Out from the Shadows

285- Out From The ShadowsHealthcare providers, mental health professionals, and affected families around the country are working hard to shine light on perinatal mood and anxiety disorders.

By Diana Price

Six weeks after Ivy Shih Leung delivered her daughter, she was hit with crippling insomnia despite, as she terms it, “mind-numbing exhaustion.” A traumatic birthing experience had resulted in the removal of her uterus and required consistent blood work and procedures that prohibited her from sleeping in the hospital; once home, Ivy became anxious as she faced caring for her newborn, who developed colic, eczema, and cradle cap in those first weeks.

Ivy’s OB/GYN prescribed Ambien® (zolpidem) to help her sleep, but her health continued to deteriorate. “Within a couple of weeks, I developed full-blown panic attacks that scared me into thinking that something was seriously wrong with me, that I might never return to my old self again, and that I may not even make it through alive,” Ivy says. In addition, she says she experienced a loss of appetite  and weight loss and lost interest in most of the activities that had brought her pleasure. “I felt completely debilitated and had difficulty thinking, concentrating, and making decisions. I felt disoriented and in a haze—I turned into a shell of a person.”

Definition and Causes of PMAD

It wasn’t until a month after she developed insomnia and two weeks after her panic attacks began that Ivy was diagnosed with postpartum depression (PPD), one of a variety of perinatal mood and anxiety disorders (PMAD). Though a majority of women (about 80 percent) will experience normal changes in mood during pregnancy and following childbirth, which might include feeling overwhelmed, tearful, tired, and full of emotion (sometimes referred to as the “baby blues” when it occurs postpartum), about 15 to 20 percent of women will develop depression or anxiety that is more significant.1

Emily Dossett, MD, MTS, a psychiatrist in private practice in Pasadena, California, and the founder and director of the Maternal Wellness Clinic at the Los Angeles County + University of Southern California (LAC + USC) Medical Center, specializes in women’s health, specifically mood disorders. Dr. Dossett says that PMAD—which includes mood and anxiety disorders that arise during pregnancy as well as postpartum up to about a year, including depression, anxiety, obsessive compulsive disorder, bipolar disorder, postpartum post-traumatic stress disorder, and postpartum psychosis—is more common than many people think. “Anxiety and depression among pregnant and postpartum women is not rare—current statistics [which reflect only self-reported cases] mean that a busy OB/GYN who is seeing 20 to 30 patients a day potentially sees 5 to 8 patients a day who are dealing with this. That’s a lot.”

According to Dr. Dossett, mood disorders and depression among pregnant and postpartum women can be the result of both biological and psychological factors. “Women’s estrogen and progesterone levels climb steadily during the course of pregnancy, and then within the first 24 hours of delivery they drop precipitously—estrogen levels can drop 95 to 98 percent in the 24 hours after delivery; these changes are likely one cause, though we can’t pinpoint a specific estrogen level that causes the problem.”

Thyroid abnormalities can also play a role, Dr. Dossett says, and research is ongoing around the impact of inflammation occurring in the body during this time that could affect the immune system and be linked to mood disorders. The impact of sleep deprivation is also considered a major factor.

Beyond the biological causes, the most significant risk factor for PMAD is a personal or family history of mood or anxiety disorders. The chances are especially high, Dr. Dossett says, if a woman is symptomatic during pregnancy. Additional risk factors include a lack of social support, a poor marital relationship, a medically complicated pregnancy, a history of trauma or abuse, loss of or separation from one’s own mother, financial stress, a traumatic labor or delivery, an infant’s medical challenges, and substance abuse.

All of these factors can play a role during what is, in general, a period of major change, Dr. Dossett says: “Women undergo an enormous transition in identity wherein all the different expectations you put on yourself and your own experiences of being mothered, whether good or bad, come to the forefront. There’s a lot of psychological upheaval.”

Screening

In retrospect Ivy believes that had her OB/GYN been more aware of the signs of PPD and had screened her to determine if some of the symptoms she was experiencing were indicative of something more than insomnia, she could have received appropriate care much sooner: “My OB/GYN completely overlooked the fact that insomnia at six weeks is a clear sign of PPD. Had I been properly diagnosed at that point, I could have been spared my painful ordeal.”

Unfortunately, Ivy’s story is not unique. Despite the fact that as many as one in seven women suffers postpartum depression,2 screening for PMAD is not consistent among OB/GYN physicians, and there is no universal recommendation or guideline to include screening as part of prenatal or postpartum care. In fact, in 2012 the American Congress of Obstetricians and Gynecologists reaffirmed its committee opinion that “there is insufficient evidence to support a firm recommendation for universal antepartum or postpartum screening. There are also insufficient data to recommend how often screening should be done.”3

When screening is conducted during a prenatal visit, it generally consists of a series of scripted questions or a brief written test created to identify symptoms of depression; it takes about 5 to ten minutes for patients to complete and is generally administered by the nurse.

Daniel Roshan, MD, FACOG, FACS, of Rosh Maternal-Fetal Medicine in New York City specializes in high-risk obstetrics and maternal and fetal medicine. He says that physicians often have trouble including mental-health screening in the very limited time they have with each patient. “The average prenatal visit is five minutes, and most doctors see 40 to 50 patients a day,” Dr. Roshan says. “So unless the patient brings up the topic herself, it’s not covered—it’s a major problem.”

Dr. Roshan says that because he specializes in high-risk pregnancies, he is especially vigilant; but, he says, all OB/GYNs need to be aware of the issue and be educated about PMAD: “Doctors can’t assume that every patient is normal; if they see something that seems abnormal, they should do something about it and refer the patient to the right mental-health resources.”

Ira Jaffe, DO, FACOG, who practices alongside Dr. Roshan at Rosh Maternal-Fetal Medicine, says that physicians who are aware of the importance of screening for PMAD often develop their own set of indicators to look for in their patients. “More often in a practice like ours,  where we get to know our patients well, if a person has a history of any kind of depression or anxiety, we’re more alert; and to identify patients who are at risk, we look for clues in their affect: we ask them how they’re doing; we notice how they’re dressed and note their personal hygiene.”

Dr. Dossett says that the farfrom- universal screening practices are in part the result of the historic divide between mental and physical healthcare: “Medicine for a long time has pretty neatly divided the body and the mind, and there hasn’t been a lot of cross-training.” Add to this precedent for treating mind and body separately the fact that in most cases doctors who screen for mental-health issues do not have on-site mental-health providers and must refer patients to a separate facility, and providers can be hesitant to engage with mental issues. “For  many prenatal health providers, to add in the mental-health piece is overwhelming, like opening Pandora’s box,” Dr. Dossett says.

One route Dr. Dossett thinks will ultimately be effective in ensuring more-comprehensive mentalhealth care during pregnancy and postpartum is to create a more integrated system of care wherein the many practitioners involved in maternal care—including physicians, lactation consultants, doulas, and childbirth educators—can communicate and work together to educate people about PMAD. “Those of us in the field are trying to push for more-integrated care so that women not only get screening and education about depression and anxiety issues in their prenatal environment but there’s also onsite mental-health care available for them—whether via a social worker or psychiatric consultant or a case

manager to refer them to resources. The old model of care where they are referred out is just not effective because women often don’t go through with it.”

Prevention and Treatment

When Ivy ultimately received a diagnosis of PPD, her general practitioner prescribed an antidepressant as well as anti-anxiety medication to help manage the panic attacks she was experiencing until the antidepressant became effective. After four weeks the antidepressant took effect, and she noticed a significant difference.

Treatment for PMAD is highly individual, depending on the diagnosis and each woman’s unique circumstances. If a woman has a personal or family history of depression or anxiety, Dr. Dossett says, ideally proactive conversations about managing mental health should begin well in advance of pregnancy. “If women are on medication or have a history of psychiatric illness, they need to consult with a mental-health care provider before they get pregnant—not early in pregnancy, but before.”

This approach is key, she says, so that women can discuss the risks and the benefits of remaining on medication during pregnancy before that medication might affect a growing fetus. “I recommend that women come in six months to a year before they try to conceive so we can create a plan to carry them through pregnancy and postpartum, including safety in breastfeeding.”

Dr. Dossett cautions women against assuming that they should automatically stop taking medication when they get pregnant. “A lot of women feel that they need to go off their medication because they don’t want to harm the baby, and medical practitioners in a very well-intentioned way might suggest to women that they go off their medication,” she says, “but there are some real risks of untreated anxiety or depression.” These risks include a rate of relapse for depression that is roughly 70 percent, Dr. Dossett says. “Rates of relapse are very real for all PMAD, including depression and anxiety, and are extremely high for women who are bipolar or have psychotic disorders.” For women with these disorders, discontinuing medication might have dire consequences, including the potential for manic episodes, loss of appetite, suicidal thoughts, and other dangerous behaviors.

Discussing these risks with a mental- health professional and weighing them against the potential impact of remaining on medication during pregnancy is critical. “There can be significant fallout for women who just stop their medication,” Dr. Dossett says. It’s always a very personal choice, she adds. “There are different categories of risk based on severity of the illness and also based on the risk of the medication itself, so it’s really and individual conversation for each woman.”

Of course, for many women, planning in advance is not an option. In these cases, an accurate, timely diagnosis and effective treatment is the best possible scenario. Depending on the diagnosis, medication, therapy, self-care, and appropriate support services— all can play a role. Dr. Dossett says that support groups, whether inperson, online, or by telephone, can be particularly helpful, alongside therapy and medication, if needed.

The reality, however, is that though treatment and support are extremely effective, many women endure anxiety and depression for too long without intervention. “I had to suffer through my PPD symptoms without any sort of reassurance that I would ever return to my old self,” Ivy says. “I didn’t know how to find a therapist with experience treating postpartum mood disorders, nor did I know how to find PPD support groups or even online PPD resources, like blogs and Facebook groups, which are so plentiful now.” Though her husband provided help with caring for their daughter, he did not understand what Ivy was going through and so could not offer the support she needed. Her feelings of isolation were intense: “I didn’t even have any friends who understood what I was going through or who could provide a shoulder to lean on and provide nonjudgmental advice,” Ivy says.

The lack of support women like Ivy experience reflects the widespread lack of awareness about PMAD, which can present a significant challenge in women getting the care they need. Myths and stigma associated with PMAD mean that many people assume that the symptoms a woman experiences are “just the baby blues” and don’t recognize the depth of her suffering. Dr. Dossett says that providing families with comprehensive information about PMAD is essential: “Education is key for families and partners because there are so many misunderstandings about what mothers are experiencing. Just helping families understand what women are going through can make a big difference.”

Conclusion

“Inroads are being made in terms of awareness of PMAD on the part of practitioners and families, but there’s a long way to go,” says Dr. Dossett. As practitioners and support and advocacy organizations continue to strive for awareness and better care for women affected, those who have recovered, like Ivy, are playing a major role in shedding light on the experience.

In 2011 Ivy published One Mom’s Journey to Motherhood: Infertility, Childbirth Complications, and Postpartum Depression, Oh My! Offering women insight from her own experience and significant research. The book, she says, is her effort to help women understand that they are not alone, to dispel common myths about motherhood, and to help partners, friends, and family “mother the mother.” Ivy says she hopes her book offers a lifeline to women: “I want other women who may be experiencing a perinatal mood disorder to know that, first and foremost, they need to keep in mind this Postpartum Support International mantra: “You are not alone. You are not to blame. With help, you will be well.”

References

1. Pregnancy and Postpartum Mental Health. Postpartum Support International website. Available at: http://www.postpartum.net/get-thefacts.aspx. Accessed March 25, 2014.

2. Wisner KL , Sit DKY , McShea MC, et al. Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings. JAMA Psychiatry. 2013;70(5):490-98. doi:10.1001/jamapsychiatry.

3. Screening for Depression during and after Pregnancy. American Congress of Obstetricians and Gynecologists website. Available at: http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Obstetric_Practice/Screening_for_Depression_During_and_After_Pregnancy. Accessed March 25, 2014.

Tips for Family and Friends

Dr. Dossett offers the following suggestions for partners, friends, and family members who want to help support a new mother.

  • Help ensure that mom has at least five hours of uninterrupted sleep per night by offering to help with nighttime feedings and soothing.
  • Make sure that there is nutritious, easyto-prepare food in the house.
  • Define boundaries for family visits; support from extended family can be helpful, but it should not be an added burden.
  • Try to listen and understand. It is not helpful to say things like, “How can you be depressed when you have this beautiful baby?” or “Go get your nails done” or “Sleep when the baby sleeps.” People think they are being helpful, but in truth such comments just make women feel more isolated. Listen, try to understand, and be emotionally available.
  • Advocate for proper assessment and treatment; it can be challenging to find knowledgeable providers, but they are out there.

Resources

Postpartum Progress

Postpartumprogress.com

“Postpartum Progress® offers in-depth information, community and hope for pregnant and new moms with postpartum depression and all other mental illnesses related to pregnancy and childbirth (including postpartum anxiety, postpartum OCD, depression during pregnancy, post-adoption depression, postpartum PTSD , depression after miscarriage or perinatal loss and postpartum psychosis). We know that perinatal mood and anxiety disorders like PPD are temporary and treatable with professional help.”

Postpartum Supp ort International

Postpartum.net

“PSI is a non-profit organization whose mission is to promote awareness, prevention and treatment of mental health issues related to childbearing in every country worldwide.”