Beyond the Blues – Understanding and Treating Prenatal and Postpartum Depression & Anxiety by Shoshana Bennett

Read this book if:  you want to learn more about prenatal and postpartum depression & anxiety.  It’s important to be educated (as pregnant women, partners, and those who care for pregnant women) as 20% of women or 70,000 affected each year.

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Preface: In U.S, over 3.5 million women give birth each year. Perinatal depression rate is ~20% so 70,000 will become ill. Rate of gestational diabetes is bw 1 and 3% and rate of down syndrome in 35 yr old mother is 3%. Screening routine for diabetes and down syndrome, but not perinatal depression (pregnancy through 1st year postpartum), which occurs in 1 in 5 mothers.

Chapter 1

Introduction of authors and their stories

Chapter 2

Perinatal Psychiatric Illness – perinatal mood and anxiety disorders (PMADs) occur during pregnancy and first year after a woman gives birth. Triggered mainly by hormonal changes, which then affect brain chemicals called neurotransmitters. Life stressors (moving, illness, poor partner support, financial problems, social isolation) affect mental state. Strong emotional, social and physical support will help her recovery. Can occur at different times of day and can feel very different from other depression.

Perinatal Mood and Anxiety Disorders: 6 main ones: depression, OCD, panic disorder, psychosis, PTSD, bipolar disorder I or II (AKA bipolar spectrum disorder).

Psychiatric Issues of Pregnancy: 15-23% experience depression. Higher in teenagers and poor women. Risk factors include life stress, history of depression, lack of social support, domestic violence and unplanned pregnancy.

26.5% had histories of depression before pregnancy, 33.4 % had first occurrence during pregnancy and 40.1 % developed postpartum as first depression.

Pregnancy vs Depression

Pregnancy: mood up and down, teary, self esteem unchanged, can fall asleep, physical problems may waken (bladder, heartburn), can fall back asleep; tires easily, rest refreshes and energizes; feels pleasure, joy and anticipation; appetite increases

Depression: mood mostly down, gloomy, hopeless; low self-esteem, guilt; may have trouble falling asleep, may have early morning wakening and difficulty falling back asleep; rest does not help reduce fatigue; lack of joy or pleasure; appetite may decrease

Depression and Anxiety in Pregnancy: when difficult to function on a day to day basis, need treatment – can be traditional (counseling/meditation) or nontraditional (yoga/acupuncture). Use whatever works best. Depression during pregnancy associated with low birth weight (less than 5.5 lbs) and preterm delivery. Severe anxiety may cause harm to a growing fetus because cortisol (hormone released during stress) can place constriction of blood vessels in placenta. Rate of relapse for major depressive disorder in women who discontinue medication is between 50 and 75%. Depression/anxiety occur in 15-23% of pregnant women; higher rates in teens and women of color; can occur anytime during pregnancy. Symptoms: sad mood, irritability, lack of joy/pleasure, not looking forward to future; guilt; excessive worry or fear; social withdrawal; appetite and sleep disturbances. Risk factors: personal/family history; lack of support; stopping psychiatric medication; history of abuse, domestic violence; history of pregnancy loss

“Baby Blues” – not a disorder – used to describe milk mood swings that occur after first few weeks of birth (begins first week postpartum; should be gone by 3 weeks postpartum). Not considered a disorder since majority of mothers experience it (80%). Symptoms: moodiness, crying, sadness, worry, lack of concentration, forgetfulness, feelings of dependency. Causes: rapid hormonal changes; physical/emotional stress of birthing; physical discomforts; emotional letdown after pregnancy and birth; awareness and fear about increased responsibility; fatigue and sleep deprivation; disappointments including the birth, partner support, nursing and the baby.

Depression & Anxiety Postpartum – 15-20% of mothers; onset usually gradual but can be rapid and begin any time in first year. Symptoms: excessive worry/fear; irritability/short temper; feeling overwhelmed and unable to cope; difficulty making decisions; sadness; hopelessness; feelings of guilt; sleep problems (often can’t sleep or sleeps too much); fatigue; physical symptoms or complaints without apparent physical cause; discomfort around baby or lack of feeling toward baby; loss of focus/concentration (miss appointments); loss of interest of pleasure; lower sex drive; changes in appetite, significant weight loss or gain. Risk Factors: 50-80% risk if previous postpartum depression/anxiety; depression or anxiety during pregnancy; personal or family history; abrupt weaning; social isolation or poor support; history of PMS or PMDD; negative mood changes while taking birth control or fertility medication; thyroid dysfunction; stopping psychiatric medication

Obsessive Compulsive Disorder (OCD): up to 9% of new others; of those – over 38% have depression. Symptoms: intrusive, repetitive, and persistent thoughts/mental pictures; thoughts often about hurting/killing baby; tremendous sense of horror and disgust about these thoughts; thoughts may be accompanied by behaviors to reduce anxiety (hiding knives); counting, checking, cleaning or other repetitive behaviors; fear of germs; fears about own health. Risk Factor: personal/family history of OCD (diagnosed or not)

Panic Disorder: 10% of postpartum women. Symptoms: episodes of extreme anxiety; shortness of breath, chest pain, sensations of choking or smothering, dizziness; hot or cold flashes, trembling, rapid heart beat, numbness or tingling sensations; restlessness, agitation or irritability; during attach the woman may fear she is going crazy, dying or losing control; panic attack may wake her up; often no identifiable trigger for panic; excessive worry or fears (including fear of more panic attacks). Risk Factors: personal/family history; thyroid dysfunction

Psychosis: serious – person loses touch with reality. 1-2 per 1000 perinatal woman. Onset usually within first 2 weeks after birth. 5% suicide and 4% infanticide rate. Symptoms: seeing, hearing, feeling thing that others do now (voice of God, devil, secret messages from TV); delusional thinking (infants death, denial of birth, or need to kill baby); mania; confusion; paranoia; symptoms that come and go (normal one minute, hearing voices the next). Risk Factors: personal/family history of psychosis, bipolar disorder or schizophrenia (diagnosed or not); previous postpartum psychotic or bipolar episode

Post-traumatic Stress Disorder (PTSD) – occurs following life-threatening or injury producing events such as sexual abuse or assault or traumatic childbirth. Occurs in up to 6% of women; rates are higher (up to 30%) for parents who have a child in NICU. Symptoms: recurrent nightmares; extreme anxiety; reliving past traumatic events. Risk factors: past traumatic events; traumatic birth; severe physical complication or injury related to pregnancy/childbirth; baby in NICU

Bipolar Disorder I or II (sometimes referred to as Bipolar Spectrum Disorder): AKA manic depression, bipolar disorders are characterized by mood swings from very high (mania) or high (hypomania) to low mood (depression). No data about how often this occurs. Women usually seek help during episode of depression and commonly misdiagnosed as depression rather than bipolar. Symptoms: mania (bipolar I)or hypomania (low level of mania in bipolar II); depression; rapid and severe mood swings. Risk Factor: personal/family history

Consequences of Untreated Parental Depression on Children: placed on top of list affecting children’s readiness for school. Impact may continue through childhood and into teen years. 50% of kids who have depressed moms will have depression by end of adolescence. At least 10% of fathers are moderately or severely depressed. Less than 50% of these dads report regularly reading to their 1 year olds. Children of depressed parents more likely to suffer from childhood psychiatric disturbance, behavioral problems, poor social functioning and impaired cognitive or language development. Suicide is the second leading cause of death in new mothers during the first year. Get treated right away to help ensure a healthy family.

Perinatal Loss: miscarriage occurs in 20% of pregnancies, but women don’t talk about it. Important to find support and know you are not alone. Women who’ve have had any neonatal loss need to be monitored carefully for distress in future pregnancies and postpartum period. Both parents suffer. Moms go through immediate psychological and emotional reaction; partners feel the need to be strong. 36% of dads suffer severe anxiety at 6 weeks after a pregnancy loss. Dads found to have more depression than moms at 13 months after the loss. Sometimes women interpret partners initial stoic response as a lack of caring. Couples need to communicate. Support plan should include nutrition, sleep, social support and possible medication.

Chapter 3: Women with Perinatal Disorders

No one is immune –doesn’t matter your profession. No matter the educational, socioeconomic level, culture, religion or personality, statistics remain consistent.

Finding a Therapist or Medical Practitioner: Postpartum Support International (PSI) at 800-944-4PPD or postpartum.net. Do not assume someone with expertise in depression or anxiety knows about perinatal mood disorders. Most insurance companies have coverage for mental health. If you can only see a doctor on their list, use these screening questions (or ask a support person to do this for you). Medical practitioners should be asked if they are comfortable prescribing psychiatric medication to pregnant/breastfeeding mothers: specific training in perinatal disorders; belong to any organization dedicated to education about perinatal mood and disorders (PPI, Marce Society, North American Society for Psychosocial OB/GYN); books recommended; theoretical orientation (research shows most effective types of therapy are cognitive-behavioral and interpersonal – you are experiencing a life crisis; long term intensive psychoanalysis is not appropriate). If can’t find, look for someone compassionate and willing to learn. Shop around until you feel satisfied that you are in capable hands.

Remind Yourself: I will recover (they have never met a women who didn’t’ after proper treatment)!; I am not alone! (1/5 women); This is not my fault (it’s a real illness); I’m a good mom (getting help shows you are taking care of family); It is essential for me to take care of myself (to get back to family). I am doing the best I can (you are taking steps, regardless of how small they seem). Depression may interfere with ability to believe these statements so say them frequently.

Basic Mom Care: many women uncomfortable asking for help since we are supposed to be supermom. It takes a village.

  • Finding Support People: we overlook those who can be of help. Physical support can be cooking, cleaning, caring for baby, shopping or taking you for a walk/appointment. Emotional support can include sitting, listening, hugging, giving encouraging words. Accept all help offered and ask for more. Brainstorm and write down list of supporter’s names and numbers – keep by phone for in times of need. Ex: partner, friends, family/extended family, neighbors, coworkers, religious communities, professionals (doulas, lactation consultants, nannies, housekeepers), hotlines and warmlines, online postpartum depression message boards, prenatal/postpartum depression support groups. Find nonjudgmental, caring support.
  • Eating: women with perinatal depression often crave sweets and carbohydrates. Try and eat something nutritious (especially protein) every time you feed baby to keep blood sugar levels even – will keep mood more stable. Try drinking food if having trouble eating (protein shakes). Avoid caffeine. Ask support person to buy yogurt, sliced deli meat and cheese, hardboiled eggs, precut vegetables, fruit and nuts. Ask people to bring food. Drink water – dehydration can increase anxiety. Appetite problems quite common. Tell practitioner about any major appetite or weight changes – can find a nutritionist familiar with depression. Women who eat a diet high in vegetables, fruit, meat, fish and whole grains had less depression and anxiety. Women with processed or fried foods, refined grains, sugary products and beer had higher rates of depression.
  • Sleeping: mood severely affected by lack of sleep. Moms more depressed, irritable and anxious when they have interrupted sleep. Nighttime sleep is the most valuable sleep in helping you recover. Sleep is necessary to restore brain health and ideally brain needs 8 hours of uninterrupted sleep each night. With 6 hours, ability to think clearly and respond is decreased, but this is what most new moms get with baby. You need to be “off duty” for a few hours per night. Baby can be fed breast milk in bottle or formula by partner or other support person.   Can split each night or alternate nights. When off, sleep away from baby in other room with earplugs. Use fan, air purifier etc to block baby noises. Even if can’t do it nightly, a few nights a week will help. Nap if you can, but naps don’t replace nighttime sleep. Sleep problems occur frequently with mood and anxiety disorders. If unable to sleep at night, talk to health practitioner.
  • Physical Activity: even a few minutes of brisk physical activity can help your mood. Walking, dancing, bike riding. If thought of walking around block is overwhelming, start slowly and work up. It gets easier as you feel better. Get support person or buddy to encourage your or participate with you. Pregnant and postpartum women who got some exercise (including walking with stroller) were found to cope better and have a reduction in depression. If have sleep problems or are sleep deprived, don’t do intense aerobics as can make sleep problems worse. Wait until you’ve had at least a couple weeks of good sleep before you resume or begin a heavy exercise program.
  • Taking Breaks: there’s no other job that’s 24/7. All good mothers take breaks. Get regularly scheduled time off each week for a minimum of 2 hours at a time (not including errands or chores – pleasure only). For every other job, breaks are mandated by law. You are not the only one who can care about your baby. Partners and family members should be given alone time to bond with baby. If not able to leave house, go to another room and use earplugs or headphones. Or maybe support person can leave house with baby and give you alone time.
  • Going Outside: world feels darker and smaller when depressed. Go outside, look up at sky, stand up straight, put arms at sides and breathe. Don’t have to actually go anywhere. Go outside 1x a day, even if standing outside front door in bathrobe.
  • Improving Your Mood – Take Control of Your Environment: avoid reading or listening to the news. If watch movie, watch a comedy. Avoid tragic/violent films. Open drapes and curtains and let sunlight. If anxious, listen to soothing music. If depressed, try music with a good beat that gets your body moving.
  • Taking care of baby: depending on level of depression, may need someone to do most, if not all of baby care. Support person, family member, doula, nanny or friend can help when partner can not. Gradually can increase care of baby as support person keeps you company.  May feel like a robot at first, but still good to experience some mommy tasks. Feelings of competence and confidence will increase and eventually you will be able to enjoy your day.   Smile, touch and interact with baby as much as able. Once up for it, sign up for infant massage or baby swimming class – these promote mother-infant bonding.
  • Scripts: Give support people suggestions of what to say and do since sometimes its hard to say how you feel. Ex: I am sorry you are suffering; we will get your through this; I am here for you; hug; this will pass.
  • For women with anxiety, fear or extreme worry: avoid caffeine and keep blood sugar level even. Turn off tv news and don’t read news. Don’t read books, magazine or internet information if you feel it makes you anxious. Avoid all media – including social media – if it fuels your worry or fear. If go to movies, select comedies. Find activities that soothe/distract you rather than stir up anxiety.
  • Preventing too much stimulation: adjust surroundings if sights, sounds, daily activity feels too much. Don’t go to family event if seems overwhelming. Lower light (if depressed, try increasing light and opening curtains). May be more sensitive to touch so wear soft clothing.

Myths About Nursing:

  • “I can’t be a good mom unless I nurse my baby” – whatever works for you and your family is the right way. Tremendous amount of pressure in our society to nurse exclusively, regardless of physical or emotional obstacles. Whether you feed your baby breast milk (from breast or bottle) or formula has no relationship to how much you love your child or what kind of mother you are. Be prepared for questions – and remind yourself you are making the best decision for your family. You can ignore questions or change subject or say “it’s none of your business”, “I can’t breastfeed; I have a life threatening illness” or “my doctor told me I can’t”. Women who breastfeed in public may also get comments. Can respond any way you like to get people off your back. Good moms make sure their babies are fed. Period.
  • “My baby won’t bond if I don’t nurse” – if this were true, there’d be whole generations of adults who never bonded with their mothers. Some mothers begin to bond when they stop breastfeeding. For moms experiencing pain breastfeeding, bottle feeding or combination will allow breastfeeding to be more relaxed and enjoyable. If you desire skin to skin, can bottle feed bare chested. Bottle feeding provides chance for good eye contact. Many chances to bond with baby – diaper changing, cuddling, bathing, smiling at baby etc.
  • “My baby can sense my depression or anxiety” – babies can sense temperature, hunger, wetness and physical contact. Babies cant read thoughts. It’s your behavior that counts (smiling, talking, touching etc). Having a nondepressed caretaker in charge for part of time will also help as you recover.
  • Bonding happens only immediately after birth” – no adopted children would bond if this were true. Don’t worry if not able to hold immediately after delivery. It’s never too late. Bonding is a process of familiarity, closeness and comfort that continues for years.

Recovery: Whatever helps you get better quickly is what is recommended.

Antidepressant Questions and Answers

  • Will medication change my personality? Depression and anxiety change your personality – people who are usually easygoing and stable may become irritable, moody, withdrawn or worried. As medication begins to work, you will feel like yourself again.
  • How long will I have to take medicine? Treatment length varies. If first depression, recommendation is to take a dose that gets you back to yourself, then continue for 9 months to a year. If have history, may suggest longer treatment. Staying on medication for recommended time is critical to reduce changes of having a relapse or recurrence of illness.
  • Will I become dependent on the antidepressant? Antidepressants are not addictive, but you should never stop taking them suddenly. Some psychiatrists recommend 2-4 months to taper off antidepressant. Most women are able to go off medication at some point.
  • What if I have side effects? Many experience no side effects at all. If they do occur, they are usually mild and temporary, lasting less than a week (nausea, fatigue, or shakiness). If decrease sex drive, may persist through course of treatment. If severe side effects or don’t clear up in a week, contact practitioner. Some have to try more than 1 to find the one best for them. Helpful to start at a very low dose and slowly work up to dosage effective for you.
  • Which antidepressant is the right one for me? Most people do well on most. If was on one previously that was helpful or if have blood relative doing well on one, that would be first choice. If anxious, one with calming effect might be chosen. If have fatigue, one with energizing effect may be tried. Most important is one that makes you feel better over time.
  • When will I feel better? How will I know if medication is working? Most begin working within 2 weeks, while older medications can take 4-6 weeks to work. Signs they are working: not crying all the time; having more patience; singing in shower again, partner notices you happier, feel more motivated, cooking again, enjoying baby more not worrying as much, smiling/laughing more, having more fun, answering email and phone calls again.
  • Won’t medication be a crutch (temporary tool until no longer need it)? You would use crutch for broken foot. Medication restores brain chemistry to a normal state. Can also help you utilize psychotherapy more effectively.
  • I want to breastfeed, but don’t want to take anything that will harm baby. Can I take medication and nurse? Yes. When infant blood was examined, few if any metabolites of medication were found. Babies exposed as healthy as those not exposed. Going untreated can affect baby’s health and is not a good option. More important for mom to get proper treatment rather than whether she feeds baby breastmilk or formula. If worried, wean yourself slowly rather than going off treatment.  Best gift you can give baby is happy, healthy mom. Usually worry disappears once medication starts working because fear caused by illness itself.
  • I am pregnant and really depressed. Do I need to feel this way for the rest of my pregnancy? 15-23% experience depression in pregnancy. Untreated depression can have harmful affects on fetus. If depressed, may not be caring for self as should. Many women self-medicate with caffeine, cigarettes, alcohol, drugs or herbs, which can be harmful. No increased risk of miscarriage or malformations have been shown from taking medication, even in first trimester. Depression can put you at higher risk for postpartum depression and can put baby at risk for developmental delays.
  • I am embarrassed and ashamed about taking medication. Am I weak because I need a medication? There is a stigma in our society about those who take psychiatric medication, based on ignorance. It is presumed we can control our brain chemistry. If someone had diabetes or thyroid disorder, they’d have medication. Don’t have to share with others. Find people who will support you.

Chapter 4: Partners

Support for partner. The sooner you become involved in the recovery process, and the greater your involvement, the more you both will benefit – together and separately. The more you understand what she is experiencing, the better supported she will feel. That will speed her recovery.

Having a baby changes things; attention that had gone to partner now goes to pregnancy/baby. we hear little about mental health of partners.

More often told glowing side of parenthood – you will feel instantly bonder and fall madly in love. There are losses associated w becoming a parent. Normal for relationship to change. If she’s been drooled on, spit up on, sucked on all day, she may be touched out and you may feel rejected. Remind yourself its not a personal rejection. You can no longer jump into bed, take off to movies or go out to dinner on a whim.

15-23% of women suffer from mood/anxiety problems during pregnancy. Some come with past/current history and others develop. 1/5 will have postpartum mood or anxiety disorder.

Some partners may have history or be experiencing mood/anxiety disorder during pregnancy. Depression and anxiety disorders (in part. OCD) worsen during times of stress and sleep deprivation.

Can’t tell by looking. When mom is experiencing a disorder, her partner is at increased risk of suffering as well. 10% of dads showed moderate to severe depression 9 months after birth. Paternal mood/anxiety disorders in first 2 months in 25%. Highest rates seen 3-6 months postpartum. When mom is depressed, rate of depression in partner significantly higher -24-50%. If partner has history, this is a high risk factor w or w out depression in mom.

Not all depressed men/women experience extreme sadness. In men, may be seen as irritability, aggression and hostility. May distance themselves, find distractions to avoid family or check out. This contributes to relationship or marital distress. Other common symptoms – falling or staying asleep, appetite changes, racing thoughts or constant worry, lack of joy/pleasure in things that used to be enjoyed. Some feel helpless and hopeless. Having new baby and increased financial burden can contribute to feeling of being trapped. Like having dark glasses on – everything gets filtered/distorted; only negative things get through.

Depression in partners affects childhood behavioral and emotional development. Children 3.5 yrs old found to have problems, boys more than girls. 4 yrs old more likely to be treated for speech, language, and behavioral problems. Associated w psychiatric disorders in children 7 yrs later, in part oppositional defiant/conduct disorders in boys.

Get support! Get educated! Find a professional. Talk to partner, friends, family. Find nonjudgmental support.

Things to Keep in Mind:

  • You didn’t cause her illness and you can’t take it away – when her brain chemistry returns to normal, she will feel like herself again. Your job to support her as this happens
  • She doesn’t expect you to fix it – don’t suggest quick fix solutions. She just needs you to listen
  • Get the support you need so you can be there for her – frequently see partner depression during/after mom’s illness. Take care of yourself and get own support. Take breaks. Regular exercise or other stress reducing activity important. Provide stand in support person while your gone.
  • Don’t take it personally – irritability common. Don’t allow self to become verbal punching bag. If you feel you didn’t deserve to be snapped at, explain that to her calmly
  • Have realistic expectations – even nondepressed postpartum woman cannot realistically be expected to cook dinner, clean house and care for baby. Remind her that parenting and taking care of home is also your job. Your relationship and family will emerge from this crisis stronger. Good days and bad days. Gradually, frequency and severity of bad days will decrease. May be a # of months before consistently has good days.
  • Let her sleep at night – she needs at least 6 hrs of uninterrupted sleep per night for brain health. If want mom back quicker, be on duty without disturbing her. Many partners express how much closer they are to children bc of nighttime care. If you cant be up at night, hire someone to take your place. Temporary baby nurse will be worth her weight in gold.
  • Be on her team – tell her when you see improvement “you’re smiling more”, “you’re calling your friends again”. If don’t see improvement, gently offer to accompany her to next apptmt

What to Say, What Not To Say

Say:

  • We will get through this
  • I’m here for you
  • I’m on your team
  • I wont leave you – were here for each other through thick and thin
  • I know you’ll get well
  • If there is something I can do to help you, please tell me (care for baby, run warm bath, put on soothing music)
  • I’m sorry you’re suffering. That must feel awful
  • I love you very much
  • The baby loves you very much
  • This is temporary
  • You’ll get yourself back – point out specifics about how you see her old self returning, such as smiling again, having more patience or going out w friends
  • You’re doing such a good job – give specific examples
  • You’re a great mom – give specific examples “I love how you smile at the baby”
  • This isn’t your fault. If I were ill, you wouldn’t blame me and you’d take care of me.

Do Not Say:

  • Think about everything you have to feel happy about
  • Just relax – usually produces opposite effect. Anxiety produces hormones that can cause physical reactions such as increased heart rate, shakiness, visual changes, shortness of breath and muscle tension. Not something she can just will away
  • Snap out of it – if she could, she would have already. A person cannot snap out of illness
  • Just think positively – illness prevents positive thinking. Its keeping her from experiencing the light, humorous and joyful aspects of life

From a Dad Who’s Been There – for years came home to house w wife in tears, baby crying, house a mess, no dinner. Can’t ask wife about day. He focused on his daughter and kept telling himself he’d be there for her. Slowly his wife recovered and they have the happy home they’ve always wanted. It will get better.

Chapter 5 Siblings, Family and Friends

The more educated you become, the more supportive you can be. Many changes in household after birth of baby. older children will not be expecting mom to be different. Children too young to understand but will notice mom’s behavior not normal. They notice if mom has been crying or yells/gets angry over little things. Stays in bed more, does not have energy to take to park, or does not seem to laugh much lately. Staring blank into space.

Communicating w Children

  • Words such as depression or anxiety unclear; use words like sad, cranky, tired, weepy, worried, grouchy
  • Reassure children they did not cause it; its not their fault nor could they prevent it
  • Let them know its not illness caused by germs. She didn’t catch it from anyone or cant pass it on
  • Let them know mom is getting help and will be better soon. Mom will have good times and bad times before she recovers
  • Ask children how they can help mom. Draw pretty pic, leave I love you notes around, offer to help w age appropriate tasks
  • Tell truth – don’t say mom is fine when she isn’t. She can say when she is feeling sad – it’s a feeling and doesn’t have to be logical or rational. Feelings are part of being human. Hiding sadness gives message its not okay to be sad.

Peoples reactions to new mom’s depression can critically affect her recovery. Sometimes mom feels too scared to tell partner about feelings, feeling disapproval and rejection.

When women become mothers, even if aren’t depressed, often crave company and approval of other moms. If woman’s mom deceased, extra important to have another woman who can fill that void. Depressed moms need extra reassurance, esp from adult females.

New moms in general sensitive to criticism. Compliment on mothering and avoid negative comments, esp related to parenting.

Things to Keep in Mind:

  • You will not be able to cure her – recovery can be up and down; typically woman advances 2 steps forward and 1 step back. May become hopeless when dips occur since depression robs her of perspective that she’s getting well. She may voice she’s back to square 1 and not getting better.
    • Remind her its temporary, shes getting better, and her moods will get back on track. Dip is part of process. Over time dips are shorter and not as deep and good times increase.
  • Encourage, do not insist – let her know you are willing to listen w out judging. Even just being there in total silence can be great support; she may not be able to communicate feelings
  • Stay in the here and now – reassure you understand she will be riding some waves in mood for a while and your support won’t be yanked before she’s ready
  • Don’t let looks fool you – women often appear normal to outside. Can look put together w makeup, jewelry and even a smile. Sometimes the more depressed she feels, the more she overcompensates.

What to Say, What Not to Say

Say:

  • I’m here for you
  • I’m sorry you are suffering. That must feel awful
  • You’re doing a great job
  • Be specific whenever you can (you’re a great mom. I love how you smile at baby)
  • You’re a great (sister, daughter, aunt)
  • You will get well
  • Would you like me to (insert task)
  • I went through this too (only if you truly did)

Do Not Say:

  • Just buck up and tough it out – not getting adequate treatment puts women at risk of chronic illness and relapse
  • I don’t get what the big deal is – depression makes everything feel like a big deal. Shes overwhelmed and unable to cope. Even small chores may seem too difficult
  • You have so much to be happy about – depression makes it hard to see positive
  • You just need more sleep
  • You just need a break from baby
  • I went through this too – don’t minimize
  • Women have been having babies fro centuries –

What You Can Do To Help

  • Make dinner
  • Watch baby (or other children) so she can take a break
  • Do laundry
  • Do dishes
  • Make lunch for her
  • Sit and listen
  • Clean house
  • Take a walk together
  • Go shopping or do errands for her
  • Write thank you notes for her
  • If partner not home, be on duty at night so she can sleep

Chapter 6 – Health Practitioners

Important not to underreact or overreact to these women’s symptoms. Treat them as matter-of-factly as any other common perinatal experience such as gestational diabetes.

Warning sings of distress not always obvious for a variety of reasons – shame, guilt or fear of judgment may cause woman to hide her feelings. She may present more socially acceptable complaints such as fatigue, headache, marital problems or a fussy baby. Just bc she is smiling or well groomed, don’t assume she feels good. Although risk factors to help predict PMADs, no particular type of person who becomes ill. Standardized screening improves detection.

She might feel accused of being a bad mom w questions and become defensive. Once she understands no shame should be attached to issues of mental health, she’ll accept info.

Culture and Language – reactions to disorders vary among cultures. Where shame is a great personal threat, women may be more reluctant to discuss symptoms and need reassurance.

Sociocultural factors and literacy levels should be considered. Coping styles differ across cultures. Will affect woman’s response to recommendations regarding treatment methods.

Do not assume an educated woman will automatically understand her condition better than a woman w less education.

What to Say, What Not to Say:

Say:

  • These feelings are quiet common
  • This is treatable
  • You will get well
  • Here is some info that will help

Do Not Say:

  • This is normal – while common, not normal
  • Join a new moms group – may be a damaging suggestion, depending largely on leader of group. Depressed mom already feeling different and inadequate compared to other new moms. Attending “normal” group may intensify her alienation. If you know leader is sensitive to mood problems, she’ll be fine in group. Ideally, she should join group designed for moms w postpartum depression and anxiety. Some belong to both groups.
  • Take a vacation – she takes brain chemistry w her. Anxiety/depression may increase due to financial investment, leaving baby, and guilt that trip didn’t cure her
  • Just get some exercise – most moms feel overwhelmed. Some have barely enough energy to wash a bottle or take a shower, let alone go to gym. Exercise alone will not cure depression. When she’s able to leave her house and take a short walk, encourage her to do so
  • Do something nice for yourself – nice but wont be enough to regulate depressed mom’s neurotransmitters
  • Sleep when baby sleeps – even nondepressed moms have difficulty sleeping when baby naps during day. Esp for those w high levels of anxiety, this will be impossible. What’s most important is that she sleeps at night when baby sleeps.

Screening – use standardized screening surveys specifically designed for perinatal use such as PPDS and EPDS (Postpartum Depression Screening Scale; Edinburgh Postnatal Depression Scale). PHQ-9 (Patient Health Questionnaire) more widely used and many familiar w it.

Prenatal Screening – if time too limited to use screening questionnaires, questions in risk assessment should be asked. At minimum, questions relating to personal/family history of mental illness, previous postpartum mood disorder and severe premenstrual mood changes should be asked (those w asterisk below).

Prepregnancy and Pregnancy Risk Assessment

Warning Signs

  • Missed apptmts
  • Excessive worrying (about own health or health of baby)
  • Looking unusually tired
  • Crying
  • Significant weight gain/loss
  • Physical complaints w no apparent cause
  • Flashbacks, fear, or nightmares regarding previous trauma
  • Her concern she won’t be a good mother

If she answers yes to any questions, she’s an increased risk of perinatal mood/anxiety disorder

  • Have you ever had episodes of being down or sad, extreme worry, panic attacks, repetitive thoughts or behaviors that are troublesome, bipolar or extreme mood swings, loss of touch w reality or an eating disorder?* Women w history should be educated about high risk for perinatal episode
  • Are you taking any medications (prescription or nonprescription) or herbs on a regular basis? Women self-medicating for insomnia, anxiety, sadness or other symptoms may indicate mood disorder?* Some use caffeine, cigarettes, marijuana, herbs, alcohol and drugs to ease emotional pain
  • Have you had a previous pregnancy or postpartum mood or anxiety disorder?* women who answer yes at extremely high risk
  • Have you ever taken and medication for depression or anxiety or mood?*
  • Have you ever had severe premenstrual mood changes PMS or PMDD?* women whose moods are affected by hormone changes are at high risk
  • Do you have any family history of mental illness (undiagnosed or diagnosed) psychiatric hospitalization or suicide?*
  • Do you have any personal or family history of substance abuse?
  • If pregnant, how have you been feeling physically and emotionally?
  • Do you feel you have adequate emotional and physical support?
  • Have you had a pregnancy or birth-related trauma (or other emotional, sexual, or physical abuse)?
  • Are you experiencing any major life stressors (moving, job change, deaths, financial problems)?
  • Have there been any health problems for you or fetus? Having twins, triplets, or multiple births puts mother at increased risk
  • Do you have a personal or family history of thyroid disorder?

Postpartum Screening – EPDS developed in 1987 by Dr. John Cox. 10 question self-report screening tool translated into many languages and used all over world. Effective w teens and dads. Can be found on many internet sites. Also shortened 3 question version.

PDSS developed in 2002 – accurately screens both postpartum depression and anxiety. Can use short or long format. Elevated score in particular symptom indicates greater amt of distress than avg. Symptom scales are Sleeping/Eating Disturbances, Anxiety/Insecurity, Emotional Lability (mood swings), Mental Confusion, Loss of Self, Guilt/Shame, Suicidal Thoughts.

PDSS more likely to identify women w symptoms of sleep disturbance, mental confusion and axiety. Refer her to perinatal specialist.

PHQ9 originally designed for family practice not more widely used in perinatal settings.

Postpartum Risk Assessment – those not screened prenatally, ask first 6 questions from PrePregnancy and Pregnancy Risk Assessment as well

Warning Signs in Mom:

  • Missed appointments
  • Excessive worrying (often about moms own health or health of baby)
  • Looking unusually tired
  • Requiring a support person to accompany her to appointments
  • Significant weight gain or loss
  • Physical complaints w no apparent cause
  • Poor milk production or breastfeeding problems (could indicate thyroid dysfunction)
  • Evading questions about her own well-being
  • Crying
  • Not willing to hold the baby or unusual discomfort handling or responding to baby
  • Not willing to allow others to care for baby
  • Excessive concern about baby despite reassurance (ex: eating sufficiently, development, weight gain)
  • Rigidity or obsessiveness (ex: regarding baby’s feeding/sleeping schedules)
  • Excessive concern about appearance of herself or baby
  • Expressing that baby doesn’t like her or that she’s not a good mom
  • Expressing lack of partner support

Warning Signs in Baby

  • Excessive weight gain or loss
  • Delayed cognitive or language development
  • Decreased responsiveness to mom

Questions to Ask:

  • How are you doing? Have good eye contact w her while you ask
  • How are you feeling about being a mom? Women who feel like they’re doing a bad job or who generally don’t like the job may be depressed
  • Do you have any particular concerns?
  • How are you sleeping (quality and quantity)? 6 hrs of uninterrupted sleep per night required for clear thinking/functioning
  • Can you fall asleep and stay asleep at night when everyone else is asleep? (Sleep problems common in every mood and anxiety disorder)
  • How is baby sleeping? Poor infant sleep is associated with maternal depression and anxiety
  • Who gets up at night w baby?
  • Have you had any unusual or scary thoughts? If yes, refer to perinatal psychotherapist or psychiatrist for immediate evaluation. Some thoughts may be normal; however, others may indicate obsessive-compulsive disorder (less urgent) or psychosis (emergency)
  • Are you receiving adequate physical and emotional help? A good support system of family and friends can make a significant difference
  • Do you generally feel like yourself? Women w perinatal mood disorders often report not feeling like their usual selves, or having a different personality
  • How is your appetite? A significant change in appetite is a warning sign. Check for rapid weight loss or gain
  • What and how often are you eating and drinking?
  • If breastfeeding or pumping, how is it going? Poor milk production may indicate a thyroid dysfunction or be a result of anxiety
  • If using formula, when and how quickly did you wean the baby? Abrupt weaning can precipitate a mood disorder or anxiety disorder
  • When was your last period? Fist menses after delivery can be a precipitating factor
  • Are you taking any medications or herbs on a regular basis? Women who are self-treating for insomnia, anxiety, sadness, fatigue or other symptoms that may indicate a mood or anxiety disorder should be evaluated by a perinatal psychotherapist
  • Are you feeling moodier than normal (tearful, irritable or worried)? This is common in mood disorders.
  • Have there been any healthy problems for your or the baby? These factors increase the risk for mood and anxiety disorders
  • How are you feeling toward your baby? Ambivalence and anger are 2 examples of feelings that may indicate postpartum depression. Discomfort around the baby may indicate anxiety or OCD.

Psychotherapists, Psychologists or Social Workers – critical element and being a part of her preconception planning and perinatal safety net. Be familiar w risk factors and most current info on how to reduce risk factors. Be familiar w research regarding relapse and current medication recommendations. Help monitor symptoms. Have info in resources section available.

Primary Care Providers – evaluate pre-pregnancy risk. Have info from resources available as well as referrals to local professionals trained in perinatal mood and anxiety disorders. Woman taking psychotropic medications who are pregnant/planning a pregnancy should be encouraged to consult psychiatrist specializing in perinatal disorders in order to determine whether to continue meds. Women on medication for bipolar disorder or psychosis should be referred to perinatal psychiatrist to develop medication plan. Need careful monitoring throughout pregnancy and postpartum.

Pediatricians and Neonatologists – well documented that mental health of parents has tremendous impact on development of children in home. If mom has been on meds during pregnancy, reassure parents that baby is fine and not experiencing any withdrawal or neonatal complications. Support mom if she wishes to feed her baby breast milk while taking antidepressant. Mothers w depression or anxiety nurse or pump for shorter durations; they give up. Moms on medications feed their babies breast milk for longer duration then those untreated.

  • Parents w babies in intensive care at high risk for depression/anxiety; they need extra support and screening. Have referrals to local professionals available.
  • Use standardized postpartum screening tool; women should be assessed throughout 1st
  • Women already on meds or those who you assess who need medical evaluation should be referred to psychiatrist specializing in mood and anxiety disorders.

OB/GYNs, Midwives and Other Women’s Healthcare Providers – many women will not be forthcoming w negative feelings or concerns unless specifically asked. Women w history of neonatal loss need monitoring and extra support.

  • Woman taking psychotropic medication who is pregnant or planning pregnancy should be encouraged to consult perinatal psychiatrist to determine whether to continue/change meds. Women on mediation for bipolar or psychosis should develop medication plan; they need careful monitoring throughout pregnancy and postpartum.
  • Use standardized postpartum screening tool.
  • Women already on meds should be referred to psychiatrist specializing in perinatal mood.

Psychiatrists – research findings and recommendations about medications in pregnancy and lactation constantly changing. Make sure give patients name of psychotherapist trained in PMADs. Essential to have list of local resources and referrals.

Birth Doulas – studies show use of doula contributes to reduction of postpartum depression. Can screen prenatally/watch for early warning signs of emotional problems. If when doing prepregnancy and pregnancy risk assessment, you discover woman has suffered previous traumatic delivery or childhood sexual abuse, she may experience flashbacks during birth.

  • Women taking psychotropic meds who is pregnant or planning pregnancy should consult w psychiatrist specializing in PMADs to determine whether to continue. Women on meds for bipolar or psychosis should be referred to psychiatrist to develop medication plan. Need careful monitoring throughout pregnancy and postpartum.
  • If interviewed before employment, can ask about particular concerns about birthing or postpartum. Let woman know that one of your strengths is sensitivity to various emotions that can occur during birth or postpartum.
  • If continue to see women postpartum, use Postpartum Risk Assessment. Info can be gathered informally, simply through chatting.

Postpartum Doulas and Visiting Nurses – can observe home and social environments of mom, which can given crucial info about her well-being and that of family unit. If notice lack of partner support or signs of marital conflict, she’s at greater risk for PMAD. If house unusually neat/clean, want to find out who is doing housework; if she’s obsessively cleaning or awake in middle of night vacuuming, this is not normal.

  • Help to create healing/supportive environment, such as opening curtains to give more light, checking to see if she has healthful food and eliminating unnecessary noise to make her home calmer and more soothing.
  • Use standardized postpartum screening tool such as EPDS or PDSS.

Lactation Consultants – may be first professional to see the mom/baby during initial postpartum weeks. Can observe/listen for potential emotional problems. Postpartum moms listen carefully to what you advise and are quite trusting of you.

  • If physical/emotional health declining, it’s not good for baby. Support person will need to feed baby during half of night if not getting enough sleep (6 hrs a night at least a few nights a week).
  • Breastfeeding difficulties may be associated w sexual abuse, childbirth trauma, OCD, depression and anxiety. Women suffering w depression and anxiety give up breastfeeding more quickly. When mental health improves, often lengthens duration of breastfeeding. Sudden weaning can precipitate mood or anxiety disorder, esp when woman is predisposed. If she’s suffering, abrupt weaning can greatly exacerbate symptoms. Esp if woman is depressed and not feeling good about herself, there can be great amount of guild if at any point she cannot or should not continue breastfeeding.   What you say or do not say at the time can make a big difference regarding how she feels about herself as a mom.
  • Many professionals unaware of current research regarding psychotropic meds in breast milk – important to be informed so you can advocate for women who want to continue taking meds. Have referral to psychiatrist w experience prescribing medication during lactation. Use standardized postpartum screening tool.

Childbirth Educators – so often heard “why didn’t we learn about this during pregnancy?” have a responsibility and opportunity to educate couples about perinatal mental illness.

  • Can invite expert in field to speak to class.
  • Rate of depression in pregnancy 15-23%. Some of women already suffering in class and at risk for postpartum disorders. No danger in giving info and great danger in omitting it. Partner might soak up info if mother to be doesn’t. often spouse who recognizes symptoms and encourages wife to seek help.
  • Hand out info from resources section and name and number of professional trained in perinatal mood disorders. If follow up w participants, ask about feelings regarding challenges as well as joys of parenthood. Be sure to call participants who didn’t attend reunion. May not be doing well and could be trying to avoid an uncomfortable situation. PSI DVD (Resources) will be helpful.

New Parent Group Leaders – statistically 1-2/10 will have PMAD. Rarely will woman disclose since she most likely will be experiencing guilt and shame. Will be aching for someone to open door and give her permission to express how she’s really feeling. If partners present, ask them how they themselves are doing. Dads/partners may have preexisting mood or anxiety disorders.   Stress of pregnancy can also worsen symptoms. Dads and partners need and deserve support too.

  • Encourage discussion about normal feelings accompanying adjustment to parenting and relationship to oneself, partner, baby, friends and family.
  • Can invite professional.

Adjunct Professionals – many others who touch lives of pregnant and postpartum women. Physical therapists, instructors in prenatal and postpartum exercise should mention possibility.

Chapter 7 – Treatment

Why is Treatment Necessary?

Research about perinatal mood and anxiety disorders has taught us new things. In past, ppl thought didn’t exist, or if they did, women didn’t need treatment and should suffer through them, and that they would eventually recover on their own. Now know that’s incorrect. Untreated illness in pregnancy will most likely lead to postpartum illness. At 7 months postpartum, depression continues in 25-50% of women who aren’t treated. They may go away after a time, but increase likelihood of another episodes or episodes later in life. The brain is at least as important as any other part of the body.

Untreated mood/anxiety illness in pregnancy associated w:

  • Self medication w potentially unsafe OTC remedies – tobacco, alcohol, drugs
  • Poor nutrition and lack of self care
  • Appetite changes and abnormal weight gain/loss
  • Poor fetal growth and low birth weight
  • Premature birth
  • Babies who cry more and are more difficult to sooth and calm
  • Behavioral problems in preschoolers
  • Developmental delays in toddlers
  • Antisocial, aggressive, and violent behavior in teens

Moms who have untreated postpartum illness may:

  • Have babies whose brain waves show depression
  • Have difficulty w bonding and attachment
  • Have babies who cry more
  • Have children w poor language and cognitive (thinking) development and poor school readiness
  • Be less likely to use car seats and are more likely to use harsh discipline
  • Have children who are 50% more likely to suffer anxiety or depression when teens

Treating parents not always enough to repair mother-child relationship; activities that involve physical touch (infant massage) shown to be helpful.

Untreated illness affects whole family. You need and deserve to be well!

Research – doesn’t always tell whole story

  • Where is it reported? Google not a reliable source. Forums/blogs not scientific. Large well-respected news sources blur scientific conclusion to create attention-getting headline
  • How many people studies? Smaller, less meaningful. Most valuable have 1000s of participants or at least other research that repeats smaller study
  • What was measured/studied? How was it measured? Many studies on effects of meds on fetus – some base on prescriptions written. Just having prescription, even if not filled, does not mean woman took medication. May not have taken dose prescribed necessary to treat. May not take into account other critical factors – cigarettes, drugs, alcohol, poor nutrition or effects of depression/anxiety if woman on inadequate dose. Genetic risk important when looking at autism etc.

Prevention – ultimate goal.  Study – Women at high risk offered extended postpartum hospital stay (5 days) in private room. Babies slept in nursery at night so moms could sleep w out interruption. Less likely to suffer from PPD and for those who did, it was milder.

Psychotherapy can be used effectively for prevention.

Women at high risk who started sertraline (Zoloft) w in 15 hrs of delivery reduced incidence.

All new moms need wellness plan bc all moms need nurturing. Need uninterrupted sleep, food/eating arrangements, breaks away from baby during week.

Treatment Guidelines – pregnant and postpartum women need to be as symptom-free as possible. Pre-conception it may be reasonable to find/change medication that’s low risk in pregnancy and of low concentration in breast milk. If woman discovers she is pregnant and is doing well on meds, fetus ahs been exposed. Risk of illness due to changing meds is high. Risk of med must always be weighed against risks of illness – on mom, fetus, infant and family. Always rule out bipolar disorder before giving antidepressants. Goal of treatment is that woman feels like herself again as quickly as possible.

Psychotherapy – talk therapy. Need perinatal mental healthcare provider – training in general population not enough. Should be familiar w local resources as well as those on web and in print. Can be done w individual, couple, family members or group setting.

Treatment involves crisis mgmt. Treatments most effective are short-term or brief psychotherapies focused on symptom reduction and improvement in functioning. Not time for long-term psychodynamic or psychoanalytic therapy. 2 models studies and effective for prevention/treatment – Interpersonal Psychotherapy (IPT) and Cognitive-Behavioral Therapy (CBT). Therapist plays active role facilitating and directing discussion and teaching problem-solving skills. Psychotherapy has been shown to have long-lasting positive impact.

IPT works to help clients address role changes, transitions and conflicts and loss and grief and build interpersonal skills as well as support resources.

CBT works by helping monitor and change thinking and behavior through education and skill building; helps clients develop new ways to think/evaluate life experiences and teaches practical skills to use immediately.

When woman unable to process/apply psychotherapeutic strategies, medication often indicated.

Social Support – provides nonjudgmental empathetic emotional support, feedback, active listening and info. Creates environment where women see they are not alone or to blame. Often uses specially trained women who have recovered. Includes support groups, telephone support, home visitors, email and online groups, faith communities and family/friends.

A variety effective in helping women recover. Contact Postpartum Support International.

Complementary and Alternative Therapies – studies being conducted on treatment that doesn’t involve meds. Therapeutic effect of massage beginning to emerge. Morning bright light therapy (natural sunlight or special light boxes) already being used either as alternative or in addition to meds. Effectiveness of omega-3 essential fatty acids DHA and EPA in prevention & treatment apparent. APA recommends 1 gm EPA plus DHA daily. From fish oil, not plant sources, which are different. Recommended to enhance, but not replace, standard treatment. Talk w care provider before taking supplements of any kind. If take omega-3s while nursing, baby’s neurological development may also be enhanced (these lipophilic acids have been added to many baby formulas).

~5% of pregnant women report using marijuana; detectable in placenta, amniotic fluid and fetus. Found to be associated w poor fetal growth in mid/late pregnancy, w effects on low birth weight being most noticeable. Even w legal medical marijuana, no safe dose has been established. Increasing concerns about long-term neurodevelopment, behavioral and possibly even metabolic consequences.

Marijuana also found in breast milk and may be higher than that found in mom’s blood. May affect brain development in children under 1. If using on regular basis, talk to care provider; there are other well-research ways to treat nausea, depression and anxiety.

A new nonmedication treatment is repetitive transcranial magnetic stimulation (TMS). Uses noninvasive brain stimulation and is showing great promise in treatment of major depression. Approved by FDA for treatment of major depressive disorder in adults and a few small studies have been done on depressed pregnant women. Depression was reduced significantly w/in 3 weeks and no ill effects were seen on mom/baby. not yet widely available. May be effective therapy for women who choose not to go on meds.

Acupuncture might be helpful treatment for treating depression in pregnancy. Some insurance companies will pay for alternative treatment.

Use whatever is known to be safe and works.

21% of pregnant women smoke, 19% use alcohol and 6% use illegal drugs as a way to alter moods.

Herbs can be wonderful, but also dangerous. Poisonous mushrooms are natural and digitalis, the heart medicine, is from a plant. Little research has been done on effectiveness of herbs during pregnant/nursing.

Very few studies on St. John’s wort during pregnancy or in breast milk. No research that shows its an effective treatment for anxiety or OCD. St. John’s wort interacts w a # of meds, including meds for heart disease, depression, seizures, certain cancers and birth control (makes less effective). You can’t tell quality/quantity of active ingredient in each dose.

No gov. regulation on herbal remedies and measured amts of active ingredients varied considerably from those claimed on labels – 0-109% for capsules and 31-80% for tablets. Like an antidepressant, SAMe, St. John’s wort and bright light therapy can all trigger hypomania or mania in women w bipolar illness.

Placenta – articles claim prevents postpartum blues and possible protects against PPD and anxiety. Part of cultural rituals around the world. No one has measured emotional health of women or animals that eat placenta. As of mid 2015, still no studies on effectiveness or benefits of placenta ingestion and mood in humans. 30% of people will feel better when given placebo.

For many years, FDA used confusing and misleading rating scale for safety labeling of meds during pregnancy – A, B, C, D, or X. meds w less research often labeled as safer, while meds that had more research sometimes labeled less safe. As of 6/2015, that system will be discarded and replaced by more informative safety labeling of meds used during pregnancy and breastfeeding.

Immediate goal is to alleviate suffering as quickly as possible. Start meds at low dosage and increased as rapidly as possible to whatever right dosage is for that woman. Undertreating can lead to chronic problems/suffering and increases risk of relapse.

All treatment must be individualized. See psychiatrist w expertise in perinatal illness. If one provider or medication/treatment doesn’t work or feel like a good fit, try another. Goal is to feel like you again. Feeling OK or better is not good enough.

Pregnancy and Medication – use of meds in pregnancy has evolved in past few years. Shift has focused on harmful effects on fetus when maternal mental illness untreated. All normal pregnancies have 3-5% of birth defect. Pregnancy causes changes in metabolism and blood volume; higher doses may be required to achieve adequate reduction in symptoms. In order to remain symptom free, 2/3 of women needed increase in dosage at 6.5 months pregnant.

American Journal of Ob/Gyn stated when psychiatric condition requires meds, benefits of med far outweigh potential minimal risks of medication. American Journal of Psychiatry published article stating that not prescribing antidepressants to woman who is depressed or likely to become ill again during pregnant may cause more risks to mom/fetus than risks of exposure to meds.

Commonly used prescription meds for perinatal/anxiety disorders:

  • Antianxiety Medications – while SSRIs are often used to treat anxiety, panic and OCD, it can sometimes take weeks before reduction in symptoms is noticed. Benzodiazepines are used for immediate relief of anxiety, but can become addictive. Women so worried about becoming addicted they don’t take enough to control symptoms. Can be used for occasional episodes of anxiety. Sometimes used w SSRIs to keep anxiety under control, on short term basis. Alprzolam (Xanax) and lorazepam (Ativan) are shorter acting (out of system more quickly) while diazepam (Valium) and clonazepam (Klonoin) are longer acting. Literature regarding antianxiety meds (benzodiazepines) during pregnancy limited. Concern before that caused birth defects such as cleft lip and palate, but now evidence that maternal anxiety itself may contributes. Risk of birth defects in 1st trimester very low and can be used w out concerns about defects in 2nd/3rd Babies born to women taking high doses at end of pregnancy may experience temporary problems. Lowest effective dose for shortest period of time recommended
  • Antidepressants – brand names vary by country
    • Do they cause miscarriage? Analysis of over 735 studies in 2013 review shows risk same in women w depression as those who took antidepressants. Neither selective serotonin reuptake inhibitors (SSRIs) nor tricyclics (TCAs) pose any increased risk
    • Can they cause prematurity? Study 2013 showed no difference in women on antidepressants vs depressed women not on meds
    • Do they cause birth defects? In all births, there is 1-3% chance. Large studies in 2013 looked at buproprion (Wellbutrin), citalopram (Celexa), fluoxetine (Prozac), paroxetine (Paxil), escitalopram (Lexapro), mirtazapine (Remeron), sertraline (Zoloft), venlafaxine (Effexor), fluvoxamine (Luvox), and nefazadone (Serzone) found that use even in 1st trimester not associated w increased risk. Growing body of research on safety of duloxetine (Cymbalta) and venlafaxine (Effexor). No consistent evidence showing risk of stillbirth. No babies had pulmonary hypertension, while babies not exposed to meds did. Motherrisk Program (studies medications that cause birth defects) found no increased risks for major malformations.
    • What about Persistent Pulmonary Hypertension of Newborn? Occurs in .1% of newborns. Rare, but serious. Didn’t show increased risk. Many of known risk factors of PPHN (obesity, smoking, shorter pregnancies, cesarean birth) more commonly seen in depressed women
    • Do they cause poor neonatal adaptation or withdrawal? Refers to symptoms (breathing problems) sometimes seen in newborns whose moms are on meds during last trimester. Unclear if caused by too much serotonin in baby or withdrawal from meds. Reported rates vary from 10-30% and seem more common in women who take paroxetine (Paxil). Symptoms begin in first few days of life and usually gone w in 3-5 days. Discontinuing meds to avoid symptoms in newborn may lead to relapse in mom. This is a mild syndrome that most often does not require treatment. Goes away by itself. Stopping meds in last trimester puts mother at greater risk of depression at end of pregnancy and during postpartum course.
    • Do they cause autism?
    • Has anyone found problems in older children exposed during pregnancy?
  • Antipsychotics – also called major tranquilizers. Older high-potency antipsychotics such as haloperidol (Haldol) have been recommended in past over low-potency or atypical agents. Children aged 4 exposed had normal IQs. No increased risk of birth defects or complciations seen of newer atypical antipsychotic meds olanzapine (Zyprexa), risperidone (Risperdal) or quetiapine (Seroquel). Newer drugs seem to have fewer side effects, although may increase weight gain. Sign up for National Pregnancy Registry for Atypical Antipsychotics: womesnmentalhealth.org/clinical-and-research-programs/pregnancyregistry/.
  • Electroconvulsive Therapy (ECT) – considered acceptable treatment for severe depression or psychosis in pregnancy. Not used for prental anxiety, panic or OCD
  • Mood Stabilizers – women w bipolar disorders should consider continuing meds throughout pregnancy bc danger of relapse so high. 24% of women w history of chronic bipolar disorder became ill during pregnancy even while on meds, so stopping quite risky. Those who stopped – half relapsed within 3 months and ~70% had relapses. Restarting lithium after stopping in 1st trimester doesn’t protect well against relapse. Medications used for seizure disorders often used as mood stabilizers. Valproate (Depakote) can cause serious birth defects and its use is not widely recommended for women of childbearing age. Lamotrigine (Lamictal), an antiseizure medication, now considered the antiepilectic drug of choice. Lithium an antimania med used to treat bipolar disorders. Risk of Ebstein’s anomaly (heart defect in fetuses) w lithium use in 1st trimester is 1-2/1000. Fetal cardiac ultrasound bw 18-20 wks recommended for those w 1st trimester exposure. No significant neurobehavioral or developmental problems reported in children. Other mood stabilizers, such as carbamazepine (Tegretol) and valproic acid (Depakote), increase rate of neural tube defects and other birth defects. Children at 3 found to have decreased IQ when exposed to Tegretol. Increased dose of folic acid used in addition to Tegretol or Depakote if these medications must be continued. Consult w psychiatrist familiar w latest research.
  • Sleep Aids – depression/anxiety can cause problems falling or staying asleep. Sleep an essential part of treatment plan. Several OTC meds considered fine while pregnant – doxylamine (Unisom) and diphendramamine (Benadryl). Trazadone (Deseryl) and amitriptyline (Elavil) are antidepressants that have a sedative effect. Zolpidem (Ambien) has faster rate of onset and considered acceptable. When anxiety contributing to sleep difficulty and other methods not effective, antianxiety meds such as Ativan or Xanax can be quite helpful.

Postpartum – birth of baby may bring about need to change med treatment plan. While growing fetus exposed to higher doses of maternal meds, a few medications can be problematic for infants receiving breast milk. Some women choose to restart or begin meds after birth. Most found in low levels in breast milk and most considered very low risk to infant.

  • Thyroid – >10% of postpartum women will develop postpartum thyroiditis. In early stages, women may experience anxiety/depression. Sometimes temporary and will go away w out treatment in ~6 months. For others, can lead to chronic thyroiditis and hypothyroidism (Hasimoto’s thyroiditis). Ask provider to check blood – suggested timing is 2-3 months postpartum: free T4, TSH, anti-TPO and antithyroglobulin test. Important to check for antithyroid antibodies (anti-TPO and antithyroglobulin) since many cases when T4 and TSH levels w/in normal ranges. If abnormal, see endocrinologist.
  • Hormone Therapy – still being evaluated for effectiveness. Research w estrogen holds promise for treatment of PPD and PPP. Has certain risks and needs to be evaluated on case-by-case basis. Its not a low level of hormones that cause mood problems for most; rather it’s a shifting of levels that women are sensitive to. Those sensitive to shifts who choose oral contraceptives (birth control) need to be monitored closely. Women may experience fewer problems on a monophasic bcp (same ratio estrogen: progesterone) as compared to a triphasic bcp (ratio of estrogen and progesterone changes weekly). Women w history of increased moodiness on bcp should consider alternative methods. Synthetic progesterone (progestin) including minipill has been associate dw worsening of symptoms. Medroxyprogesterone acetate (Depo-Provera), a long-acting progesterone injection, not a good option since cannot be discontinued should it aggravate mood problems. Reports of mood problems after insertion of progesterone releasing IUD. These resolve once its removed. Hormone therapy not recommended, at this time, as sole treatment for disorders. Research has started looking at use of estrogen patch as form of treatment.
  • Medications – if you or blood relative had positive experience w meds, that’s first choice. 1 study found venlafaxine (Effexor) and another found sertraline (Zoloft) to be effective for PPD. Buproprion (Wellbutrin) for women w depression but w out anxiety seems to be energizing and also reduces sex side effects. Not one med that is better than other. Best is one that works for her. All SSSRIs work well. Each women has individual chemistry. Woman should start SSRI at low dose w regular follow up, increasing dosage until adequate response achieved. Treatment of anxiety, including OCD usually requires higher dose. She should report feeling 100% back to herself. Undertreating can lead to chronic illness and increased risk of relapse

Meds & Breast Milk – for some women, breast milk may feel like only positive thing they have to offer. Most meds found in very low amts in breast milk and babies. A few are not recommended/must be used w caution.  

  • Antianxiety meds – low doses of short-acting meds such as alprazolam (Xanax) or Lorazepam (Ativan) can be used on occasional basis for anxiety, panic and poor sleep. Acceptable to take benzodiazepines (antianxiety meds); no adverse effects seen in infants 2 weeks+
  • Antidepressants– of most commonly used antidepressants, sertraline (Zoloft) and paroxetine (Paxil) detected in smallest amts in infant. Fluoxetine (Prozac), citalopram (Celexa) and Escitalopram (Lexapro) found in small amts in infatns blood and no significant probs in infant. Found to have normal development and IQ at 1 yr. generally safe to breast feed while taking antidepressants. First choice should be med that’s worked in past or successful w blood relative. Benefits of breast milk far outweigh risks of meds.
  • Antipsychotics– aka major tranquilizers, used to treat psychosis and also used to treat women suffering from severe anxiety. Also enhance effectiveness of SSRIs. High-potency antipsychotics such as haloperidol (Haldol) used for moms who breastfeed. Babies should be watched for sleepiness but no reports of infant problems. 2nd generation or atypical antipsychotics Olanzapine (Zyprexa), Risperidone (Risperdal) or Quetiapine (Seroquel) seen in very small amts in breast mill and considered compatible.
  • ECT– acceptable treatment for severe depression or psychosis postpartum and doesn’t affect breast milk. May be used in treating bipolar disorder postpartum. Not used for postpartum anxiety, panic or OCD
  • Mood stabilizers – safety of taking carbamazepine (Tegretol) or valproate (Depakote) while breastfeeding is undecided. In past, women told not to breastfeed if taking lithium. Small studies have shown little risk to infant. Babies need to have blood tests to monitor lithium levels. Lamotrigine (Lamictal) considered acceptable.
  • Sleep aids– Zolpidem (Ambien), Temazepam (Restoril), Trazadone (Deseryl), Nortirptyline (Pamelor) and amitriptyline (Elavil) frequently prescribed.

Medical Protocols – treatments should be followed in sequence. Effective for depression, psychosis, OCD, anxiety and panic. SSRIs are first choice in treatment of OCD, anxiety and panic. Use lowdose antianxiety or antipsychotic meds on short term basis for anxiety and panic. Often high doses SSRIs need for longer periods of time.
Prepregnancy

  • 1 episode of major depression if on meds + asymptomatic for 6-12 months
    • Treatment 1 – taper off meds + psychotherapy (monitor closely for relapse) + social support
    • Treatment 2- resume meds + continue psychotherapy + social support
  • Severe recurrent prior episodes
    • T1 – continue meds + psychotherapy + social support
    • T2 – psychotherapy + meds + social support
  • Mild major depression or severe major depression (1st episode)
    • T1 – psychotherapy + social support
    • T2 – psychotherapy + social support + meds
  • Bipolar disorder –
    • T1 – continue or switch if on Valproic acid (Depakote) or Carbamazepine (Tegretol) to lithium or Lamotrigine (Lamictal) + have psychiatrist monitor closely psychotherapy + social support
    • T2 – switch to high potency antipsychotic if necessary + continue psychotherapy + social support when stable

Pregnancy (including 1st trimester)

  • 1 episode mild major depression, currently in remission
    • T1 – try slowly tapering medication + psychotherapy + social support
    • T2 – resume medication + psychotherapy + social support
  • 1 episode severe major depression, currently in remission
    • T1 – if stable consider slow tapering off or maintenance of medication + psychotherapy + social support
    • T2 – medication + psychotherapy + social support if relapse
  • Mild major depression, first or recurrent
    • T1 – + psychotherapy + social support
    • T2 – medication + psychotherapy + social support
  • Severe major depression, first episode
    • T1 – medication + psychotherapy + social support
    • T2 – ECT + psychotherapy
  • Recurrence or relapse of depression if off meds if mild major depression
    • T1 – + psychotherapy + social support
    • T2 – resume meds + psychotherapy + social support
  • Severe major depression, currently symptomatic
    • T1 – resume meds + psychotherapy + social support
    • T2 – ECT + psychotherapy + social support
  • Psychosis in any trimester (do not rely on psychosocial interventions alone; requires hospitalization)
    • T1 – antipsychotic, add mood stabilizer or antidepressant if needed once stable; psychotherapy when stable. OR ECT + psychotherapy
    • T2 – hospitalization

Postpartum

  • Mild major depression/anxiety
    • T1 – + psychotherapy + social support
    • T2 – + psychotherapy + social support + meds
  • Severe major depression/anxiety
    • T1 – + psychotherapy + social support + meds
    • T2 – consider addition of atypical antipsychotic
  • Postpartum psychosis (hospitalization required; do not rely on psychosocial interventions alone)
    • T1 –antipsychotic + psychotherapy once stable
    • T2 – consider ECT

Prevention of Postpartum Depression in Women w History of Depression, Anxiety, Other Mood Disorder or Prior Postpartum Illness

  • 1st pregnancy
    • T1 – meet w psychotherapist when risk identified (prepregnancy or pregnancy) + psychoeducation for woman and partner
    • T2 – intervention (refer to pregnancy treatment protocol) if symptomatic)
  • Prior postpartum depression/anxiety
    • T1 – psychoeducation for woman and partner as early as possible + consider starting antidepressant (SSRI) 2-4 weeks before delivery or at delivery + psychotherapy
    • T2 – intervention (refer to pregnancy treatment protocol) if symptomatic)
  • Prior postpartum psychosis
    • T1 – refer to psychiatrist, start antipsychotic upon delivery + psychotherapy
    • T2 – intervention (refer to pregnancy treatment protocol) if symptomatic)

Resources

Websites and Helplines:

  • Childbirth and Postpartum Professional Association – CAPPA.net – doula training/locating doula
  • Doulas of N. America – dona.org
  • org – meds in pregnancy and lactation
  • The Marce Society – marcesociety.com – scientific research in field; annual conference
  • Massachusetts General Hospital for Women’s Mental Health – womensmentalhealth.org
  • Motherrisk – motherisk.org – med exposure during pregnancy and postpartum. Toll free help lines
  • MotherToBaby – evidence based info; meds and other exposures during pregnancy/lactation
  • North American Society for Psychosocial OB/GYN – naspog.org – society or researchers, clinicians, educators and scientists. Outstanding conferences
  • Pec Indman’s Website – pecindman.com
  • Postpartum Progress Blog – postpartumprogress.com – award winning blog on PPD and other mental illnesses related to childbirth
  • Postpartum Support International (PSI) – postpartum.net – telephone support, interntl directory of members. Annual conference. Healthy mom, Happy Family DVD
  • Shoshana Bennett’s website – DrShosh.com – film Dark Side of Full Moon; free app PPDGone
  • Postpartum Dads/Partners – postpartumdads.org, psotpartummen.com

Apps

  • Infant Risk Mobile App for Healthcare Providers (author of Meds in Mother’s Milk)
  • MommyMeds Pregnancy Safety Guide
  • PPDGone! – free – videos, audios, articles
  • org – 3 free texts per week during pregnancy and until baby is 1

Books

  • Postpartum Mood and Anxiety Disorders: A Guide
  • Traumatic Childbirth
  • Children of the Depressed: Healing Childhood Wombs that Come from Growing Up w Depressed Parent
  • Postpartum Depression for Dummies
  • Pregnant on Prozac
  • Why Is Mommy Sad? A Child’s Guide to Parental Depression
  • Mood and Anxiety Disorders during Pregnancy and Postpartum
  • Perinatal Mental Health: the Edinburgh Postnatal Depression Scale
  • Life Will Never Be The Same: A Real Moms Postpartum Survival Guide
  • What Happened to Mommy?
  • Jane Honikman books (founder of PSI)
  • Community Support for New Families, Guide to Organizing Postpartum Parent Support Network in Your Community
  • I’m Listening: Guide to Supporting Postpartum Families
  • Transformed by Postpartum Depression: Women’s Stories of Trauma and Growth
  • The postpartum Husband
  • Therapy and postpartum woman
  • What am I thinking? Having a baby after PPD
  • Cognitive Behavioral Therapy for Perinatal Distress
  • Dropping Baby and Other Scary Thoughts: Breaking Cycle of Unwanted Thoughts in Motherhood
  • Tokens of Affection: Reclaiming Your Marriage After Postpartum Depression
  • This Isn’t What I expected: Overcoming PPD
  • Parenting Well When You’re Depressed; A Complete Resource
  • The Smiling Mask: Truths about PPD and Parenthood
  • Mother To Mother PPD support book
  • Infanticide: Psychosocial and Legal Perspective on Mothers Who Kill
  • Understanding PP Psychosis: a temporary madness
  • The Pregnancy & Postpartum Anxiety Workbook

Resources for Neonatal Loss

  • griefwatch.com
  • handsonline.org
  • missfoundation.org
  • nationalshare.org
  • Something Happens – book for children and parents
  • Molly’s Rosebush
  • Pregnancy After a Loss: a Guide to Pregnancy After Miscarriage, stillbirth or Infant Death
  • Empty Cradle, Broken Heart
  • Surviving the death of Your Baby
  • Help, Comfort and Hope After Losing Your Baby in Pregnancy or First Year
  • A Guide for Fathers: When baby Dies

About The Author

Jessica