, child and their interaction. Findings like these increase our hopes that researchers will establish new methods of prevention and treatment which can transform the prevalence rates of PPD among new mothers.

References:

This video clip is from Steve Jobs’ 2005 Stanford Commencement Speech, when he urged young graduates to find love in life and make the days count.

Transcript below is from the Stanford University website.

‘You’ve got to find what you love,’ Jobs says

This is a prepared text of the Commencement address delivered by Steve Jobs, CEO of Apple Computer and of Pixar Animation Studios, on June 12, 2005.

I am honored to be with you today at your commencement from one of the finest universities in the world. I never graduated from college. Truth be told, this is the closest I’ve ever gotten to a college graduation. Today I want to tell you three stories from my life. That’s it. No big deal. Just three stories.

The first story is about connecting the dots.

I dropped out of Reed College after the first 6 months, but then stayed around as a drop-in for another 18 months or so before I really quit. So why did I drop out?

It started before I was born. My biological mother was a young, unwed college graduate student, and she decided to put me up for adoption. She felt very strongly that I should be adopted by college graduates, so everything was all set for me to be adopted at birth by a lawyer and his wife. Except that when I popped out they decided at the last minute that they really wanted a girl. So my parents, who were on a waiting list, got a call in the middle of the night asking: “We have an unexpected baby boy; do you want him?” They said: “Of course.” My biological mother later found out that my mother had never graduated from college and that my father had never graduated from high school. She refused to sign the final adoption papers. She only relented a few months later when my parents promised that I would someday go to college.

And 17 years later I did go to college. But I naively chose a college that was almost as expensive as Stanford, and all of my working-class parents’ savings were being spent on my college tuition. After six months, I couldn’t see the value in it. I had no idea what I wanted to do with my life and no idea how college was going to help me figure it out. And here I was spending all of the money my parents had saved their entire life. So I decided to drop out and trust that it would all work out OK. It was pretty scary at the time, but looking back it was one of the best decisions I ever made. The minute I dropped out I could stop taking the required classes that didn’t interest me, and begin dropping in on the ones that looked interesting.

It wasn’t all romantic. I didn’t have a dorm room, so I slept on the floor in friends’ rooms, I returned coke bottles for the 5¢ deposits to buy food with, and I would walk the 7 miles across town every Sunday night to get one good meal a week at the Hare Krishna temple. I loved it. And much of what I stumbled into by following my curiosity and intuition turned out to be priceless later on. Let me give you one example:

Reed College at that time offered perhaps the best calligraphy instruction in the country. Throughout the campus every poster, every label on every drawer, was beautifully hand calligraphed. Because I had dropped out and didn’t have to take the normal classes, I decided to take a calligraphy class to learn how to do this. I learned about serif and san serif typefaces, about varying the amount of space between different letter combinations, about what makes great typography great. It was beautiful, historical, artistically subtle in a way that science can’t capture, and I found it fascinating.

None of this had even a hope of any practical application in my life. But ten years later, when we were designing the first Macintosh computer, it all came back to me. And we designed it all into the Mac. It was the first computer with beautiful typography. If I had never dropped in on that single course in college, the Mac would have never had multiple typefaces or proportionally spaced fonts. And since Windows just copied the Mac, it’s likely that no personal computer would have them. If I had never dropped out, I would have never dropped in on this calligraphy class, and personal computers might not have the wonderful typography that they do. Of course it was impossible to connect the dots looking forward when I was in college. But it was very, very clear looking backwards ten years later.

Again, you can’t connect the dots looking forward; you can only connect them looking backwards. So you have to trust that the dots will somehow connect in your future. You have to trust in something — your gut, destiny, life, karma, whatever. This approach has never let me down, and it has made all the difference in my life.

My second story is about love and loss.

I was lucky — I found what I loved to do early in life. Woz and I started Apple in my parents garage when I was 20. We worked hard, and in 10 years Apple had grown from just the two of us in a garage into a $2 billion company with over 4000 employees. We had just released our finest creation — the Macintosh — a year earlier, and I had just turned 30. And then I got fired. How can you get fired from a company you started? Well, as Apple grew we hired someone who I thought was very talented to run the company with me, and for the first year or so things went well. But then our visions of the future began to diverge and eventually we had a falling out. When we did, our Board of Directors sided with him. So at 30 I was out. And very publicly out. What had been the focus of my entire adult life was gone, and it was devastating.

I really didn’t know what to do for a few months. I felt that I had let the previous generation of entrepreneurs down – that I had dropped the baton as it was being passed to me. I met with David Packard and Bob Noyce and tried to apologize for screwing up so badly. I was a very public failure, and I even thought about running away from the valley. But something slowly began to dawn on me — I still loved what I did. The turn of events at Apple had not changed that one bit. I had been rejected, but I was still in love. And so I decided to start over.

I didn’t see it then, but it turned out that getting fired from Apple was the best thing that could have ever happened to me. The heaviness of being successful was replaced by the lightness of being a beginner again, less sure about everything. It freed me to enter one of the most creative periods of my life.

During the next five years, I started a company named NeXT, another company named Pixar, and fell in love with an amazing woman who would become my wife. Pixar went on to create the worlds first computer animated feature film, Toy Story, and is now the most successful animation studio in the world. In a remarkable turn of events, Apple bought NeXT, I returned to Apple, and the technology we developed at NeXT is at the heart of Apple’s current renaissance. And Laurene and I have a wonderful family together.

I’m pretty sure none of this would have happened if I hadn’t been fired from Apple. It was awful tasting medicine, but I guess the patient needed it. Sometimes life hits you in the head with a brick. Don’t lose faith. I’m convinced that the only thing that kept me going was that I loved what I did. You’ve got to find what you love. And that is as true for your work as it is for your lovers. Your work is going to fill a large part of your life, and the only way to be truly satisfied is to do what you believe is great work. And the only way to do great work is to love what you do. If you haven’t found it yet, keep looking. Don’t settle. As with all matters of the heart, you’ll know when you find it. And, like any great relationship, it just gets better and better as the years roll on. So keep looking until you find it. Don’t settle.

My third story is about death.

When I was 17, I read a quote that went something like: “If you live each day as if it was your last, someday you’ll most certainly be right.” It made an impression on me, and since then, for the past 33 years, I have looked in the mirror every morning and asked myself: “If today were the last day of my life, would I want to do what I am about to do today?” And whenever the answer has been “No” for too many days in a row, I know I need to change something.

Remembering that I’ll be dead soon is the most important tool I’ve ever encountered to help me make the big choices in life. Because almost everything — all external expectations, all pride, all fear of embarrassment or failure – these things just fall away in the face of death, leaving only what is truly important. Remembering that you are going to die is the best way I know to avoid the trap of thinking you have something to lose. You are already naked. There is no reason not to follow your heart.

About a year ago I was diagnosed with cancer. I had a scan at 7:30 in the morning, and it clearly showed a tumor on my pancreas. I didn’t even know what a pancreas was. The doctors told me this was almost certainly a type of cancer that is incurable, and that I should expect to live no longer than three to six months. My doctor advised me to go home and get my affairs in order, which is doctor’s code for prepare to die. It means to try to tell your kids everything you thought you’d have the next 10 years to tell them in just a few months. It means to make sure everything is buttoned up so that it will be as easy as possible for your family. It means to say your goodbyes.

I lived with that diagnosis all day. Later that evening I had a biopsy, where they stuck an endoscope down my throat, through my stomach and into my intestines, put a needle into my pancreas and got a few cells from the tumor. I was sedated, but my wife, who was there, told me that when they viewed the cells under a microscope the doctors started crying because it turned out to be a very rare form of pancreatic cancer that is curable with surgery. I had the surgery and I’m fine now.

This was the closest I’ve been to facing death, and I hope it’s the closest I get for a few more decades. Having lived through it, I can now say this to you with a bit more certainty than when death was a useful but purely intellectual concept:

No one wants to die. Even people who want to go to heaven don’t want to die to get there. And yet death is the destination we all share. No one has ever escaped it. And that is as it should be, because Death is very likely the single best invention of Life. It is Life’s change agent. It clears out the old to make way for the new. Right now the new is you, but someday not too long from now, you will gradually become the old and be cleared away. Sorry to be so dramatic, but it is quite true.

Your time is limited, so don’t waste it living someone else’s life. Don’t be trapped by dogma — which is living with the results of other people’s thinking. Don’t let the noise of others’ opinions drown out your own inner voice. And most important, have the courage to follow your heart and intuition. They somehow already know what you truly want to become. Everything else is secondary.

When I was young, there was an amazing publication called The Whole Earth Catalog, which was one of the bibles of my generation. It was created by a fellow named Stewart Brand not far from here in Menlo Park, and he brought it to life with his poetic touch. This was in the late 1960′s, before personal computers and desktop publishing, so it was all made with typewriters, scissors, and polaroid cameras. It was sort of like Google in paperback form, 35 years before Google came along: it was idealistic, and overflowing with neat tools and great notions.

Stewart and his team put out several issues of The Whole Earth Catalog, and then when it had run its course, they put out a final issue. It was the mid-1970s, and I was your age. On the back cover of their final issue was a photograph of an early morning country road, the kind you might find yourself hitchhiking on if you were so adventurous. Beneath it were the words: “Stay Hungry. Stay Foolish.” It was their farewell message as they signed off. Stay Hungry. Stay Foolish. And I have always wished that for myself. And now, as you graduate to begin anew, I wish that for you.

Stay Hungry. Stay Foolish.

Thank you all very much.

Beyond the emotional and psychological suffering experienced by women with PPD, there are multiple negative effects for the infant. Women who experience more severe or prolonged PPD symptoms are more likely to develop insecure attachment to their infants and perceive their baby in a negative way, unable to enjoy the bonding and joy reported by healthy mothers.¹  A body of research shows that children of depressed mothers tend to receive lower scores on measures of intellectual and motor development when compared to children born to non-depressed mothers. These babies also tend to be fussier  and of more difficult temperament.¹  Another unfortunate consequence is that children of depressed mothers typically react poorly to stress, show poorer academic performance, delayed development of self-regulation, low self-esteem, lack of social competence and multiple behavioral problems.²

At least one study³ has shown that infants born to depressed mothers experience significant sleep disturbance in the developmental period between two weeks and the first six months of life. The difference is compelling when compared to infants of non-depressed mothers. This is especially troubling since it is known that this initial phase of life is a critical developmental period for sleep-wake cycles, melatonin and temperature rhythms.³

Depressed mothers tend to be more irritable and hostile towards their child, interacting with either intrusive, controlling and over-stimulating style or with withdrawn, passive and under-stimulating style.⁴ Neither of those extremes is beneficial for infant development. In comparison with healthy mothers, mothers with PPD touch their babies less frequently and more often do it in a negative, harmful way. Depressed mothers also have different vocal behavior, more negative affect and engage in less baby talk. Overall, they spend less time playing with the child or reading, talking, and touching. This contributes to creating an inadequate environment for the developing infant, which is deprived of mother-child bonding, synchrony and enrichment activities. Additionally, depressed mothers are less likely to begin breastfeeding and even when they do, they are more likely to discontinue in around 4 to 16 weeks.⁴

Women with PPD are more likely to start smoking or abuse alcohol and illicit substances which can further exacerbate the severity of their symptoms and the negative effect on the child. Further, these mother are at greater risk for experiencing physical, emotional or sexual abuse.⁵

References:

1. Cho, H. J., Kwon, J. H., & Lee, J. J. (2008). Antenatal cognitive-behavioral therapy for prevention of postpartum depression: a pilot study. Yonsei Medical Journal, 49(4), 553-562.   2. Goodman, S. H. & Gotlib, I. H. (1999). Risk for psychopathology in the children of depressed mothers: a developmental model for understanding mechanisms of transmission. Psychological Review, 106(3), 458-490.   3. Armitage, R., Flynn, H., Hoffmann, R., Vazquez, D., Lopez, J., & Marcus, S. (2009). Early developmental changes in sleep in infants: the impact of maternal depression. Sleep, 32(5), 693-696.   4. Field, T. (2010). Postpartum depression effects on early interactions, parenting and safety practices: a review. Infant Behavioral development, 33(1), 1. doi:10.1016/j.infbeh.2009.10.005.   5. Fitelson, E., Kim, S., Baker, A. S., & Leight, K. (2011). Treatment of postpartum depression:clinical, psychological and pharmacological options. International Journal of Women’s Health, 3, 1-14.

Postpartum Depression (PPD): A Psychological Disorder

Postpartum Depression (PPD) is a fairly common complication of childbirth and often accompanies the postpartum period, leading to psychological suffering for the mother, negative effects on the infant and strained family relationships.¹

Pregnancy, childbirth and the postpartum period involve intense emotional experiences for most women and are characterized by a major developmental transition, physical and psychological demands, body image changes, as well as psychosocial changes, all within a short period of time.² Sadly, psychiatric disorders are the leading cause of maternal deaths, very often through suicide.¹

Women with PPD suffer from depressive mood and profound sadness, frequent crying, insomnia, lack of appetite, fatigue, lack of motivation, low self-esteem, perceived inability to cope, suicidal ideation as well as multiple physical complaints.^3,4

Some researchers attempt to conceptualize PPD as a complicated maternal identity formation, where the new mother is unable to achieve a sense of maternal competence and incorporate her new psychosocial role.³ In other words, there is a dominating American middle-class perspective on mothering, which expects an intense child-centered parenting that is both economically and emotionally demanding. Yet, we often fail to appreciate the largely diverse population of the United States in the context of child rearing. Thus, mothers who may not fit the middle-class American script may feel like a failure and begin to experience growing maternal incompetence, diminished self-efficacy, self-esteem and increased distress. All of these may be contributing to the onset of PPD.³

Why is this Disorder Often Undiagnosed?

Women diagnosed with PPD often describe themselves as “bad mothers” and report intense feelings of guilt and shame.^{3, p.374}  This gives us an idea about the social stigma associated with PPD and would partly explain why most women do not seek professional help and remain undiagnosed and untreated. That is why helping professionals need to put every effort into promoting psycho-education and establishing PPD as a diagnosable, treatable disorder, so that no mother and her child remain in suffering. In fact, researchers point out that some women may experience the diagnosis of PPD as a relief, helping them accept their symptoms and reduce their personal feelings of guilt, self-blame and shame.³

How Common Is The Disorder?

The estimated prevalence rate of PPD is about 13%, with higher incidence among teenage mothers.⁵ A study of women in Sweden has shown depressive symptoms in around 17% of pregnant women during the late stages of pregnancy and in 13% of new mothers.⁶ Other studies have found prevalence rates of 14% in both early pregnancy and during the first year after delivery.^{Rubertsson cited in 6}

Such prevalence rates pinpoint PPD as a serious public health issue that affects not only mothers, but also their children and other family members.

Risk Factors

Many life events and psychological factors have been identified as risk factors for PPD. Among these, anxiety and depression during pregnancy have shown to be strong predictors for the onset of PPD.⁷ Many studies have also established low socioeconomic status as a strong risk factor.^3,6 Obese pregnant women are also at higher risk of developing PPD.⁷

Postpartum depression might be more common than you have imagined. It is not as common as “baby blues” also referred to as “postpartum blues” that affect about 75% of new mothers within the first ten days after delivery.^8,9 PPD’s symptoms are more serious and longer lasting than those of postpartum blues. Still, if your wife, partner, or friend is experiencing such profound sadness, you should not underestimate the possible seriousness of the issue. Pay close attention to the symptoms and provide support and understanding. (An article on prevention and treatment will be posted soon).

References:

1. Bick, D. & Howard, L. (2010). When should women be screened for postnatal depression? Expert Reviews of Neurotherapeutics, 10(2), 151-154.    2. Clark, A., Skouteris, H., Wertheim, E. H., Paxton, S. J., & Milgrom J. (2009). The relationship between depression and body dissatisfaction across pregnancy and the postpartum. Journal of Health Psychology, 14(1), 27-35.   3. Abrams, L. S. & Curran, L. (2011). Maternal identity negotiations among low-income women with symptoms of postpartum depression. Qualitative Health Research, 21(3), 373-385.   4. Cho, H. J., Kwon, J. H., & Lee, J. J. (2008). Antenatal cognitive-behavioral therapy for prevention of postpartum depression: a pilot study. Yonsei Medical Journal, 49(4), 553-562.   5. O’Hara, M. W. & Swain, A. M. (1996). Rates and risks of postpartum depression: a meta-analysis. International Review of Psychiatry, 8, 37-54.   6. Claesson, I., Josefsson, A., & Sydsjo, G. (2010). Prevalence of anxiety and depressive symptoms among obese pregnant and postpartum women: an intervention study.  BioMed Central Public Health, 10, 766-776.   8. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.

Many philosophers, writers, psychologists (especially Existential psychologists) and stress management experts talk about humans’ ultimate ability to choose. We always have a choice! If we cannot always change events, we are free to choose how to perceive these events, what to think of them and what to focus on.¹

Even when faced with the worst possible situation, we have the power to focus on the positive (How can this make me stronger? What can I learn from this? There are people out there suffering greater hardships than me. Is there any way I can help them?) while de-emphasizing the terrible side of things. Of course, this is easier said than done, but you can begin moving in this direction in little steps. Try developing selective awareness for the positive and make it a lifestyle.

Here are some little things you can do that will help you come to better know and cherish the positive things in your life.

1. Learn to accept compliments and congratulations.

I have often wondered why so many people are having a hard time accepting an honest compliment. I would say, “What a lovely dress!” and hear back, “What? This old thing!” At a dinner invitation I may congratulate the host on preparing such an abundant and delicious treat. At this point, I often receive, “Oh, it’s nothing really. I just put a few things together in a hurry.” . . . Puzzling, isn’t it?

Have I ever given such responses? It is quite possible, but I surely try to shift in a different direction. So, what are we really saying when we give such a response to an honest compliment? There are a few options: “I am not worthy of a compliment” or “I am not used to being complimented, so I can’t react adequately” , “I’m not used to people giving me credit for my looks/taste/abilities” and so on.¹ We have gotten so used to receiving criticism, we don’t even know how to accept a proper compliment. Sometimes, the feeling behind a compliment is sheer embarrassment. We feel embarrassed because someone has noticed something good about us! How ironic is that? Isn’t recognition what we generally want?  Someone has noticed a good thing in us/about us and is offering a friendly tap on the back – this is wonderful – accept it! There is nothing wrong with saying, “Thank you! I haven’t worn this dress in a long time, but I’m glad it still looks good” or “Thank you! I am truly glad you like the meal. I was trying to prepare a nice dinner for my guests to enjoy.”

Learning to accept compliments and congratulations will naturally take you to the next step . . .

2. Congratulate yourself.

I have to put a disclaimer here: I am not suggesting that we all should become obnoxious and self-absorbed, but there is nothing wrong about giving yourself credit for sincere effort, hard work or successful outcome. Our self-efficacy, the perception that we can face challenges and deal with problems effectively, is based on successful previous experience. If we never notice the progress we are doing, we can never build a sense of self-efficacy that can make us stronger and more determined in overcoming bigger challenges. This can be applied to virtually anything, from quitting smoking to being more productive at work. Give yourself credit for the effort and for the work. Notice the positive, the progress, every step of the way, and this will surely make the journey more pleasant and the goal closer to reach.

3. Take time to recognize the positive.

We are usually so consumed with daily routine and hassles that we don’t physically give ourselves the time to sit down and reflect. We move from one task to the next, often with a sense of urgency, we deal with distress and forget about contentment. Take some time of your day to spend with a good friend, only that friend is YOU. Reflect on the things that happened, offer support, an honest compliment and congratulations. If your best friend was in distress, wouldn’t you try to comfort him/her? Wouldn’t you try to pull them out of the dark hole they are in and show them the beauty outside? How are YOU any different? Why can’t you be your own best friend?!

Taking time to reflect on the positive can only take as little as a few minutes at the end of the day, while driving home from work, brushing your teeth, or before going to bed. Jot it down, if you wish to make it more tangible and keep a list for future reference. I’d say, you owe it to yourself.

References: 1.  Greenberg, J. S. (2011). Comprehensive Stress Management, 12th ed. McGraw Hill.

 Transcript:

    “President Faust, members of the Harvard Corporation and the Board of Overseers, members of the faculty, proud parents, and, above all, graduates.

The first thing I would like to say is ‘thank you.’ Not only has Harvard given me an extraordinary honour, but the weeks of fear and nausea I have endured at the thought of giving this commencement address have made me lose weight. A win-win situation! Now all I have to do is take deep breaths, squint at the red banners and convince myself that I am at the world’s largest Gryffindor reunion.

Delivering a commencement address is a great responsibility; or so I thought until I cast my mind back to my own graduation. The commencement speaker that day was the distinguished British philosopher Baroness Mary Warnock. Reflecting on her speech has helped me enormously in writing this one, because it turns out that I can’t remember a single word she said. This liberating discovery enables me to proceed without any fear that I might inadvertently influence you to abandon promising careers in business, the law or politics for the giddy delights of becoming a gay wizard.

You see? If all you remember in years to come is the ‘gay wizard’ joke, I’ve come out ahead of Baroness Mary Warnock. Achievable goals: the first step to self improvement.

Actually, I have wracked my mind and heart for what I ought to say to you today. I have asked myself what I wish I had known at my own graduation, and what important lessons I have learned in the 21 years that have expired between that day and this.

I have come up with two answers. On this wonderful day when we are gathered together to celebrate your academic success, I have decided to talk to you about the benefits of failure. And as you stand on the threshold of what is sometimes called ‘real life’, I want to extol the crucial importance of imagination.

These may seem quixotic or paradoxical choices, but please bear with me.

Looking back at the 21-year-old that I was at graduation, is a slightly uncomfortable experience for the 42-year-old that she has become. Half my lifetime ago, I was striking an uneasy balance between the ambition I had for myself, and what those closest to me expected of me.

I was convinced that the only thing I wanted to do, ever, was to write novels. However, my parents, both of whom came from impoverished backgrounds and neither of whom had been to college, took the view that my overactive imagination was an amusing personal quirk that would never pay a mortgage, or secure a pension. I know that the irony strikes with the force of a cartoon anvil, now.

So they hoped that I would take a vocational degree; I wanted to study English Literature. A compromise was reached that in retrospect satisfied nobody, and I went up to study Modern Languages. Hardly had my parents’ car rounded the corner at the end of the road than I ditched German and scuttled off down the Classics corridor.

I cannot remember telling my parents that I was studying Classics; they might well have found out for the first time on graduation day. Of all the subjects on this planet, I think they would have been hard put to name one less useful than Greek mythology when it came to securing the keys to an executive bathroom.

I would like to make it clear, in parenthesis, that I do not blame my parents for their point of view. There is an expiry date on blaming your parents for steering you in the wrong direction; the moment you are old enough to take the wheel, responsibility lies with you. What is more, I cannot criticise my parents for hoping that I would never experience poverty. They had been poor themselves, and I have since been poor, and I quite agree with them that it is not an ennobling experience. Poverty entails fear, and stress, and sometimes depression; it means a thousand petty humiliations and hardships. Climbing out of poverty by your own efforts, that is indeed something on which to pride yourself, but poverty itself is romanticised only by fools.

What I feared most for myself at your age was not poverty, but failure.

At your age, in spite of a distinct lack of motivation at university, where I had spent far too long in the coffee bar writing stories, and far too little time at lectures, I had a knack for passing examinations, and that, for years, had been the measure of success in my life and that of my peers.

I am not dull enough to suppose that because you are young, gifted and well-educated, you have never known hardship or heartbreak. Talent and intelligence never yet inoculated anyone against the caprice of the Fates, and I do not for a moment suppose that everyone here has enjoyed an existence of unruffled privilege and contentment.

However, the fact that you are graduating from Harvard suggests that you are not very well-acquainted with failure. You might be driven by a fear of failure quite as much as a desire for success. Indeed, your conception of failure might not be too far from the average person’s idea of success, so high have you already flown.

Ultimately, we all have to decide for ourselves what constitutes failure, but the world is quite eager to give you a set of criteria if you let it. So I think it fair to say that by any conventional measure, a mere seven years after my graduation day, I had failed on an epic scale. An exceptionally short-lived marriage had imploded, and I was jobless, a lone parent, and as poor as it is possible to be in modern Britain, without being homeless. The fears that my parents had had for me, and that I had had for myself, had both come to pass, and by every usual standard, I was the biggest failure I knew.

Now, I am not going to stand here and tell you that failure is fun. That period of my life was a dark one, and I had no idea that there was going to be what the press has since represented as a kind of fairy tale resolution. I had no idea then how far the tunnel extended, and for a long time, any light at the end of it was a hope rather than a reality.

So why do I talk about the benefits of failure? Simply because failure meant a stripping away of the inessential. I stopped pretending to myself that I was anything other than what I was, and began to direct all my energy into finishing the only work that mattered to me. Had I really succeeded at anything else, I might never have found the determination to succeed in the one arena I believed I truly belonged. I was set free, because my greatest fear had been realised, and I was still alive, and I still had a daughter whom I adored, and I had an old typewriter and a big idea. And so rock bottom became the solid foundation on which I rebuilt my life.

You might never fail on the scale I did, but some failure in life is inevitable. It is impossible to live without failing at something, unless you live so cautiously that you might as well not have lived at all – in which case, you fail by default.

Failure gave me an inner security that I had never attained by passing examinations. Failure taught me things about myself that I could have learned no other way. I discovered that I had a strong will, and more discipline than I had suspected; I also found out that I had friends whose value was truly above the price of rubies.

The knowledge that you have emerged wiser and stronger from setbacks means that you are, ever after, secure in your ability to survive. You will never truly know yourself, or the strength of your relationships, until both have been tested by adversity. Such knowledge is a true gift, for all that it is painfully won, and it has been worth more than any qualification I ever earned.

So given a Time Turner, I would tell my 21-year-old self that personal happiness lies in knowing that life is not a check-list of acquisition or achievement. Your qualifications, your CV, are not your life, though you will meet many people of my age and older who confuse the two. Life is difficult, and complicated, and beyond anyone’s total control, and the humility to know that will enable you to survive its vicissitudes.

Now you might think that I chose my second theme, the importance of imagination, because of the part it played in rebuilding my life, but that is not wholly so. Though I personally will defend the value of bedtime stories to my last gasp, I have learned to value imagination in a much broader sense. Imagination is not only the uniquely human capacity to envision that which is not, and therefore the fount of all invention and innovation. In its arguably most transformative and revelatory capacity, it is the power that enables us to empathize with humans whose experiences we have never shared.

One of the greatest formative experiences of my life preceded Harry Potter, though it informed much of what I subsequently wrote in those books. This revelation came in the form of one of my earliest day jobs. Though I was sloping off to write stories during my lunch hours, I paid the rent in my early 20s by working at the African research department at Amnesty International’s headquarters in London.

There in my little office I read hastily scribbled letters smuggled out of totalitarian regimes by men and women who were risking imprisonment to inform the outside world of what was happening to them. I saw photographs of those who had disappeared without trace, sent to Amnesty by their desperate families and friends. I read the testimony of torture victims and saw pictures of their injuries. I opened handwritten, eye-witness accounts of summary trials and executions, of kidnappings and rapes.

Many of my co-workers were ex-political prisoners, people who had been displaced from their homes, or fled into exile, because they had the temerity to speak against their governments. Visitors to our offices included those who had come to give information, or to try and find out what had happened to those they had left behind.

I shall never forget the African torture victim, a young man no older than I was at the time, who had become mentally ill after all he had endured in his homeland. He trembled uncontrollably as he spoke into a video camera about the brutality inflicted upon him. He was a foot taller than I was, and seemed as fragile as a child. I was given the job of escorting him back to the Underground Station afterwards, and this man whose life had been shattered by cruelty took my hand with exquisite courtesy, and wished me future happiness.

And as long as I live I shall remember walking along an empty corridor and suddenly hearing, from behind a closed door, a scream of pain and horror such as I have never heard since. The door opened, and the researcher poked out her head and told me to run and make a hot drink for the young man sitting with her. She had just had to give him the news that in retaliation for his own outspokenness against his country’s regime, his mother had been seized and executed.

Every day of my working week in my early 20s I was reminded how incredibly fortunate I was, to live in a country with a democratically elected government, where legal representation and a public trial were the rights of everyone.

Every day, I saw more evidence about the evils humankind will inflict on their fellow humans, to gain or maintain power. I began to have nightmares, literal nightmares, about some of the things I saw, heard, and read.

And yet I also learned more about human goodness at Amnesty International than I had ever known before.

Amnesty mobilises thousands of people who have never been tortured or imprisoned for their beliefs to act on behalf of those who have. The power of human empathy, leading to collective action, saves lives, and frees prisoners. Ordinary people, whose personal well-being and security are assured, join together in huge numbers to save people they do not know, and will never meet. My small participation in that process was one of the most humbling and inspiring experiences of my life.

Unlike any other creature on this planet, humans can learn and understand, without having experienced. They can think themselves into other people’s places.

Of course, this is a power, like my brand of fictional magic, that is morally neutral. One might use such an ability to manipulate, or control, just as much as to understand or sympathise.

And many prefer not to exercise their imaginations at all. They choose to remain comfortably within the bounds of their own experience, never troubling to wonder how it would feel to have been born other than they are. They can refuse to hear screams or to peer inside cages; they can close their minds and hearts to any suffering that does not touch them personally; they can refuse to know.

I might be tempted to envy people who can live that way, except that I do not think they have any fewer nightmares than I do. Choosing to live in narrow spaces leads to a form of mental agoraphobia, and that brings its own terrors. I think the wilfully unimaginative see more monsters. They are often more afraid.

What is more, those who choose not to empathise enable real monsters. For without ever committing an act of outright evil ourselves, we collude with it, through our own apathy.

One of the many things I learned at the end of that Classics corridor down which I ventured at the age of 18, in search of something I could not then define, was this, written by the Greek author Plutarch: What we achieve inwardly will change outer reality.

That is an astonishing statement and yet proven a thousand times every day of our lives. It expresses, in part, our inescapable connection with the outside world, the fact that we touch other people’s lives simply by existing.

But how much more are you, Harvard graduates of 2008, likely to touch other people’s lives? Your intelligence, your capacity for hard work, the education you have earned and received, give you unique status, and unique responsibilities. Even your nationality sets you apart. The great majority of you belong to the world’s only remaining superpower. The way you vote, the way you live, the way you protest, the pressure you bring to bear on your government, has an impact way beyond your borders. That is your privilege, and your burden.

If you choose to use your status and influence to raise your voice on behalf of those who have no voice; if you choose to identify not only with the powerful, but with the powerless; if you retain the ability to imagine yourself into the lives of those who do not have your advantages, then it will not only be your proud families who celebrate your existence, but thousands and millions of people whose reality you have helped change. We do not need magic to change the world, we carry all the power we need inside ourselves already: we have the power to imagine better.

I am nearly finished. I have one last hope for you, which is something that I already had at 21. The friends with whom I sat on graduation day have been my friends for life. They are my children’s godparents, the people to whom I’ve been able to turn in times of trouble, people who have been kind enough not to sue me when I took their names for Death Eaters. At our graduation we were bound by enormous affection, by our shared experience of a time that could never come again, and, of course, by the knowledge that we held certain photographic evidence that would be exceptionally valuable if any of us ran for Prime Minister.

So today, I wish you nothing better than similar friendships. And tomorrow, I hope that even if you remember not a single word of mine, you remember those of Seneca, another of those old Romans I met when I fled down the Classics corridor, in retreat from career ladders, in search of ancient wisdom:
As is a tale, so is life: not how long it is, but how good it is, is what matters.

I wish you all very good lives. Thank you very much.”

Since there has been a significant increase in the prevalence of chronic diseases, poor patient adherence to treatment has become a major health care problem. More than 90 million Americans live with some sort of a chronic illness³ and these people account for 70% of the annual mortality in the United States.⁴ Poor adherence to treatment is linked to more than 125,000 deaths each year, not to mention, innumerable and completely unnecessary clinic appointments, emergency room visits, hospitalizations, nursing home admissions and additional diagnostic tests. The estimated annual cost of such unnecessary procedures and treatment complications is anywhere between 13 and 15 billion US dollars, which is a tremendous financial strain.^{1, 2, 5} To sum up, poor adherence to treatment is costly, complicated, painful and can even cost one’s life. So, why do we do it?

The term adherence suggests that the patient plays an active role in treatment and the healing process.⁶ No doctor can wave a magic wand and make problems disappears. Usually, healing requires efforts and persistence on the side of the patient, especially when dealing with chronic illnesses. Often times, a major lifestyle change is required, such as changing your diet, exercising or quitting a bad habit. If you’ve tried any of those (or, as in my case, all of them) you know it is a daunting task, which requires will power and patience. What makes matters worse is that it takes a long time before you begin to feel better or experience any other benefits from your efforts. That explains why more than 75% of patients neglect recommended lifestyle changes or are unable to follow through.⁷

However, noncompliance does not always suggest willful disregard of professional advice. We also see cases of doctor-patient miscommunication, patient’s failure to accurately remember the advice or mere knowledge and skill deficits among patients.⁶

Failure to Remember

One study⁸ investigated how many of doctors’ recommendations were actually understood and remembered by patients (and their parents) in a a childhood diabetic clinic. On average, the health-care provided gave about seven recommendations per patient, with both the child and parents present. However, when asked about those, patients and parents recalled only about two recommendations. Shockingly enough, in 40% of the cases, the remembered “recommendations” were never made by the doctor (but were probably some outside information or false memories).

Another study⁹ observed that patients recalled only about 50% of the physician’s instructions.

When elderly patients suffering heart failure were interviewed, 45% of them could not remember the name of the medication prescribed, 50% could not remember the prescribed dose and 64% could not remember when they were supposed to take it.¹⁰

These are just a few examples that show the difficulty of treatment adherence, even when both the patient and health care provider are well-meaning.

Keep this in mind next time you visit your physician. The advice and recommendations they provide may be perfectly clear at the moment, but may soon fade away. There is nothing shameful about taking notes, for example. After all, the faintest ink is better than the strongest memory.

Patient-Doctor Miscommunication

What about the cases when professional advice is so vague that is practically useless? Then patient will be in trouble, even if they remember exactly what the doctor said.

Sometimes, physicians forget that technical knowledge which is a given for them is alien to most of us. Therefore, they may quickly go over diagnosis and treatment, leaving you nodding along, not understanding any of it. In this case, you should not feel intimidated and should not hesitate to ask questions until you clearly understand your situation and recommended treatment. After all, your physician is there to help you.

Other times, health-care providers only give advice in general terms (“Get more exercise” or “Avoid high-fat foods” or “Cut off the alcohol”)⁶. This is not specific enough for most patient to comprehend and break down in small and measurable steps, so they can measure progress and get more motivated. On the contrary, such a general suggestion can be overwhelming, causing you to give up easily. Other times, people make some change, but it’s hard to know if that is what the doctor had recommended. For example, what does “more exercise” suggest? Taking the stairs instead of the elevator? Walking for 30 minutes each week? Running for half an hour three times a day? Which is it? Make sure you can answer questions like these before you leave your doctor’s office.

Knowledge and Technical Skills Deficits

Quite often, treatment involves behaviors and procedures performed by patients, that require some level of skillful administration (insulin injections, glucose testing, using an inhaler, etc). Many researchers have studies these disease management behaviors in patients and have found out that even when people were certain they did everything right, there were mistakes than tempered effective treatment.⁶ A study of asthmatic children¹¹ observed that 93% of them used a deficient meter-dose inhaler (MDI) technique and their parent were also unaware of it. Among adult asthma patients, more than 75% made at least one technical error in the MDI process (even after having received previous training)¹². Glucose testing errors and deficient insulin injections have been documented multiple times among children and adults with diabetes.¹³ After closely studying parents who were giving factor replacement therapy to their hemophiliac children, numerous administration errors were recorded even after years of experience.¹⁴ This is not tho say that parrots and patients don’t care, but simply shows how easy it is to make mistakes and be inadvertently non-compliant with treatment. Just keep that in mind and take any steps necessary to get trained and repeatedly supervised by professionals.

You can never be too careful with matters of health. It is the single most important thing we possess, so cherish it and take good care.

If you would like to learn more about adherence to treatment and disease prevention visit the Center for Disease Control and Prevention.

References:

1. DiMatteo, M. R. (1994). Enhancing patient adherence to medical recommendations. Journal of the American Medical Association, 271, 79-80.   2. Rapoff, M. A. (1999). Adherence to Pediatric medical regimens. New York: Kluwer Academic/Plenum Press.   3. Centers for Disease control and Prevention. (2004). Chronic disease prevention.   4. Centers for Disease control and Prevention. (1999). Chronic Diseases and their risk factors: The nation’s leading cause of death.   5. Mistry, S. K., & Sorrentino, A. P.  (1999). Patient nonadherence: The $100 billion problem. American Druggist, 216, 56-62.   6. Johnson, S. b. & Carlson, D. N. (2004). Medical Regimen Adherence: Concepts, Assessment, and Interventions. Handbook of Clinical and Health Psychology, Vol. 2. American Psychological Association, Washington, DC.   7. Epstein, L.  & Cluss, P. (1982). A behavioral medicine perspective on adherence to long-term medical regimens. Journal of Consulting and Clinical Psychology, 50, 950-971.   8. Page, P., Verstraete, D. G.,  Robb, J. R., and Etzwiler, D. D. (1981). Patient recall of self-care recommendations in diabetes. Diabetes Care, 4. 96-98.   9. Falvo, D. & Tippy, P. (1988). Communicating information to patients: Patient satisfaction and adherence as associated with resident skill. Journal of Family Practice, 26, 643-647.   10. Cline, C. M., Bjorck-Linne, A. K., Israelsson, B. Y., Willenheimer, R. B., & Erhardt, L. R. (1999). Non-compliance and knowledge of prescribed medication in elderly patients with heart failure. European Journal of Heart Failure, 2, 145-149.   11. Winkelstein, M. L., Huss, K., Butz, A., Eggleston, P., Vargas, P., and Rand, C. (2000). Factors associated with medication self-administration in children with asthma. Clinical Pediatrics, 39, 337-345.   12. Larson, J. S., Hahn, M., and Ekholm, B. (1994). Evaluation of conventional press and breath MDI technique in 501 patients. Journal of Asthma, 31, 193-199.   13. Perwien, A., Johnson, S. B., Dymtrow, D., and Silverstein, J. (2000). Blood glucose monitoring skills in children with type 1 diabetes. Clinical Pediatrics, 39, 351-357.   14.  Sergis-Deavenport, E. & Varni, J. W. (1983). Behavioral assessment and management of adherence to factor replacement therapy in hemophilia. Journal of Pediatric Psychology, 8, 367-377.

“One cold winter’s day a number of porcupines huddled together quite closely in order, through their mutual warmth, to prevent themselves from being frozen. But they soon felt the effects of their quills on one another, which made them again move apart. Now, when the need for warmth once again brought them together, the drawback of the quills was repeated so they were tossed between two evils, until they discovered the proper distance fro which they could best tolerate one another.”

Image by AlexRK.