Mending Mental Health in Motherhood

Dr. Chapa:
Defined as major and minor depressive episodes that occur during pregnancy or in the first 12 months after delivery, perinatal depression is one of the most common medical complications during pregnancy and the postpartum period, but despite its prevalence, many women suffering from perinatal depression often go undetected. So, what steps can we take to better identify and care for these patients so that we can boost their mental health and, most importantly, possibly even save their lives?

Welcome to Clinician’s Roundtable on ReachMD. I’m Dr. Hector Chapa, and joining me to discuss mental health in perinatal women is Dr. Meredith Williamson. She’s a licensed counseling psychologist at Texas A&M University Health Science Center in Bryan, Texas. Dr. Williamson, welcome to the program.

Dr. Williamson:
Thank you so much for having me.

Dr. Chapa:
Well, this is a perfect discussion for you, and it’s very timely because this issue of perinatal depression and even suicide, which, to be honest, we didn’t really talk about very much before, is now making headline news, and it should be. So, let’s get right to it. By taking a look at some of the latest data regarding this, what would you say, Dr. Williamson, is the actual number or incidence or prevalence of perinatal depression in the general population? And is it on the rise?

Dr. Williamson:
So when I’m working with patients, I often tell them that about 15 percent of women who give birth are likely to experience depression in the perinatal period, so that’s about 1 in 7 or 1 in 8 women are likely to experience it.

Dr. Chapa:
Now, do those that the same historically or do you see in your particular practice that it’s increasing as some of the media tends to suggest?

Dr. Williamson:
So in my practice, it has been prevalent for a long time actually, but I think the decrease in stigma related to mental health, I think there’s more and more people seeking help, and we’re also hopefully across the country doing a better job of actually asking women both during pregnancy and during the postpartum period whether they’re experiencing depression, and so I think that may be one of the reasons that it seems to be on the rise, although it may be that it’s always been there.

Dr. Chapa:
Now, one of the things that’s also been addressed, especially in medical circles, is three letters, right – S-D-H’s. Those are social determinants of health, and we’ve uncovered this issue of racial disparities, specifically with certain medical conditions like diabetes and hypertension, and even to include access to care. Do you think that places certain patient populations at higher risk than others for perinatal depression? And is that affecting their ability to get care for it?

Dr. Williamson:
I think historically, actually, it was thought that older white women were more likely to struggle with mental health in that postpartum period, but I think with the prevalence and increased prevalence of screening, that’s still a population that struggles, but I think younger women and women of minority status are starting to really see that, and I think that’s in part just  the likelihood that screening is increasing, but also I think with those social determinants of health there’s often extra barriers, both to seeking care and also just in their own lives that are likely contributing to that increase in postpartum depression. 

Dr. Chapa:
Now, I’m a big fan of cognitive behavioral therapy, I really am. I’m not quick to write a script even though I’m not against pharmacotherapy for depression or anxiety by any means, but I’m a big fan of retraining your brain how to think. You can provide some insights on cognitive behavioral therapy, Dr. Williamson, I’d appreciate that specifically in regards to perinatal depression. Is there any data for that? Does it work? And how would you approach cognitive behavioral therapy?

Dr. Williamson:
Those are all great questions. So, I think to start the conversation when we talk about depression in general, one of the ways to describe it is that it’s a biopsychosocial problem. So, this idea that there may be genetic predispositions that predispose someone to depression, either a family history of depression or other things in their genetic makeup, their social factors, lack of social support, partner violence, different strains, maybe they are a first-time mom, have multiple children in the home, low socioeconomic status, or you have the psychological factors. They may already have other mental health conditions or may be predisposed due to other stressors in their life to develop those either currently or in the future, and so when we talk about what cognitive behavioral therapy really does is it’s looking at the relationship between someone’s thoughts, their feelings, and their behaviors. So, we look at that interplay between those and then try to address, each of those aspects of someone and what’s going on with them, and so especially in the perinatal period, you have a mom that’s come home, oftentimes with a new baby, may or may not have support, and especially for first-time moms, that thought of “Am I doing everything right?” Or they may have had a delivery or a birth that was somewhat traumatic for them or not the way they had planned, and so they’re dealing with all of these thoughts about I’m not good enough, or maybe they planned on breastfeeding and that’s not working out very well, and so they’re feeling like it’s their fault, and oftentimes, they may not have support and may feel alone and isolated, and so those thoughts that I’m not good enough, there’s something wrong with me, I’m not prepared to be a mother, I’m gonna be really poor at this, or  I’m not feeling that I’m good enough, can lead to feelings of depression or anxiety that then can lead to behaviors, and so those behaviors can be things like avoidance, so they just give up or seem to be distant from their child, or it can be hyperactivity where they’re searching the internet trying to find solutions to these things that they’re concerned are making them a poor mother, and then that feeds into these cognitions cause it may still not to them feel like it’s getting better, and it makes them feel and say to themselves in terms of their thoughts that I’m a really bad mom or I’m not taking good enough care, and so that inner relationship is what we’re looking at and how those thoughts are affecting someone’s feelings and their behaviors, and oftentimes, we try to fix behaviors and feelings, but we don’t take into account that intense driver, which is someone’s thoughts, and so as a clinician, what I do is I look at that, and I say, “Okay, I know you may be feeling really down and depressed, but I want to back up a little bit, and I want to look at how we got there and the kinds of things just throughout your day that you may be telling yourself or you may be hearing from others outside of you that may be influencing how you’re feeling and what you’re doing,” and intervene there while also trying to address the behaviors to increase the strengths that the mother may have and encourage her to succeed.

Dr. Chapa:
You know, all of us for some reason are wired towards thinking the worst, right? And we kind of have this negativity bias so that when your boss calls you or leaves you a message, you automatically think – and for those of you listening, you know this is true – Oh no, what did I do? When it could be a compliment or maybe asking for your advice. We have this negativity bias that, that I am not doing what I should be doing and so addressing that it’s okay to have those thoughts but not to act on them, I think you hit something very important there. For those of you just tuning in, we’re listening to Clinician’s Roundtable on ReachMD, and I’m Dr. Hector Chapa, and I’m speaking with Dr. Meredith Williamson about perinatal depression, a very important topic. Now, Dr. Williamson, as we zero in on detection or lack thereof, can you tell us why this often goes undiagnosed or unnoticed?

Dr. Williamson:
I can give an example from my personal life. So I’m a mother, and when I had my first child, I went to the doctor and I was there, and the doctor’s office was good enough to be screening for depression in the postpartum period, so they started asking me if I felt depressed, and the nurse said, “Why would you ever be depressed? You just had a baby, that’s so stupid,” and I think that speaks to kind of this cultural idea of having a baby as a joyful thing, and it can also be a very painful thing, but then comes the reality that you have to care for this new life, and no one is ever prepared for that fully, and so I think that cultural idea that birth equals joy and then the lack of normalizing the experience of this as a hard thing that takes work, and no one is the best at it the first time, second time, third time, even the sixth time around is really what’s sad about where we are, and I think clinicians – myself included – could do a better job at preparing women from the time that they come in for their first prenatal appointment that this is where they’re headed instead of just focusing on the medical complications that are ahead.

Dr. Chapa:
And there you read my mind cause I was just about to ask you, whether you’re a health care provider or just a family member, what should we be looking for and how can we make this okay to discuss with our pregnant friends, family members, or patients?

Dr. Williamson:
Yeah, I would say first of all, that I wouldn’t wait for a warning sign. As a clinician, encourage all clinicians to have these discussions with every patient instead of just those that they think are maybe at risk or maybe screen positive for depression so that brings into the light of making sure you’re asking your patients on a regular interval how they’re feeling, especially if you’re a primary care physician or something like that seeing a patient long term. In terms of warning signs, we’re looking for two big things, and one is just a change in your interest level, so how interested are you in your life in general – it could be in a variety of things – and then also how sad or down you may feel, and so it may be related to your baby, you may be so overwhelmed with your baby that you’ve lost interest in friends or positive habits that you may have had before, and so you’re kind of trying to take a survey to see how that may be affecting them as a whole. That can then lead to feelings of just kind of misery or feeling like a failure as a mom, and that’s a common feeling, but when it’s pervasive, that’s when you’d be concerned, or this anxiety that I’m not doing it right and that becomes kind of a driver in making them seek help from you or help from other sources. So, that’s the clinician piece. I think as a layperson, when that person finds out they’re pregnant, if you’re their partner or you’re the person that they’ve identified as their primary support, it would be coming alongside them and just talking together and we make a birth plan often, but we don’t make an aftercare plan, and so what can we have in place to prepare for life after baby, and when it’s good but also when it’s really challenging, not just for the two weeks after birth, but how is our life gonna look for years to come, I think is really important.

Dr. Chapa:
Dr. Williamson, all of these have been great insights and great points, but if I’m a listener and I’m somebody who potentially is suffering from depression or anxiety, where can I go to get some help?

Dr. Williamson:
So what I typically recommend is there is a website –it’s called the Postpartum Support International, and they have a phone number you can call 24 hours a day, 7 days a week. There’s not someone that answers that live, but you can leave a message, and they’ll respond within 24 hours, and that number is 1-800-944-4773, and then in addition to that, they actually for providers have a perinatal consultation service, and so you can also call as a provider, and they have psychiatric consultation if you have a question about a patient specifically.

Dr. Chapa:
So, Dr. Williamson, you’ve given some very helpful, very practical and very real insights for this very important discussion because it’s robbing women of their joy and, in some cases, even their lives. Perinatal depression and anxiety and mood disorders needs to be discussed, and as I’ve heard it said before, we’ve got to be able to say, “It’s okay to not be okay.” So, Dr. Williamson, it was great having you on the program.

Dr. Williamson:
Thank you so much.

Dr. Chapa:
I’m Dr. Hector Chapa. To access this and other episodes in our series, visit reachmd.com/cliniciansroundtable, where you can be part of the knowledge. Thanks for listening.