Shelane Gaydos always wanted a big family. The Herndon, Virginia, woman and her husband, both Fairfax County police officers, had three little girls and were expecting their fourth child when they learned during a routine 12-week ultrasound that the baby's heart had stopped beating.
Gaydos was devastated. In the days that followed, she blamed herself, worried aloud that she had let her husband down, and told her sister that she felt like a failure. She took time off work, stopped sleeping. Two weeks after the doctor's appointment, she ended her life.
Her family and friends have spent the past two years trying to understand what happened to the 35-year-old woman they knew to be ambitious, passionate and fiercely dedicated to her children.
"It was natural, of course, that she would be depressed," said her mother, Joanne Bryant of Fairfax Station, Virginia, who is now helping to raise her three grandchildren. "We did not know to what degree."
Gaydos's family believes her death was the result of postpartum psychosis, a rare illness that can cause delusions and paranoia. And they have become advocates for raising awareness about the range of mental-health issues - often referred to in somewhat misleading shorthand as postpartum depression - that can affect expectant or new mothers.
At least 1 in 7 women experience anxiety or depression during pregnancy or in the first year after birth, making mental-health disorders the most common complication of pregnancy. Despite this, maternal depression remains vastly underdiagnosed and undertreated, with just 15 percent of women affected seeking professional help.
In recent years, advocates say, there has been new progress in understanding and treating an illness that half a million U.S. women experience each year. Medical providers are screening for depression more routinely, and lawmakers are beginning to look for solutions for expanding treatment options.
Last November, Congress passed the Bringing Postpartum Depression Out of the Shadows Act as part of a large medical research funding bill to provide federal grants to states to create programs that screen and treat women for maternal depression. The bill had broad bipartisan support, but funding for the grants is now in question. The House last week approved just $1 million of the $5 million originally allocated. The Senate has yet to vote.
Rep. Katherine Clark, D-Mass., who introduced the bill, said many women struggle silently through what is supposed to be "the happiest time of their lives."
"Moms have a lot of guilt about how they feel, so they don't seek treatment," she said. "We want to reduce the stigma and increase awareness that this is highly treatable."
Maryland created a statewide "Task Force to Study Maternal Mental Health" in 2015 that prompted the state to design a plan for a system for advising pediatricians and obstetricians to treat maternal depression. The D.C. Council is considering a bill that would create a similar task force.
"Postpartum depression is where breast cancer was 30 years ago: We whispered about it," said Adrienne Griffen, founder and executive director of Postpartum Support Virginia. "This is the next generation's issue."
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About 80 percent of women experience "baby blues" within the first few weeks of child birth, often defined by mood swings and irritability or sadness. Maternal depression is longer lasting and has more-severe symptoms, which can include anxiety, sleeplessness, extreme worry about the baby, feelings of hopelessness, and recurrent "intrusive thoughts" about hurting themselves or the baby.
Women are more likely to attempt suicide during the first year after childbirth than during any other time in their lives, and they tend to choose more lethal means.
These mood disorders are triggered by fluctuating hormones, including estrogen and progesterone, that ramp up during pregnancy and then drop off sharply after birth. Another significant hormonal shift occurs when women stop breast-feeding.
Researchers are trying to understand what predisposes some women to be more sensitive to these hormonal fluctuations, while others are not.
It's clear that environmental stressors play a role. The prevalence of depression is far higher for women who are poor or in abusive relationships or for women whose babies are born premature or disabled.
The stress of having a child is also exacerbated by unrealistic societal expectations, advocates say, and a poor social safety net that offers no federal paid leave program for new mothers.
"Women are supposed to have a full-time job, breast-feed, fit into a Size 6, go back to work a week after their baby is born, and do it all themselves, not to mention without sleeping," said Jamie Zahlaway Belsito, advocacy chair of the National Coalition for Maternal Mental Health.
Studies have shown that untreated maternal depression can harm not just mothers but also their children, and can lead to delays in cognitive and emotional development. Severe depression during pregnancy is associated with health risks, including pre-eclampsia and preterm delivery.
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With mounting evidence about the effects of maternal depression and with the availability of reliable screening tools, the American Congress of Obstetricians and Gynecologists (ACOG) recommended in 2015 that women be screened at least once for depression during pregnancy and again in the postnatal period. And last year, the U.S. Preventive Services Task Force, an influential federal panel, made a similar recommendation. The American Academy of Pediatrics in 2010 recommended that pediatricians screen mothers for postpartum depression at well-baby visits during the first six months.
Some mental-health advocates recommend that screenings happen more frequently.
"If they know we are going to ask this time and again, and if they know it's important for their health and their baby's health, they will be more likely to get the support they need," said Lenore Jarvis, a pediatric emergency room doctor at Children's National Health System.
Jarvis noticed a pattern of mothers coming to the emergency room worried about babies who did not have a clear medical problem. As a doctor, she would examine the baby and report back that everything was fine. But she felt she was not getting to the root of the problem.
She launched a pilot study to give depression screenings to mothers whose visits were not urgent and to provide resources to help those who needed it. The study found that 27 percent scored positive, and 7 percent reported having suicidal thoughts. More than half of the women who screened positive said they had never been screened before.
Despite the push, many women are still not being screened, advocates say.
One challenge is that many obstetricians or pediatricians lack specialized training to respond to maternal mental-health concerns, and they do not know where to refer mothers for help. The ACOG is developing training materials to help obstetricians, and it published a technical document to advise doctors who want to prescribe medications to pregnant or lactating women.
A statewide program in Massachusetts, which many advocates consider promising, makes a perinatal psychiatrist available full time to consult by phone with pediatricians and obstetricians or other caregivers who need advice to treat mothers.
Treatment options can include individual or group therapy, medication, home visits by a nurse or social worker, or simply a follow-up phone call.
"For some women it just helps to know that they are not the only ones going through this," Jarvis said.
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Nadia Monroe, a University Park mother, was not diagnosed with postpartum depression until she returned to work four months after her baby was born. Despite panic attacks and chronic anxiety, it wasn't until she tried to quit her job because she was struggling to function that her boss sent her directly to see her obstetrician and called the office herself to sound an alarm.
Monroe eventually saw a psychiatrist and received a prescription for antidepressants that helped stabilize her mood.
"I didn't have to suffer for so long," said Monroe, now a mother of two who runs a free peer support group for other mothers experiencing postpartum depression.
To raise awareness, friends and family of Shelane Gaydos organized a 5K run last fall to honor the police officer and avid runner, who was often out on trails with a baby stroller. They hope to make the symptoms well known to women and those who love them. They plan to have another run in October.
"If Shelane had known that this was curable, that she could have gotten better, she would have been that patient who did every single thing, so she could still be here for those girls," said Laura Tiso, a longtime friend who worked with Gaydos at the Fairfax County police.
Two years after his wife died, Brian Gaydos said he has finally stopped asking God every day to bring her back.
His life has changed "more than 180 degrees," as he became a single father to his three daughters and learned to cope without the woman he called his best friend and soul mate.
When people ask him what happened, he tells them: "She died from a disease called postpartum depression." He said the answer makes many people uncomfortable:
"You have to break through the uncomfortable," he said. "We are losing a silent battle that no one wants to talk about."