SINGAPORE - By all accounts, Karen Tan had appeared to be a picture of marital bliss. No one would have suspected she was depressed. She had a doting husband, her new baby was, in her own words, well and "thriving", and her home was "very clean".

After their marriage, the theatre actress and her gynaecologist husband moved to London where they lived for seven years. Their first daughter, Rachel, was born in the United Kingdom in 1996.

Beneath her well-kept household, however, Karen was an emotional wreck.

Speaking to TODAY, the 43-year-old recounted her spiralling moods after the birth of her first child, made worse by the lack of family support during her time overseas.

"My husband and I didn't realise it was depression until months later because in the mornings, I would still get up and do things, but something inside me was wrong. I would cry at night. I couldn’t sleep and I found it difficult to be happy."

However, Karen did not want to take any medication that would cause her to be too "zoned out" to care for the baby.

By sheer will, she bounced back. In 2005, after the birth of her second daughter, Karen lapsed into depression again. "I felt the same feelings of inadequacy all over again, even though this time, I had a maid and my family with me. I felt I wasn’t good enough to be a mother."

I am a lousy mother

Other than her persistent low moods and insomnia, Karen's feelings of excessive self-blame and guilt are not uncommon among women suffering from postnatal depression, said Dr Helen Chen, senior consultant and head of Mental Wellness Service at KK Women's and Children's Hospital (Kandang Kerbau Hospital).

"Afflicted mothers often report difficulty in bonding with their child, in part because of their depressed mood and lack of interest or energy, and in part because they view themselves as bad mothers," said Dr Chen, who has been treating Karen for three years.

Baby blues are considered normal for up to 70 per cent of women in the first one to two weeks after childbirth.

During this period, a new mother may become more emotional at times, explained Dr Chen. In most cases, it is usually mild - they may feel weepy, irritable and anxious - and the condition will eventually go away.

Not typical baby blues

Depression, however, works differently. "The woman’s low mood persists for longer than two weeks and symptoms are severe, such that her ability to function is affected," said Dr Chen.

Women undergoing severe postnatal depression may also hear voices, have suicidal thoughts or an impulse to hurt her baby.

In her practice, Dr Chen has encountered many such cases.

"The ones I worry most about are those who suffer from postpartum psychotic depression. In this condition, suffering women hear voices or have delusional beliefs that make them lose touch with reality. They are most at risk of harming themselves or their infants," she said.

For instance, one of Dr Chen's patients had, in that psychotic state, left home as she was terrified that her violent impulses might harm her baby. Fortunately, her family arranged for prompt treatment when she returned.

It is estimated that maternal depression - a term which includes depression during pregnancy and after delivery - affects one in 10 women.

A recent National University Hospital survey found that about 12 and seven per cent of women here suffer from depression during their pregnancy and after childbirth, respectively.

Another study conducted at Kandang Kerbau Hospital found that as high as 20 per cent of the pregnant and recently delivered women surveyed had significant depressive symptoms, although they were not necessarily having clinical depression.

Dr Chen stressed that this form of depression is not solely due to hormonal changes that occur during pregnancy and after childbirth. "Otherwise every woman would be afflicted!" she said.

Research has shown that hormonal changes only causes a new mother to be more vulnerable to depression, so that in the face of other stressors, the balance tips her over to clinical depression, explained Dr Chen.

Women at risk include first-time mothers, those with ill infants, those with a family history of mental illness, and young mothers, particularly those under 21.

Other risk factors include marital problems, family conflicts or financial issues.

Not all in the mind

Like hypertension or diabetes, maternal depression is a medical condition that requires clinical attention, said Dr Chen.

Yet, too often, the sufferer's condition is dismissed by people around her. Karen said, "If you have cancer or other illnesses, people will sympathise with you; here, no one will say the same thing if you're depressed. It's really, really sad for women struggling with this condition."

According to Dr Chen, it is common for family or spouses to say to the suffering mother, 'It's all in your mind' or 'Snap out of it'.

"I think it stems from the stigma of mental illness which often leads to the mother keeping the suffering to herself because everyone around her expects her to be happy and excited about her baby," she said.

That is why Kandang Kerbau Hospital Mental Wellness Service is organising a play aptly named "When The Bough Breaks", which will run next month.

Produced by The Necessary Stage, the play is about a woman's struggles with postnatal depression and her recovery process.

Karen appears as a doctor, counselor as well as support group worker in the play, which also stars Ong Shu An, Rodney Oliveiro and Catherine Sng.

Through the play, Karen hopes to create greater awareness of maternal depression and encourage sufferers to seek medical help.

Ever candid about her experience with postnatal depression, Karen said: "I know people are going to read this and say, 'Oh, what is Karen Tan complaining about? She has a maid and a family and a comfortable life.'"

"But regardless of your educational level or background, it can still hit you."

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